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 first-line treatment for eosinophilic esophagitis, specifically omeprazole 20 mg twice daily for 8-12 weeks. 1

PPI Therapy as Initial Treatment

Dosing and Duration

• Recommended regimen: Omeprazole 20 mg twice daily for 8-12 weeks 1
• For children: 1 mg/kg twice daily (up to 40 mg twice daily) 1
• Twice-daily dosing is significantly more effective than once-daily dosing regardless of total daily dose 2
• Treatment should continue for at least 8-12 weeks before assessing histological response 1

Efficacy of PPI Therapy

• PPI therapy induces histological remission in approximately 48.8% of patients 3
• Clinical symptom improvement occurs in approximately 71% of patients 3
• Patients with inflammatory phenotype respond better than those with stricturing/fibrotic disease 3
• Extending treatment from 8 to 12 weeks increases response rates (OR 2.7) 3

Assessment of Response

After 8-12 weeks of PPI therapy, response should be evaluated with:

• Symptom assessment
• Repeat endoscopy with biopsy to assess histological response 1
• Histological remission defined as <15 eosinophils per high-power field 1

Alternative First-Line Options

If PPI therapy fails or is contraindicated, consider:

Topical Corticosteroids

• Strong recommendation with moderate quality evidence 1
• Induces histological remission in approximately 65% of patients compared to 13.3% for placebo 4
• Options include:
  • Fluticasone (swallowed from inhaler)
  • Budesonide (as viscous slurry or orodispersible tablet)

Dietary Therapy

• Effective but more challenging to implement than medication
• Options include:
  1. Six-food elimination diet with PPI (52% complete remission) 5
  2. Elemental diet (highly effective but poor compliance and quality of life) 1

Maintenance Therapy

For patients who achieve remission with PPI:

• Continue PPI therapy as maintenance
• Consider dose reduction to lowest effective dose (many patients maintain remission on omeprazole 20 mg daily) 6
• Long-term histological remission is maintained in approximately 70% of patients 1

Important Considerations

• PPIs are not FDA-approved specifically for EoE, but their use is supported by strong guideline recommendations 1
• Clearly communicate to primary care providers that PPI is being used for EoE management, not GERD 1
• Patients with stricturing phenotype have lower response rates to PPI therapy both initially and long-term 3
• Discontinuation of PPI therapy after remission leads to high rates of relapse (87.5% symptom recurrence) 1

Pitfalls to Avoid

1. Using once-daily PPI dosing, which is significantly less effective than twice-daily dosing 2
2. Stopping therapy too early (before 8-12 weeks) before assessing response
3. Failing to perform follow-up endoscopy to confirm histological response
4. Not recognizing that patients with fibrotic/stricturing disease may need additional interventions beyond PPI therapy
5. Assuming symptom improvement alone indicates disease control (histological assessment is essential)

The evidence strongly supports starting with PPI therapy as the initial treatment for EoE due to its favorable efficacy, safety profile, and ease of administration compared to other options.