What is the recommended treatment for esophagitis?

Treatment of Esophagitis

For eosinophilic esophagitis, the recommended first-line treatments are proton pump inhibitors (PPIs) twice daily for 8-12 weeks or topical steroids, with PPIs being preferred as initial therapy due to their safety profile and effectiveness. 1

Treatment Algorithm for Eosinophilic Esophagitis

First-Line Therapy

• Proton pump inhibitor therapy (e.g., omeprazole 20 mg twice daily) for 8-12 weeks 1
• Assess histological response while on treatment, as symptoms may not correlate with histological activity 1
• For patients who achieve histological response, continue PPI therapy as maintenance treatment 1

Second-Line Therapy (if PPI fails)

• Topical steroids are highly effective for inducing both histological and clinical remission 1
• Maintenance treatment with topical steroids is recommended as clinical and histological relapse is high after withdrawal 1

For Fibrostenotic Disease

• Endoscopic dilatation is effective and safe for improving symptoms in patients with strictures 1
• Combined approach of dilatation with topical steroids yields better clinical outcomes 1

Dietary Management Options

• Elimination diets are effective in achieving clinico-histological remission 1
• Six food elimination diet has higher histological remission rates than two or four food elimination diets, but with lower compliance 1
• Support from an experienced dietitian is strongly recommended when undertaking dietary therapy 1

Evidence Strength and Considerations

The recommendation for PPI therapy is supported by moderate-quality evidence with a strong recommendation level 1. A meta-analysis showed that PPI treatment is more effective than placebo, systemic steroids, and certain biological treatments, though less effective than topical budesonide preparations 1.

For topical steroids, the evidence quality is high with a strong recommendation level 1. Studies show they fail to induce histologic remission in approximately one-third of patients, compared to >85% of patients treated with placebo 1.

Important Clinical Considerations

• PPI dosing: Omeprazole 20 mg twice daily is the recommended dose for eosinophilic esophagitis 1
• Duration: Treatment should continue for at least 8-12 weeks before assessing histological response 1
• Follow-up: Repeat endoscopy with biopsy is necessary to assess treatment response while on therapy 1
• Maintenance: For patients who respond to treatment, maintenance therapy is recommended as relapse rates are high 1

Common Pitfalls to Avoid

• Relying solely on symptom improvement without histological confirmation 1
• Discontinuing treatment too early (before 8-12 weeks) 1
• Failing to consider endoscopic dilatation for patients with fibrostenotic disease 1
• Using immunomodulators (e.g., azathioprine, 6-mercaptopurine) which are not recommended 1
• Using anti-histamines, montelukast, or sodium cromoglycate which are not effective for eosinophilic esophagitis 1

For patients with refractory disease or significant concomitant atopic disease, joint management by a gastroenterologist and specialist allergist is recommended to optimize treatment 1.