What is the management approach for eosinophilic esophagitis?

Management Approach for Eosinophilic Esophagitis (EoE)

The management of eosinophilic esophagitis should follow a stepwise approach, with proton pump inhibitors as first-line therapy, followed by topical corticosteroids, dietary interventions, and endoscopic dilation for strictures as needed. 1

First-Line Treatment: Proton Pump Inhibitors (PPIs)

• PPIs should be initiated at twice-daily dosing for 8-12 weeks before assessing histological response 1
• PPIs are effective in inducing both histological and clinical remission in many EoE patients 1
• For patients who achieve histological response, standard PPI doses are effective for maintaining long-term remission 2
• If PPI therapy causes unwanted side effects (diarrhea, gastrointestinal infections, or magnesium deficiency), consider switching to alternative treatments such as diet or topical steroids 3

Second-Line Treatment: Topical Corticosteroids

• Topical corticosteroids are indicated when PPI therapy fails to achieve adequate response 1
• Topical steroids are preferred over oral corticosteroids due to a better safety profile 1
• Treatment with topical steroids should be continued for at least 8-12 weeks before evaluating histological response 4
• Medical treatment with topical steroids is likely to reduce the development of strictures in EoE 3
• In patients with EoE in remission after short-term use of topical glucocorticosteroids, continuation of treatment is suggested over discontinuation 3
• 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 3

Dietary Approaches

• Multiple dietary strategies may be effective in reducing esophageal eosinophil counts 3
• A step-up strategy (starting with 1- or 2-food elimination) is recommended as an initial approach to minimize dietary restriction and reduce the number of endoscopies 5, 6
• Elemental diets have the highest efficacy but lowest compliance and should be reserved for patients refractory to other treatments 2, 7
• Empiric elimination diets (2-food, 4-food, or 6-food) are more practical and have moderate evidence of effectiveness 6, 8
• A dietitian's support is crucial during the process of elimination and reintroduction of foods 4, 1
• The psychological impact of dietary therapy should be appreciated and discussed with patients with EoE and their carers 3

Management of Complications: Endoscopic Dilation

• Endoscopic dilation is effective in improving symptoms in patients with fibrostenotic disease due to EoE 3
• Dilation can be performed safely using either balloon or bougie dilators 3
• Clinical outcomes of patients with stricture are better if therapeutic dilation is combined with effective anti-inflammatory therapy with topical steroids 3
• Endoscopists can underestimate the frequency of strictures and narrow lumen esophagus in EoE 3
• In adult patients with dysphagia from a stricture associated with EoE, endoscopic dilation is suggested over no dilation 3
• Esophageal dilation does not address the esophageal inflammation associated with EoE 3

Treatment for Refractory Cases

• Patients with EoE refractory to treatment and/or with significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 3, 1
• Novel biologics (dupilumab, cendakimab, benralizumab) show promise but are currently recommended only in the context of clinical trials 3, 1
• Anti-IgE therapy is not recommended for EoE 3
• Montelukast, cromolyn sodium, immunomodulators, and anti-TNF should only be used in the context of clinical trials 3

Monitoring and Follow-up

• If symptoms recur while on treatment, repeat endoscopy for assessment and obtain further histology 1
• Endoscopy with biopsy is recommended while the patient is on treatment to evaluate the histological response, as symptoms do not always correlate with histological activity 4, 9
• In case of a perforation in EoE (which can occur spontaneously), if there is limited extravasation, the patient should be managed conservatively, with multidisciplinary input from gastroenterology, surgery, and radiology specialists 3

Treatment Algorithm

1. Initial Assessment:

   • Confirm diagnosis with endoscopy and biopsy (≥15 eosinophils per high-power field) 1
   • Assess for strictures or narrowing of esophageal lumen 3

2. First-Line Treatment:

   • Start PPI therapy (twice-daily dosing) for 8-12 weeks 1, 2
   • Evaluate response with repeat endoscopy and biopsy 1

3. If Inadequate Response to PPI:

   • Switch to topical corticosteroids for 8-12 weeks 3, 1
   • OR consider dietary elimination approach (step-up strategy starting with 1-2 food elimination) 5, 6

4. If Strictures Present or Persistent Dysphagia Despite Treatment:

   • Perform endoscopic dilation 3
   • Continue anti-inflammatory therapy with topical steroids 3

5. Maintenance Therapy:

   • For responders to PPI: Continue with standard PPI dose 2
   • For responders to topical steroids: Continue topical steroids 3
   • For responders to dietary therapy: Continue with identified elimination diet 6, 8

6. For Refractory Cases:

   • Refer for joint management by gastroenterologist and allergist 3, 1
   • Consider clinical trials of novel biologics 3, 1