What are the treatment options for Eosinophilic Gastro Intestinal Disorders (EGID)?

Treatment Options for Eosinophilic Gastrointestinal Disorders (EGID)

The primary treatment options for Eosinophilic Gastrointestinal Disorders include pharmacological therapy with proton pump inhibitors and topical glucocorticosteroids, as well as dietary interventions ranging from targeted elimination diets to elemental formulas, with the choice depending on disease severity and patient factors.

Pharmacological Treatment Options

First-Line Pharmacological Therapy

• Proton Pump Inhibitors (PPIs)
  • Recommended as initial therapy for symptomatic esophageal eosinophilia 1
  • Should be tried before moving to more intensive treatments

Corticosteroid Therapy

• Topical Glucocorticosteroids

  • Strongly recommended over no treatment 1
  • More favorable side effect profile compared to oral steroids
  • Suggested over oral glucocorticosteroids 1
  • Can be used as maintenance therapy after achieving remission 1

• Oral Glucocorticosteroids

  • Reserved for severe cases or when rapid improvement is needed
  • Higher risk of adverse effects compared to topical steroids

Dietary Treatment Options

Dietary Therapy Algorithm

1. Two-Food Elimination Diet (TFED)

   • Start with eliminating milk +/- wheat or egg for 8-12 weeks 1
   • Repeat endoscopy to assess response
   • If in remission: reintroduce one food at a time (8-12 weeks per food) with endoscopy after each reintroduction

2. Four-Food Elimination Diet (FFED)

   • If TFED fails, progress to eliminating milk, wheat, egg, and soy for 8-12 weeks 1
   • Repeat endoscopy to assess response
   • If in remission: follow reintroduction protocol as above

3. Six-Food Elimination Diet (SFED)

   • If FFED fails, eliminate milk, wheat, egg, soy, fish/shellfish, and tree nuts/peanuts for 8-12 weeks 1
   • Approximately 74% of patients show significant clinical and histological improvement 1
   • Repeat endoscopy to assess response
   • If in remission: follow reintroduction protocol as above

4. Elemental Diet

   • Gold standard for determining if food antigens are responsible for EGID 1
   • Extremely effective (92-98% response rate in children) 1
   • Symptoms resolve within 7-10 days with histological resolution within 4-5 weeks 1
   • Major limitations: poor palatability often requiring tube feeding, high cost, significant lifestyle disruption 1

Important Considerations for Dietary Therapy

• All patients on elimination diets should be managed by a multidisciplinary team including a specialist dietitian 1
• Consultation with a registered dietitian is strongly encouraged to ensure proper caloric and nutrient intake 1
• Allergy testing (skin prick, specific IgE, patch testing) is not recommended for guiding dietary elimination 1
• Consider patient lifestyle, family resources, and ability to adhere to dietary restrictions 1

Combination Therapy

• Combining elimination diets with pharmacological treatment is not routinely recommended 1
• Should be reserved for patients who fail monotherapy 1
• In pediatric studies, combination therapy showed higher histological remission rates (80%) compared to swallowed steroids (50%) or allergy-directed diets (60%) alone 1

Emerging Therapies

• Biologic agents targeting specific inflammatory pathways (e.g., anti-IL-5) show promise 1
• Not yet recommended for routine use outside of clinical trials 1

Monitoring and Assessment

• Histological assessment is the best criterion for treatment response 1
• Should be performed 8-12 weeks after initiating treatment 1
• Target: <15 eosinophils/mm³ in esophageal tissue 1

Treatment Selection Considerations

• For most patients, pharmacotherapy (particularly topical steroids) is easier to implement than dietary restriction 1
• Dietary therapy is the only approach targeting the potential cause of the disease 2
• Patient's age, nutritional status, lifestyle, social support, and willingness to undergo repeated endoscopies influence treatment selection 2

Common Pitfalls and Caveats

1. Relying solely on symptom improvement without histological assessment may lead to ongoing inflammation
2. Using allergy testing alone to guide elimination diets has poor predictive value 1
3. Failing to provide adequate nutritional support during elimination diets
4. Not considering the significant lifestyle impact of strict dietary interventions
5. Discontinuing treatment prematurely before adequate assessment of response

Remember that treatment goals include not only symptom improvement but also histological resolution of eosinophilia to prevent potential long-term complications of chronic inflammation.