What is the treatment for esophageal eosinophilia?

Treatment of Esophageal Eosinophilia

Topical glucocorticosteroids are the most effective first-line treatment for esophageal eosinophilia, with proton pump inhibitors and dietary elimination therapy serving as alternative first-line options based on patient factors and preferences. 1, 2

First-Line Treatment Options

Proton Pump Inhibitors (PPIs)

• Dosing:
  • Adults: 20-40 mg twice daily for 8-12 weeks
  • Children: 1 mg/kg per dose, twice daily for 8-12 weeks (maximum adult dose)
• Efficacy: Approximately 41.7% of patients achieve histologic remission with PPIs 2, 3
• Maintenance: Responders should continue at the same or reduced dose 2, 4
• Step-down approach:
  • 81% of PPI-responsive patients maintain remission when reduced to once-daily dosing
  • 83% of these patients maintain remission when further reduced to 20 mg once daily 4

Topical Swallowed Corticosteroids

• Options:
  • Fluticasone (sprayed and swallowed)
  • Budesonide (oral viscous suspension)
• Efficacy: 64.9% histologic remission rate compared to 13.3% with placebo 3
• Administration: Patients should not eat or drink for 30-60 minutes after administration
• Side effects: Esophageal candidiasis (monitor for white plaques during follow-up endoscopy) 1
• Caution: Very low certainty about effects of maintenance therapy due to limited long-term studies 1

Dietary Therapy

• Approaches:
  • Elemental diet: Highest efficacy (>90%) but poor compliance; reserved for refractory cases 2, 5
  • Six-food elimination diet: 79% remission rate (eliminates milk, wheat, egg, soy, fish/shellfish, nuts) 2
  • Four-food elimination diet: 60% remission rate (eliminates milk, wheat, egg, soy) 2
  • Two-food elimination diet: 43% remission rate (eliminates milk +/- wheat or egg) 2
• Implementation: Requires support from an experienced dietitian 2
• Food reintroduction: Necessary to identify specific triggers; requires endoscopy with biopsy after each food reintroduction 2, 6
• Long-term compliance: Only about 55% of initial responders maintain compliance and remission at 9 months 6

Treatment Algorithm

1. Initial assessment: Confirm diagnosis with endoscopy showing ≥15 eosinophils per high-power field
2. First-line therapy options:
   • Topical corticosteroids (preferred based on highest efficacy)
   • PPI trial (especially if GERD symptoms are prominent)
   • Dietary elimination (especially in patients with known food allergies or children)
3. Follow-up: Endoscopy with biopsy after 8-12 weeks of treatment to assess histologic response
4. For responders:
   • Maintain therapy with the lowest effective dose
   • Consider step-down approach for PPIs
   • For dietary therapy, begin systematic food reintroduction
5. For non-responders:
   • Switch to an alternative first-line therapy
   • Consider combination therapy (e.g., PPI plus topical steroids)
   • Consider endoscopic dilation if fibrostenotic disease is present

Management of Refractory Disease

• Combination therapy: Consider PPI plus topical steroids or dietary therapy
• Endoscopic dilation: For patients with strictures or narrowing causing dysphagia 2
• Specialist referral: Patients with refractory disease should be co-managed by gastroenterology and allergy specialists 2
• Novel therapies: Biologics such as dupilumab may be considered in refractory cases 2

Monitoring and Follow-up

• Endoscopic assessment: Required to confirm histologic remission (<15 eosinophils/hpf) 1, 2
• Symptom monitoring: Symptoms may not correlate with histologic activity, so endoscopic assessment is crucial 2
• Long-term follow-up: Necessary as spontaneous remission is uncommon 2

Important Considerations

• Disease progression: Untreated disease may progress from inflammation to fibrostenotic disease with stricture formation 2
• Complications: Esophageal eosinophilia is the most common cause of spontaneous esophageal perforation 2
• Maintenance therapy: Required for most patients as disease recurrence is common after treatment discontinuation 1, 2
• GERD overlap: Some patients may have both GERD and esophageal eosinophilia and require treatment for both conditions 1

Treatment Pitfalls to Avoid

• Relying on symptoms alone: Symptoms may improve despite persistent inflammation
• Using allergy testing to guide dietary elimination: Not recommended as it poorly predicts food triggers 2
• Discontinuing therapy prematurely: Maintenance therapy is typically required
• Overlooking strictures: Endoscopists often underestimate the frequency of strictures in these patients 2
• Delaying treatment: Chronic inflammation may lead to esophageal remodeling and stricture formation