What is the treatment approach for eosinophilic asthma versus eosinophilic esophagitis (EoE)?

Treatment Approach for Eosinophilic Asthma versus Eosinophilic Esophagitis (EoE)

Eosinophilic asthma and eosinophilic esophagitis require distinct treatment approaches despite their shared eosinophilic pathophysiology, with inhaled corticosteroids being first-line for eosinophilic asthma and topical swallowed corticosteroids being first-line for EoE. 1

Eosinophilic Asthma Treatment

First-line Therapy

• Inhaled corticosteroids (ICS) - Standard daily doses (200-250 μg fluticasone propionate or equivalent) achieve 80-90% of maximum therapeutic benefit 2
  • More effective than leukotriene receptor antagonists in reducing airway eosinophilia 3
  • Rapidly suppresses airway inflammation within 1 week of initiation

Step-up Options

1. ICS/LABA combination - When standard ICS doses are insufficient

   • Allows maintenance of anti-inflammatory control at lower steroid doses 4

2. Biologic therapies for severe eosinophilic asthma:

   • Mepolizumab (anti-IL-5): FDA-approved for severe eosinophilic asthma in patients ≥6 years old 5
     • Mechanism: Blocks IL-5, reducing eosinophil production, differentiation, and survival
     • Dosing: 100 mg SC every 4 weeks (adults/adolescents); 40 mg SC every 4 weeks (children 6-11 years)
     • Reduces blood eosinophils by approximately 84% compared to placebo

Eosinophilic Esophagitis Treatment

First-line Therapies

1. Topical swallowed corticosteroids (strong recommendation, moderate quality evidence) 1

   • Fluticasone or budesonide formulations designed for asthma but swallowed rather than inhaled
   • Dosing: 880-1760 μg/day for adults, 440-880 μg/day for children 1
   • Administration technique is critical:
     • MDI without spacer, sprayed into mouth with sealed lips
     • Swallow medication without rinsing
     • No eating/drinking for 30 minutes after administration

2. Proton pump inhibitors (PPIs) (conditional recommendation, very low-quality evidence) 1

   • 42% histologic response rate
   • May be preferred initial therapy due to safety profile and ease of administration

Alternative/Additional Approaches

1. Dietary therapy - Elimination diets to remove food triggers 1

2. Systemic corticosteroids - Reserved for emergent cases only 1

   • Not recommended for long-term use due to significant systemic side effects
   • Similar histologic improvement but more side effects compared to topical steroids

Key Differences in Management

Aspect	Eosinophilic Asthma	Eosinophilic Esophagitis
Route of steroid	Inhaled	Swallowed
First-line	ICS	Topical corticosteroids or PPIs
Biologics status	FDA-approved (mepolizumab)	Investigational only
Dietary therapy	Limited role	Major therapeutic option

Ineffective Treatments for Both Conditions

• Montelukast (leukotriene receptor antagonist):

  • Inferior to ICS for eosinophilic asthma 3
  • No effect on esophageal eosinophilia in EoE 1

• Cromolyn sodium:

  • No therapeutic effect in EoE 1
  • Not recommended for either condition

• Anti-IgE therapy:

  • Not recommended for EoE (conditional recommendation against use) 1

Treatment of Comorbid Disease

For patients with both conditions:

• Optimize treatment of each condition separately
• For patients with significant concomitant atopic disease, joint management by gastroenterologist and allergy specialist is recommended 1
• Consider that the same inhaled steroid agents used for asthma can be repurposed (swallowed) for EoE 1

Monitoring Response

• EoE: Repeat endoscopy with biopsies is strongly recommended if symptoms recur while on treatment 1
• Eosinophilic asthma: Monitor symptom control, lung function, and exacerbation frequency

Emerging Therapies

Biologic therapies targeting the IL-4/IL-13 pathway (e.g., dupilumab) and IL-5 pathway (e.g., benralizumab) show promise for both conditions but are currently recommended only in the context of clinical trials for EoE 1