What is the treatment for eosinophilic esophagitis?

Treatment for Eosinophilic Esophagitis

Topical corticosteroids are the first-line treatment for eosinophilic esophagitis (EoE) due to their high efficacy in achieving both clinical and histological remission. Treatment selection should follow a stepwise approach based on disease severity, patient preference, and response to therapy.

First-Line Treatment Options

Topical Corticosteroids

• Topical steroids are highly effective for inducing histological and clinical remission in EoE 1
• High-quality evidence supports their effectiveness with a strong recommendation level 1
• Clinical and histological relapse is high after withdrawal, so maintenance treatment should be recommended following clinical review 1
• Topical steroids likely reduce the development of strictures in EoE 1

Proton Pump Inhibitors (PPIs)

• PPIs are effective in inducing histological and clinical remission in patients with EoE 1
• Should be given twice daily for at least 8–12 weeks prior to assessment of histological response 1
• In patients who achieve histological response, PPIs appear effective in maintaining remission 1
• If PPIs cause unwanted side effects (diarrhea, GI infections, magnesium deficiency), consider switching to alternative treatments such as diet or topical steroids 1
• For treatment of EoE, omeprazole is dosed at 20 mg once daily for 4-8 weeks in adults and weight-based dosing in children 2

Dietary Therapy Options

Elimination Diets

• Elimination diets are effective in achieving clinico-histological remission in both adults and pediatric patients 1
• A six-food elimination diet results in higher histological remission rates than two or four food elimination diets, but is associated with lower compliance and increased number of endoscopies 1
• Support from an experienced dietitian throughout both the elimination and reintroduction process is strongly recommended 1
• The psychological impact of dietary therapy should be appreciated and discussed with patients 1

Important Considerations for Dietary Therapy

• Allergy testing to foods (e.g., skin prick, specific IgE, and patch testing) is not recommended for choosing the type of dietary restriction therapy 1
• Exclusive elemental diets have limited role in EoE, with high efficacy but low compliance rates and should be reserved for patients refractory to other treatments 1
• Combining elimination diets with pharmacological treatment is not routinely recommended but can be considered in cases of drug treatment failure 1

Management of Fibrostenotic Disease

Endoscopic Dilation

• Endoscopic dilation is effective in improving symptoms in patients with fibrostenotic disease due to EoE 1
• Safe in patients with EoE and can be performed using either balloon or bougie dilators 1
• Clinical outcomes of patients with stricture are better if therapeutic dilation is combined with effective anti-inflammatory therapy with topical steroids 1
• Endoscopists can underestimate the frequency of strictures and narrow lumen esophagus in EoE 1

Treatment Monitoring and Follow-up

• After initiation of therapy (dietary or pharmacological), endoscopy with biopsy while on treatment is recommended to assess response, as symptoms may not always correlate with histological activity 1
• If symptoms recur while on treatment, repeating an endoscopy for assessment and to obtain further histology is recommended 1
• Patients with EoE refractory to treatment and/or with significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 1

Treatments Not Recommended

• Immunomodulators (e.g., azathioprine, 6-mercaptopurine) are not recommended in the management of EoE 1
• Monoclonal antibody therapies typically used for inflammatory bowel disease (anti-TNF, anti-integrin) are not recommended 1
• Sodium cromoglycate, montelukast, and antihistamines are not recommended but may have a role in concomitant atopic disease 1

Emerging Therapies

• Novel biologics used in other allergic conditions (such as dupilumab, cendakimab, and benralizumab) have shown promise in the treatment of EoE but are still considered emerging therapies 1, 3
• These should be considered for patients with refractory disease who have failed standard therapies 3

Treatment Algorithm

1. Initial therapy: Start with either topical corticosteroids or PPI therapy for 8-12 weeks 1
2. Assess response: Perform endoscopy with biopsy to evaluate histological response 1
3. If responsive: Continue maintenance therapy with the effective agent 1
4. If non-responsive:
   • Consider switching to the alternative first-line therapy (PPI to topical steroids or vice versa) 1
   • Consider dietary therapy with elimination diet under dietitian supervision 1
   • Evaluate for strictures that may require dilation 1
5. For refractory disease: Consider referral to specialized centers for consideration of novel biologics or combination therapy 1, 3

Remember that EoE is a chronic disease requiring long-term management, and treatment decisions should prioritize reduction of inflammation to prevent disease progression and complications that affect quality of life 4, 5.