What is the recommended treatment for eosinophilic esophagitis symptoms?

Treatment of Eosinophilic Esophagitis Symptoms

Topical corticosteroids are the first-line treatment for eosinophilic esophagitis symptoms, with high-quality evidence supporting their effectiveness in achieving both clinical and histological improvement. 1

First-Line Treatment Options

Topical Corticosteroids

• Fluticasone propionate (440-880 μg twice daily) or budesonide (2 mg/day in divided doses) are effective for inducing remission over 4-8 weeks 2
• Administration technique is crucial: patients should spray the metered dose inhaler in the mouth with lips sealed around the device, then not eat, drink, or rinse for 30 minutes 1
• Topical steroids lead to significant histological improvement with high certainty (63% higher than placebo) 3
• Clinical symptoms typically improve within 7 days, with histological improvement within 4 weeks 1
• Esophagus-targeted formulations (such as orodispersible budesonide tablets) have been developed with response rates up to 85% 4

Proton Pump Inhibitors (PPIs)

• PPIs are considered an effective first-line treatment option, particularly in patients with coexisting GERD 5
• Recommended dose is omeprazole 20 mg twice daily for 8-12 weeks 6
• If PPIs cause unwanted side effects (diarrhea, GI infections, magnesium deficiency), consider switching to topical steroids or dietary therapy 1

Second-Line and Adjunctive Treatments

Dietary Therapy

• Dietary elimination may be effective when food allergies are identified as triggers 6
• Should be conducted under supervision of an experienced dietitian 6
• The psychological impact of dietary therapy should be discussed with patients 1

Endoscopic Dilation

• Effective for improving symptoms in patients with fibrostenotic disease 1
• Can be performed safely using either balloon or bougie dilators 1
• Clinical outcomes are better when combined with effective anti-inflammatory therapy with topical steroids 1

Systemic Corticosteroids

• Reserved for patients requiring urgent symptom relief 1
• Indicated for severe dysphagia, dehydration, significant weight loss, or esophageal strictures 1
• Dosage: 1-2 mg/kg/day of prednisone (maximum 60 mg) 1
• Risk factors with long-term use include growth abnormalities, bone abnormalities, mood disturbances, and adrenal axis suppression 1

Maintenance Therapy

• Clinical and histological relapse is high after withdrawal of topical steroid treatment, making maintenance therapy necessary 1
• The duration of treatment should be at least 8-12 weeks before evaluating histological response 6
• Medical treatment with topical steroids likely reduces the development of strictures 1

Treatment Monitoring and Follow-up

• If symptoms recur while on treatment, endoscopy should be repeated for assessment and to obtain further histology 1
• Endoscopists should be aware they may underestimate the frequency of strictures and narrow lumen esophagus 1
• Candida infection may occur in a small proportion of patients treated with topical corticosteroids and should be managed with topical antifungals while continuing topical steroids 1

Treatment for Refractory Cases

• Patients with refractory disease and/or significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 1
• Novel biologics used in other allergic conditions (dupilumab, cendakimab, benralizumab) have shown promise in treatment-resistant cases 1
• Immunomodulators (azathioprine, 6-mercaptopurine), anti-TNF, and anti-integrin therapies are not recommended 1
• Sodium cromoglycate, montelukast, and antihistamines are not recommended but may have a role in concomitant atopic disease 1