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

Initial Treatment for Eosinophilic Esophagitis (EoE)

Proton pump inhibitor (PPI) therapy should be used as the initial treatment for Eosinophilic Esophagitis, specifically omeprazole 20 mg twice daily for 8-12 weeks in adults. 1

Treatment Algorithm

1. First-line therapy: PPI treatment

   • Adults: Omeprazole 20 mg twice daily for 8-12 weeks 1
   • Children: 1 mg/kg twice daily (up to 40 mg twice daily) for 8-12 weeks 1
   • Reassess with endoscopy and biopsies after initial treatment period

2. Response assessment after 8-12 weeks:

   • Complete response (histological remission <15 eosinophils/HPF): Continue PPI as maintenance therapy
   • Partial or no response: Proceed to second-line options

3. Second-line options (for PPI non-responders):

   • Topical steroids: Budesonide or fluticasone 1
   • Dietary therapy: Six-food elimination diet or elemental diet 1

Evidence for PPI Therapy

PPI therapy has emerged as an effective first-line treatment for EoE with strong supporting evidence:

• Meta-analysis of 33 studies showed partial clinical response rates of 60.8% and histological response rates of 50.5% 1
• A cross-sectional study of 534 adults and 76 children demonstrated histological response in 48.8% and clinical response in 71.0% of patients 1
• The AGA/JTF guidelines suggest using PPI over no treatment based on an overall histologic response rate of 42% 1

The British Society of Gastroenterology (BSG) strongly recommends PPI therapy with omeprazole 20 mg twice daily for at least 8-12 weeks before assessing histological response 1. This recommendation is based on evidence showing higher response rates with twice-daily dosing compared to once-daily dosing.

Maintenance Therapy

For patients who achieve histological response to PPI therapy, continued maintenance therapy is effective:

• A prospective study of 57 children showed 70.1% maintained long-term histological remission over 12 months on maintenance PPI therapy 1
• A retrospective cohort study of 75 PPI-responsive patients observed sustained histological remission in 73% on maintenance PPI therapy for at least 12 months 1

Important Clinical Considerations

• Early treatment is crucial: Delay in diagnosis and treatment may lead to increased fibrosis and stricture formation. Studies show stricture rates of 17% with diagnostic delay <2 years versus 71% with delay >20 years 1
• Endoscopic follow-up: Repeat endoscopy with biopsies is essential to confirm histological response after initial treatment 1
• PPI dose reduction: After achieving remission, consider step-down therapy. Studies show 81% of patients maintain remission with once-daily dosing 2
• Symptom monitoring: Clinical symptoms may not correlate with histological activity; some patients with persistent inflammation may report symptom improvement 1

Common Pitfalls to Avoid

1. Relying solely on symptoms: Clinical symptoms do not always correlate with histological activity. Endoscopic assessment with biopsies is necessary to confirm response 1
2. Inadequate PPI dosing: Using standard once-daily dosing instead of the recommended twice-daily dosing may result in suboptimal response 1
3. Premature discontinuation: Stopping PPI therapy after symptom improvement without confirming histological remission may lead to disease progression 1
4. Failure to consider comorbid GERD: EoE and GERD can coexist; treating only one condition may result in persistent symptoms 1
5. Overlooking maintenance therapy: After achieving remission, maintenance therapy is essential to prevent relapse 1

By following this treatment approach, clinicians can effectively manage EoE and potentially prevent long-term complications such as esophageal strictures and food impaction.