What is the treatment for Eosinophilic Gastroenteritis?

Treatment of Eosinophilic Gastroenteritis

The first-line treatment for eosinophilic gastroenteritis (EGE) is systemic corticosteroids, which are effective in inducing remission in the majority of patients, though relapses are common and may require maintenance therapy. 1

Pharmacological Treatment Options

First-Line Therapy

• Systemic Corticosteroids
  • Most effective initial treatment for inducing remission
  • Typically prednisolone is used in most cases 1, 2
  • Dosing: Usually starts with prednisolone at moderate doses with gradual tapering
  • Response rate: Approximately 89% of patients respond clinically 2
  • Caution: 50% of patients may relapse following tapering, requiring maintenance doses 2

Second-Line Options

1. Proton Pump Inhibitors (PPIs)

   • Can be effective in some cases of EGE 3
   • Recommended dosing: Twice daily for at least 8-12 weeks 3
   • Example: Omeprazole 20mg twice daily 3, 4
   • Should be assessed for histological response while on treatment

2. Topical Corticosteroids

   • Non-enteric-coated budesonide may be used in selected cases 5
   • Advantage: Lower risk of adrenal suppression compared to systemic steroids

3. Leukotriene Receptor Antagonists

   • Montelukast has shown efficacy in some cases 5, 2
   • May be particularly useful in patients with concurrent atopic conditions

4. Mast Cell Stabilizers

   • May be considered in selected cases 6
   • Less evidence for efficacy compared to steroids

Refractory Cases

For patients who fail to respond to conventional therapy:

1. Biologic Agents

   • Vedolizumab (anti-integrin therapy) has shown promise in steroid-refractory cases 1
   • 75% of steroid-refractory patients showed clinical and histological improvement with vedolizumab 1
   • Other biologics being investigated include:
     • Anti-IL-4 and anti-IL-5 antibodies
     • Anti-TNFα agents
     • Anti-IgE antibodies 6
   • Note: Anti-TNF and anti-integrin therapies typically used for IBD are not routinely recommended for eosinophilic disorders 3

2. Novel Therapies

   • AK002 (anti-siglec antibody) has shown promise in research 6
   • Suplaplast tosilate (selective Th2 cytokine inhibitor) may help reduce eosinophilic infiltration 5

Dietary Management

• Elimination Diets

  • May be effective, especially in patients with food allergies 5
  • More established in eosinophilic esophagitis than in EGE
  • Should be managed with support from an experienced dietitian 3

• Amino Acid-Based Diets

  • Can be helpful particularly in children with food-triggered EGE 5
  • Limited role in adults due to compliance issues

• Elemental Diets

  • High efficacy but low compliance rates
  • Should be reserved for patients refractory to other treatments 3

Monitoring and Follow-up

• Endoscopic Evaluation

  • Repeat endoscopy with biopsies is recommended to assess treatment response 3
  • Should be performed while still on treatment
  • Multiple biopsies from different segments are essential due to patchy nature of disease

• Symptom Recurrence

  • If symptoms recur while on treatment, repeat endoscopy is recommended 3
  • May indicate need for treatment adjustment or maintenance therapy

Special Considerations

• Atopic Patients

  • About 39% of EGE patients have concurrent atopic conditions 2
  • May benefit from additional management of allergic conditions

• Refractory Disease

  • Patients with refractory disease should be jointly managed by gastroenterologists and allergists 3
  • Consider referral to specialized centers for advanced therapies

• Complications

  • Endoscopic dilatation may be needed for strictures
  • Surgical intervention is rarely needed and generally limited to treating obstruction or perforation 7

Common Pitfalls and Caveats

1. Diagnostic Challenges

   • EGE can mimic common GI disorders, leading to delayed diagnosis
   • Requires high index of suspicion, especially in patients with atopic history
   • Endoscopic appearance may be normal or non-specific 2

2. Treatment Monitoring

   • Clinical symptoms may not correlate with histological activity
   • Endoscopic assessment with biopsies is necessary to confirm remission

3. Steroid Dependence

   • Long-term steroid use carries significant side effects
   • Consider steroid-sparing strategies in patients requiring maintenance therapy

4. Disease Patterns

   • Natural history includes three patterns: single outbreak, recurrent course, or chronic disease 7
   • Treatment approach may need adjustment based on disease pattern

By following this structured approach to treatment, focusing on corticosteroids as first-line therapy and considering alternative options for maintenance or refractory disease, most patients with eosinophilic gastroenteritis can achieve symptomatic control and improved quality of life.