What is the treatment for eosinophilic esophagitis?

Treatment for Eosinophilic Esophagitis

First-line treatment options for eosinophilic esophagitis (EoE) include proton pump inhibitors (PPIs), topical swallowed corticosteroids, or dietary therapy, with the choice depending on patient factors and preferences. 1

Medical Treatment Options

Proton Pump Inhibitors (PPIs)

• Adult dosing: 20-40 mg twice daily for 8-12 weeks 1
• Pediatric dosing: 1 mg/kg per dose, twice daily for 8-12 weeks (maximum adult dose) 1
• Approximately 41.7% of patients respond to PPI therapy 1, 2
• Maintenance therapy at the same or reduced dose is recommended for responders 1
• Omeprazole is a commonly used PPI with established dosing guidelines 3

Topical Corticosteroids

• Highly effective for inducing both histological and clinical remission 1
• Options include:
  • Fluticasone (swallowed, not inhaled)
  • Budesonide (formulated for esophageal delivery)
• Systematic reviews show histologic remission in 64.9% of patients compared to 13.3% with placebo 2

Dietary Therapy

• Effective alternative first-line approach with several options:
  1. Six-food elimination diet: Removes milk, wheat, egg, soya, fish/shellfish, tree nuts/peanuts (79% remission rate)
  2. Four-food elimination diet: Removes milk, wheat, egg, soya (60% remission rate)
  3. Two-food elimination diet: Removes milk +/- wheat or egg (43% remission rate)
  4. Elemental diet: High efficacy but poor compliance; reserved for refractory cases 1

Important: Support from an experienced dietitian is strongly recommended during both elimination and reintroduction phases 1

Endoscopic Treatment

• Endoscopic dilation is effective and safe for improving symptoms in patients with fibrostenotic disease 1
• Can be used with both balloon and bougie dilators
• Better clinical outcomes when combined with effective anti-inflammatory therapy 1
• Reserved for patients with symptomatic esophageal narrowing 2

Assessment of Treatment Response

• Requires endoscopy with biopsy while on treatment
• Remission is defined as <15 eosinophils/0.3 mm² 1
• Symptoms may not correlate with histological activity, making objective assessment necessary 1, 2

Management of Refractory Disease

• Patients with refractory disease should be jointly managed by a gastroenterologist and specialist allergist 1
• Consider novel biologics such as dupilumab for refractory cases 1, 4, 5
• Dupilumab was approved in Spain in April 2024 as the second drug for EoE treatment 5

Clinical Pearls and Pitfalls

Important Considerations

• EoE is a chronic condition requiring maintenance therapy as spontaneous remission is uncommon 1
• Untreated disease may progress from inflammation to esophageal strictures 1
• EoE is the most common cause of spontaneous esophageal perforation 1

Common Pitfalls

1. Relying on symptoms alone: Symptoms may not correlate with histological activity; endoscopy with biopsy is necessary to assess treatment response 1
2. Using allergy testing to guide dietary restrictions: Not recommended for choosing dietary restrictions in EoE patients 1
3. Underestimating stricture frequency: Endoscopists often underestimate the frequency of strictures in EoE patients 1
4. Discontinuing treatment prematurely: Long-term maintenance therapy is necessary as spontaneous disease remission is uncommon 1
5. Overlooking pharmacogenetic factors: Variations in CYP2C19 and STAT6 genes may affect PPI response in EoE patients 6

Treatment Algorithm

1. Initial therapy: Start with PPI (e.g., omeprazole 20-40 mg twice daily for adults)
2. Assess response after 8-12 weeks with endoscopy and biopsy
3. If responsive: Continue maintenance therapy with PPI at same or reduced dose
4. If non-responsive to PPI:
   • Switch to topical corticosteroids OR
   • Consider dietary therapy with dietitian support
5. For patients with fibrostenotic disease: Consider endoscopic dilation in addition to medical therapy
6. For refractory disease: Consider dupilumab or other biologics under specialist care

Remember that treatment goals include symptomatic, histologic, and endoscopic remission to improve quality of life and prevent disease progression.