What is the initial treatment for Eosinophilic Esophagitis (EoE)?

Initial Treatment for Eosinophilic Esophagitis (EoE)

Proton pump inhibitors (PPIs) are the recommended first-line treatment for eosinophilic esophagitis, specifically omeprazole 20 mg twice daily for 8-12 weeks. 1

Treatment Algorithm

Step 1: PPI Therapy

• Medication: Omeprazole 20 mg twice daily before meals
• Duration: 8-12 weeks
• Goal: Achieve both clinical and histological remission

PPIs have been shown to be effective in inducing histological and clinical remission in patients with EoE, with response rates of approximately 50% 1. The British Society of Gastroenterology (BSG) guidelines strongly recommend this approach despite the evidence being classified as moderate quality.

Step 2: Assess Response

After 8-12 weeks of PPI therapy, patients should undergo repeat endoscopy with biopsies to assess histological response. This is crucial as symptoms may not always correlate with histological activity 1.

Response categories:

1. Complete response: Clinical and histological remission (<15 eosinophils/HPF)
2. Partial response: Symptom improvement but persistent eosinophilia
3. No response: Persistent symptoms and eosinophilia

Step 3: Management Based on Response

If Complete Response (PPI-Responsive EoE):

• Continue PPI therapy as maintenance
• Consider step-down therapy to omeprazole 40 mg once daily, and potentially to 20 mg once daily in patients who maintain remission 2
• Long-term histological remission is maintained in approximately 70% of patients on maintenance PPI therapy 1

If Partial or No Response:

Move to second-line therapies:

1. Topical steroids:

   • Budesonide orodispersible tablet 1 mg twice daily
   • Swallowed fluticasone 880 mcg (four puffs) twice daily
   • Topical steroids have shown histological remission rates of 64.9% compared to 13.3% for placebo 3

2. Elimination diets:

   • Six-food elimination diet (SFED): removes milk, wheat, egg, soy, nuts, fish/seafood
   • Histological response rate of approximately 72% 1
   • Consider dietitian consultation to ensure proper nutrition

Important Considerations

Monitoring

• Regular clinic visits to assess symptoms, compliance, and adverse effects
• Repeat endoscopy with biopsies 8-12 weeks after initiating therapy
• Continued monitoring based on symptoms and treatment response

Potential Pitfalls

1. Inadequate PPI trial: Many patients are incorrectly diagnosed with EoE before completing a full 8-week PPI trial at adequate dosing 4

2. Symptom-histology discordance: Up to 50% of patients with persistent eosinophilia may report symptom improvement 5, highlighting the importance of endoscopic assessment

3. Maintenance therapy challenges: Without maintenance therapy, most patients will relapse. In one study, 87.5% of patients who discontinued PPI therapy after 12 months experienced symptom recurrence 1

4. Treatment adherence: Long-term dietary restrictions can significantly impact quality of life, leading to poor adherence over time. In one study, only 55% of patients maintained compliance with elimination diets at 9 months 6

Evolution of Understanding

It's important to note that our understanding of EoE has evolved significantly. Previously, EoE and GERD were considered mutually exclusive conditions, but current evidence suggests they can coexist and have complex interactions 1. The term "PPI-responsive esophageal eosinophilia" (PPI-REE) was previously used to describe patients who responded to PPI therapy, but current guidelines now consider these patients as having a PPI-responsive variant of EoE rather than a separate condition.

By following this treatment algorithm, clinicians can effectively manage most patients with EoE, reducing both symptoms and esophageal inflammation to improve long-term outcomes.