Stepwise Treatment Approach for Eosinophilic Allergy
Proton pump inhibitors (PPIs) should be used as first-line therapy for eosinophilic esophagitis (EoE), followed by topical steroids if inadequate response, with biologics reserved for refractory cases. 1
First-Line Treatment
- Proton Pump Inhibitor (PPI) Therapy:
- Start with twice-daily PPI therapy for 8-12 weeks before assessing histological response 1
- PPIs are effective in inducing both histological and clinical remission in patients with EoE 1
- For patients who achieve histological response, PPI therapy is effective for maintaining remission 1
- The American Gastroenterological Association (AGA) suggests using PPI over no treatment (conditional recommendation) 1
Second-Line Treatment
- Topical Corticosteroids:
- Indicated when PPI therapy fails to achieve adequate response 1
- High-grade evidence supports their effectiveness for inducing histological and clinical remission 1
- Preferred over oral corticosteroids due to better safety profile 1
- Maintenance treatment should be recommended following clinical review, as relapse rates are high after withdrawal 1
- Topical steroids likely reduce the development of strictures in EoE 1
Dietary Approaches
- Elimination Diets:
- Consider after inadequate response to medication or as an alternative first-line approach 1
- Three main dietary approaches:
- Elemental Diet: Highest efficacy but lowest compliance; should be reserved for patients refractory to other treatments 1
- Empiric 6-Food Elimination Diet: Removes common allergenic foods; moderate evidence of effectiveness 1
- Allergy Testing-Based Elimination Diet: Limited accuracy but may be useful in specific cases 1
Management of Complications
- Fibrostenotic Disease:
Treatment for Refractory Cases
- Biologics:
- Novel biologics (dupilumab, cendakimab, benralizumab) show promise but are currently recommended only for patients with coexisting allergic diseases 1
- Anti-IL-5 pathway agents like mepolizumab have shown reduction in eosinophil count but limited symptom improvement 1
- Anti-IL-13 monoclonal antibody cendakimab has demonstrated significant reduction in eosinophil count and dysphagia scores in phase 2 trials 1
- Benralizumab (anti-IL-5 receptor antibody) has shown efficacy in eosinophilic asthma and may benefit EoE patients 1
Treatments Not Recommended
- Immunomodulators (azathioprine, 6-mercaptopurine) are not recommended 1
- Anti-TNF and anti-integrin therapies typically used for inflammatory bowel disease are not recommended 1
- Sodium cromoglycate, montelukast, and antihistamines are not recommended for EoE management but may have a role in concomitant atopic disease 1
Monitoring and Follow-up
- If symptoms recur while on treatment, repeat endoscopy for assessment and obtain further histology 1
- Endoscopists should be aware they may underestimate the frequency of strictures and narrow lumen esophagus in EoE 1
Multidisciplinary Management
- Patients with EoE refractory to treatment and/or with significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 1
- Joint allergy clinics with an allergist and dietician are suitable for children with EoE who have other atopic diseases 1
Common Pitfalls and Caveats
- Relapse is common after withdrawal of topical steroid treatment, necessitating maintenance therapy 1
- Spontaneous perforation of the esophagus can occur at any age and is more common in EoE than other conditions 1
- Endoscopists frequently underestimate the presence of strictures, requiring careful evaluation 1
- While allergy testing is often performed, its accuracy for identifying specific food triggers for EoE is limited 1