What is the management plan for eosinophilic esophagitis?

Management of Eosinophilic Esophagitis

The management of eosinophilic esophagitis (EoE) should primarily consist of topical corticosteroids as first-line therapy, with proton pump inhibitors, dietary interventions, and endoscopic dilation as additional options based on disease presentation and patient factors. 1

First-Line Pharmacological Therapy

Topical Corticosteroids

• Strong recommendation with high-quality evidence for inducing both histological and clinical remission 1
• Dosing: Should be administered for 8-12 weeks before assessing histological response
• Maintenance: Continuation of topical steroids is recommended after achieving remission due to high relapse rates after withdrawal 1
• Benefit: Likely to reduce development of strictures in the long term 1
• Monitoring: Watch for potential side effects including candida infection

Proton Pump Inhibitors (PPIs)

• Effective for inducing histological and clinical remission (moderate quality evidence) 1
• Dosing: Should be given twice daily for at least 8-12 weeks before assessing response 1
• Can be effective for maintenance therapy in patients who achieve initial response 1

Dietary Management Options

Step-Up Approach to Dietary Elimination

1. Two-food elimination diet (milk +/- wheat or egg) for 8-12 weeks, then repeat endoscopy 1

   • If in remission: Reintroduce one food at a time with endoscopy after each reintroduction
   • If not in remission: Proceed to next step

2. Four-food elimination diet (milk, wheat, egg, soya) for 8-12 weeks, then repeat endoscopy 1

   • Achieves remission in approximately 60% of patients 1
   • If in remission: Reintroduce one food at a time with endoscopy after each reintroduction
   • If not in remission: Proceed to next step

3. Six-food elimination diet (milk, wheat, egg, soya, fish/shellfish, tree nuts/peanuts) for 8-12 weeks 1

   • Highest histological remission rates (approximately 79%) 1
   • Associated with lower compliance due to restrictiveness 1, 2

Important Dietary Considerations

• Support from an experienced dietitian is strongly recommended throughout elimination and reintroduction 1
• Most common food triggers identified are milk, wheat, and soy 2
• Allergy testing (skin prick, specific IgE, patch testing) is not recommended for choosing dietary restrictions 1
• Elemental diets have high efficacy but poor compliance and should be reserved for treatment-refractory cases 1

Management Algorithm

1. Initial Assessment and Treatment:

   • Confirm diagnosis with ≥15 eosinophils per high-power field on esophageal biopsy 3
   • Start with either:
     • Topical corticosteroids (preferred first-line) 1, OR
     • PPI therapy twice daily 1, OR
     • Dietary approach if patient prefers non-pharmacological treatment 1

2. Reassessment after 8-12 weeks:

   • Repeat endoscopy to assess histological response
   • If symptoms recur while on treatment, repeat endoscopy for reassessment 1

3. For patients with fibrostenotic disease:

   • Endoscopic dilation is effective and safe for improving symptoms 1
   • Best outcomes achieved when dilation is combined with anti-inflammatory therapy 1
   • Can be performed using either balloon or bougie dilators 1

4. For refractory disease:

   • Consider combination therapy (not routinely recommended but can be considered) 1
   • Patients with significant concomitant atopic disease should be jointly managed by gastroenterologist and allergist 1
   • Novel biologics (dupilumab, cendakimab, benralizumab) show promise but currently recommended only in clinical trial settings 1

Common Pitfalls to Avoid

1. Relying solely on symptoms for assessing disease activity - symptoms may not correlate with histological activity 3

2. Underestimating strictures - endoscopists often underestimate the frequency of strictures 1

3. Discontinuing treatment prematurely - high relapse rates occur after withdrawal of therapy 3

4. Using allergy testing to guide dietary elimination - this approach is less effective, especially in adults 3, 4

5. Treating with dilation alone - addresses mechanical obstruction but not underlying inflammation 3

6. Using ineffective therapies - sodium cromoglycate, montelukast, antihistamines, immunomodulators, and anti-TNF therapies are not recommended 1

By following this structured approach to EoE management, clinicians can effectively control symptoms, achieve histological remission, and prevent disease progression and complications while minimizing treatment burden on patients.