Treatment of Eosinophilic Esophagitis
Topical corticosteroids are the first-line treatment for eosinophilic esophagitis, with proton pump inhibitors (PPIs) at twice-daily dosing for 8-12 weeks as an equally effective alternative, and elimination diets reserved for motivated patients with dietitian support. 1
Initial Treatment Selection
The American Gastroenterological Association endorses topical corticosteroids as first-line therapy due to high-quality evidence demonstrating superior efficacy in achieving both clinical symptom relief and histological remission (reducing esophageal eosinophil counts to <15 eosinophils per high-power field). 1
PPIs represent an equally valid first-line option and should be dosed at twice-daily frequency (e.g., omeprazole 20 mg twice daily) for a minimum of 8-12 weeks before assessing histological response. 1, 2 The anti-inflammatory effects in EoE are independent of acid suppression, and approximately 50% of patients achieve remission with this approach. 3
Dietary Therapy Approach
For patients preferring drug-free treatment or those with significant atopic comorbidities, empiric elimination diets are highly effective but require substantial commitment:
Start with a two-food elimination diet (2FED) removing dairy and wheat/gluten for 8-12 weeks, which represents the least restrictive evidence-based approach. 1, 4
Step up to four-food elimination (4FED) if 2FED fails, adding egg and legumes to the restriction list. 4, 5
Reserve six-food elimination diet (6FED) for refractory cases, removing milk, wheat, egg, soy, nuts, and fish/seafood, which achieves remission in over 70% of adults but requires the highest restriction burden. 1, 6
Mandatory dietitian involvement throughout elimination and reintroduction phases is essential to prevent nutritional deficiencies and address the psychological impact of dietary restrictions. 1, 7
Elemental diets (amino acid-based formulas) are highly effective but impractical for most patients and should be reserved only for severe refractory cases. 4, 5
Management of Fibrostenotic Disease
Endoscopic dilation is indicated for patients with esophageal strictures or persistent dysphagia despite histological remission, using either balloon or bougie dilators. 1 Combining dilation with anti-inflammatory therapy (topical steroids) produces superior clinical outcomes compared to dilation alone. 1
Monitoring and Follow-Up
Endoscopy with esophageal biopsies while on treatment is mandatory to assess therapeutic response, as symptoms correlate poorly with histological activity—patients may feel better while inflammation persists, or vice versa. 1, 3 Perform this assessment at 8-12 weeks after initiating therapy or dietary changes. 1, 5
Refractory Disease Management
For patients failing standard therapies:
Joint management with gastroenterology and allergy specialists is recommended, particularly for those with significant concomitant atopic disease. 1
Novel biologics (such as dupilumab) show promise but remain emerging therapies reserved for treatment-refractory cases. 1
Avoid immunomodulators, monoclonal antibodies for inflammatory bowel disease, sodium cromoglycate, montelukast, and antihistamines as these are not effective for EoE management (though antihistamines may help concomitant atopic conditions). 1
Common Pitfalls
Do not rely on symptoms alone to gauge treatment response—histological assessment is essential as clinical improvement may occur without mucosal healing. 1, 3
Avoid allergy testing-directed food elimination, as standard IgE testing poorly predicts EoE food triggers, especially in adults. 4, 5
Do not use standard PPI dosing (once daily)—twice-daily dosing for 8-12 weeks is required for adequate anti-inflammatory effect in EoE. 1, 3
Recognize that treatment duration matters: extending therapy to 12 weeks increases remission rates compared to shorter courses. 3