What are the management options for eosinophilic esophagitis?

Management of Eosinophilic Esophagitis (EoE)

Proton pump inhibitors (PPIs) and topical corticosteroids are the first-line treatments for eosinophilic esophagitis, with dietary therapy and endoscopic dilation serving as important adjunctive approaches based on patient presentation and response to initial therapy. 1, 2

First-Line Treatment Options

Proton Pump Inhibitors (PPIs)

• PPIs are recommended as an initial treatment approach for EoE patients 1
• Start with twice-daily dosing for 8-12 weeks before assessing histological response 1
• PPIs have demonstrated effectiveness in maintaining remission in the majority of adult patients who achieve initial response 3, 1

Topical Corticosteroids

• Highly effective for inducing both histological and clinical remission in EoE 2
• Preferred over oral corticosteroids due to better safety profile 1
• Typical regimens include:
  • Fluticasone propionate 440-880 μg twice daily 4
  • Budesonide 2 mg/day in divided doses 4
• Administration technique is critical: patients should swallow the medication and avoid eating or drinking for 45 minutes afterward to maximize esophageal coating 4
• Most common side effect is oral/esophageal candidiasis 4

Maintenance Therapy

• Maintenance therapy is necessary as EoE is a chronic disease with high relapse rates after treatment discontinuation 1, 5
• Options for maintenance include:
  • Continued PPI therapy (possibly at reduced dose) 3
  • Topical corticosteroids (possibly at lower maintenance dose) 3, 1
  • Continued dietary elimination in those who responded to this approach 3
• Limited evidence exists for optimal maintenance dosing, but continued therapy is important to prevent disease progression to fibrostenotic disease 3

Dietary Approaches

• Elimination diets are effective for inducing remission and can be considered as first-line therapy or after inadequate response to medication 1, 2
• Options include:
  • Elemental diet (highest efficacy but lowest compliance) - reserved for refractory cases 1
  • Six-food elimination diet (removes common allergens) with moderate effectiveness 1, 2
• Support from an experienced dietitian is strongly recommended throughout both elimination and reintroduction phases 2

Management of Complications

• Endoscopic dilation is effective and safe for improving symptoms in patients with strictures 1, 2
• Can be performed using either balloon or bougie dilators 1, 2
• Best outcomes are achieved when dilation is combined with effective anti-inflammatory therapy using topical steroids 2
• Pooled perforation rate is approximately 0.4%, with most complications occurring before 2009 3

Treatment for Refractory Cases

• Novel biologics show promise but are currently recommended only for patients with coexisting allergic diseases or who have failed standard therapies 1, 2
• Options include:
  • Dupilumab, cendakimab, benralizumab 1
  • Anti-IL-5 pathway agents like mepolizumab 1
  • Anti-IL-13 monoclonal antibody cendakimab 1

Monitoring and Follow-up

• Repeat endoscopy with biopsy while on treatment is recommended to assess response, as symptoms may not always correlate with histological activity 2
• If symptoms recur while on treatment, repeat endoscopy for assessment 1
• Patients with refractory EoE and/or significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 1, 2

Treatment Algorithm

1. Initial therapy: Start with either PPI (twice daily) or topical corticosteroids for 8-12 weeks 1, 2
2. Assess response: Perform follow-up endoscopy with biopsy to evaluate histological response 2
3. If responsive: Continue maintenance therapy with the effective agent, possibly at reduced dose 3, 1
4. If non-responsive to initial therapy:
   • If started with PPI, switch to topical corticosteroids 1, 2
   • Consider dietary elimination approach 1
   • Evaluate for strictures that may require dilation 3, 1
5. For refractory disease: Consider referral to specialized center for advanced therapies including biologics 1

Common Pitfalls to Avoid

• Relying solely on symptom improvement without histological confirmation of response 2
• Discontinuing therapy after initial response without maintenance plan 5
• Failing to provide proper instruction on topical steroid administration technique 4
• Underestimating the frequency of strictures in EoE patients 1
• Not considering multidisciplinary management with allergists for patients with concomitant atopic conditions 1, 2