What is the treatment for eosinophilic enteritis?

Treatment of Eosinophilic Enteritis

The first-line treatment for eosinophilic enteritis is oral corticosteroids for a short period, which have shown good efficacy in controlling symptoms and reducing eosinophilic infiltration. 1

First-Line Treatment Options

Corticosteroid Therapy

• Systemic corticosteroids: Oral prednisolone at 0.5-1 mg/kg/day is the most effective agent for controlling symptoms 2, 3
• Treatment duration: Typically 2-4 weeks with gradual tapering
• Response rate: Up to 80% of patients show clinical improvement
• Caution: Long-term use can lead to significant side effects including growth abnormalities, bone abnormalities, mood disturbances, and adrenal suppression 2

Dietary Approaches

• Elimination diets: Consider as an effective alternative therapy, particularly in patients with suspected food allergies 4
  • Empiric elimination diets: Remove common allergens (milk, wheat, eggs, soy, nuts, seafood)
  • Elemental diet: Amino acid-based formula that eliminates all potential food allergens
    • High efficacy but poor compliance due to palatability issues
    • May require enteral feeding via nasogastric or gastrostomy tube 4
  • Consultation with a registered dietitian is strongly encouraged to ensure proper nutrition 4

Second-Line Treatment Options

Antihistamines and Mast Cell Stabilizers

• Antihistamine drugs and sodium cromoglycate have been used with variable success 1, 3
• Less effective than corticosteroids but may be considered in mild cases or as adjunctive therapy

Leukotriene Receptor Antagonists

• Montelukast has shown favorable responses in some patients 3
• Not recommended as first-line therapy due to limited evidence 4

Treatment for Refractory Cases

Immunomodulators

• Azathioprine and 6-mercaptopurine are not recommended based on current evidence 4
• Low grade of evidence and weak recommendation 4

Biologic Therapies

• Anti-TNF therapies are not recommended for eosinophilic enteritis 4
• Novel biologics targeting IL-5 (such as benralizumab) have shown promise but await further clinical trials 4
• Anti-IL-5 antibodies demonstrated effectiveness in an adolescent with hypereosinophilic syndrome with esophageal eosinophilia 4
• Dupilumab and other biologics used in allergic conditions may be considered in refractory cases 4

Management Algorithm

1. Confirm diagnosis through endoscopy with biopsy showing eosinophilic infiltration
2. Rule out other causes of eosinophilia (parasitic infections, inflammatory bowel disease, drug reactions)
3. Initial treatment:
   • Start oral corticosteroids (prednisolone 0.5-1 mg/kg/day) for 2-4 weeks
   • OR consider dietary elimination approach if patient prefers non-pharmacological option
4. Assess response after 4-8 weeks:
   • If improved: Gradually taper corticosteroids
   • If no improvement: Consider alternative or combination therapy
5. For refractory disease:
   • Consider consultation with allergist/immunologist 4
   • Evaluate for more aggressive dietary elimination
   • Consider trial of antihistamines or leukotriene antagonists
   • In severe cases, consider novel biologics in clinical trial settings

Monitoring and Follow-up

• Regular monitoring of eosinophil counts every 1-3 months 2
• Repeat endoscopy with biopsy if symptoms recur while on treatment 4
• Watch for relapse, as approximately 50% of patients may experience a chronic relapsing course 1
• Monitor for corticosteroid side effects if long-term therapy is required

Special Considerations

• Eosinophilic enteritis is often associated with food allergies and atopic diseases (70% of cases) 3
• The disease can affect different layers of the intestinal wall (mucosal, muscular, or serosal), which influences clinical presentation and treatment response 1
• Fatal cases have been reported that were refractory to corticosteroid therapy, elemental diet, and antimicrobials 5
• Severe presentations may include anemia requiring prompt intervention 6

Remember that while eosinophilic enteritis is generally considered benign, approximately half of patients may experience unpredictable relapses and follow a chronic course requiring long-term management strategies 1.