What are the treatment options for eosinophilic esophagitis?

Treatment Options for Eosinophilic Esophagitis

The first-line treatment options for eosinophilic esophagitis (EoE) are proton pump inhibitors (PPIs) or topical swallowed corticosteroids, with dietary therapy as an effective alternative approach. 1

Pharmacological Treatment Options

Proton Pump Inhibitors (PPIs)

• Dosing and duration:
  • Adults: 20-40 mg twice daily for 8-12 weeks 2, 1
  • Children: 1 mg/kg per dose, twice daily for 8-12 weeks (maximum adult dose) 1
• PPIs are effective in inducing both histological and clinical remission 2
• Assessment of response requires endoscopy with biopsy while on treatment 2
• For PPI responders (approximately 41.7% of patients), maintenance therapy should be continued at the same or reduced dose 3, 2

Topical Corticosteroids

• Highest level of evidence supports topical steroids for inducing histological and clinical remission 2
• Options include fluticasone and budesonide formulations 1
• Clinical and histological relapse is high after withdrawal, making maintenance treatment necessary 2
• Topical steroids are likely to reduce the development of strictures 2
• Potential side effect: Candida infection may occur in a small proportion of patients 1

Dietary Management

• Three main approaches:
  1. Two-food elimination diet (milk +/- wheat or egg): 43% remission rate 2
  2. Four-food elimination diet (milk, wheat, egg, soya): 60% remission rate 2
  3. Six-food elimination diet (milk, wheat, egg, soya, fish/shellfish, tree nuts/peanuts): 79% remission rate but lower compliance 2
• Support from an experienced dietitian is strongly recommended throughout elimination and reintroduction phases 2
• Food triggers can only be identified by documenting disease remission after elimination followed by recurrence on reintroduction 1
• Allergy testing is not recommended for choosing dietary restrictions 2, 1
• Elemental diets have high efficacy but low compliance rates and should be reserved for patients refractory to other treatments 2

Management of Complications

Strictures and Narrow Esophagus

• Endoscopists often underestimate the frequency of strictures 2
• Endoscopic dilation is effective and safe for improving symptoms in patients with fibrostenotic disease 2
• Clinical outcomes are better when therapeutic dilation is combined with effective anti-inflammatory therapy with topical steroids 2
• Both balloon and bougie dilators can be safely used 2

Refractory Disease

• Patients with refractory disease should be jointly managed by a gastroenterologist and specialist allergist 2
• Novel biologics (such as dupilumab) have shown promise in treatment-refractory cases 2, 4
• Not recommended treatments:
  • Immunomodulators (azathioprine, 6-mercaptopurine) 2
  • Anti-TNF and anti-integrin therapies 2
  • Sodium cromoglycate, montelukast, and antihistamines 2

Treatment Algorithm

1. Initial treatment: Start with either PPI (twice daily for 8-12 weeks) or topical corticosteroids 1
2. Assessment of response: Perform endoscopy with biopsy while on treatment (remission defined as <15 eosinophils/0.3 mm²) 1
3. For responders: Continue maintenance therapy with the effective treatment 1
4. For non-responders to PPI: Switch to topical corticosteroids or consider dietary therapy 2
5. For patients with strictures: Perform endoscopic dilation in combination with anti-inflammatory therapy 2
6. For refractory cases: Consider novel biologics and joint management with an allergist 2

Important Clinical Considerations

• EoE is the most common cause of spontaneous esophageal perforation 2
• Symptoms may not correlate with histological activity, making endoscopic assessment crucial 1
• Long-term untreated disease may progress from inflammation to esophageal strictures 2
• Maintenance therapy is necessary as spontaneous disease remission is uncommon 2

The treatment approach should be based on the patient's clinical presentation, with endoscopic assessment being essential for diagnosis and monitoring of treatment response.