What is the treatment for eosinophilic esophagitis?

Treatment of Eosinophilic Esophagitis

The treatment of eosinophilic esophagitis should begin with either topical corticosteroids or proton pump inhibitors (PPIs) as first-line therapy, with the choice guided by patient preference and clinical context, followed by endoscopic assessment at 8-12 weeks to confirm histological response. 1, 2

Initial Diagnostic Consideration

Before initiating treatment, PPIs should be used diagnostically to exclude PPI-responsive esophageal eosinophilia, which may represent GERD or a distinct PPI-responsive phenotype rather than true EoE. 1 Administer PPIs at 20-40 mg twice daily in adults or 1 mg/kg twice daily in children for 8-12 weeks. 1 Patients who achieve complete clinical and histological remission with PPIs alone are reclassified as having PPI-responsive esophageal eosinophilia rather than EoE. 1

First-Line Treatment Options

Topical Corticosteroids (Preferred First-Line)

Topical corticosteroids are the most effective first-line treatment for confirmed EoE, achieving histological remission in 64.9% of patients compared to 13.3% with placebo. 2, 3 These agents directly target the inflammatory cascade and have strong evidence supporting their use. 1, 2

• Continue topical steroid therapy for 8-12 weeks before assessing histological response via endoscopy with biopsy. 1
• Common formulations include fluticasone and budesonide administered as swallowed preparations. 3, 4
• Budesonide demonstrates very high short-term efficacy with 92% response rates in clinical studies. 5

Proton Pump Inhibitors (Alternative First-Line)

PPIs are effective as primary therapy in true EoE, achieving histological response in 41.7% of patients versus 13.3% with placebo. 3 They work through acid suppression and potentially through direct anti-inflammatory mechanisms. 1

• Administer PPIs at 20-40 mg twice daily for adults for at least 8-12 weeks before histological reassessment. 1
• PPIs are particularly useful when GERD coexists with EoE as a comorbid condition. 1
• In responders, PPIs appear effective for maintaining remission long-term. 1

Dietary Therapy

Elimination diets achieve clinico-histological remission in both adults and children, though they require significant patient commitment and dietitian support. 1, 2

Dietary Approach Algorithm

• Six-food elimination diet (SFED) produces the highest histological remission rates but has lower compliance and requires more endoscopies during food reintroduction. 1
• Two-food or four-food elimination diets offer a balance between efficacy and practicality, with reasonable remission rates and better adherence. 1
• Mandatory dietitian involvement throughout elimination and reintroduction phases is strongly recommended to ensure nutritional adequacy and proper execution. 1, 2

Critical caveat: Allergy testing (skin prick tests, specific IgE, patch testing) should NOT be used to guide dietary elimination choices, as these tests do not reliably predict food triggers in EoE. 1 Food triggers can only be definitively identified through systematic elimination followed by controlled reintroduction with endoscopic confirmation. 1

• In clinical practice, only 36% of patients who start elimination diets successfully identify food triggers, and only 55% maintain remission at 9 months due to poor long-term adherence. 5
• Elemental diets (amino acid formulas) have high efficacy but very low compliance and should be reserved for refractory cases. 1

Treatment Monitoring

Endoscopy with biopsy while on treatment is mandatory to assess response, as symptoms do not reliably correlate with histological activity. 1, 2 This is a critical pitfall—patients may feel better symptomatically while ongoing inflammation progresses to fibrosis.

• Histological remission is defined as <15 eosinophils per 0.3 mm² (high-power field) in any biopsy specimen. 1
• Obtain at least 6 biopsies from different esophageal sites for accurate assessment. 1
• Reassess at 8-12 weeks after treatment initiation, regardless of symptom improvement. 1, 2

Management of Fibrostenotic Disease

Endoscopic dilation is effective for symptomatic strictures, improving dysphagia in patients with established fibrosis. 2 However, dilation should be combined with anti-inflammatory therapy (topical steroids) for optimal outcomes, as dilation alone does not address underlying inflammation. 2

Refractory Disease

For patients failing initial therapy:

• Combining dietary elimination with pharmacological treatment can be considered, though this is not routinely recommended. 1
• Novel biologics (such as dupilumab) show promise for refractory cases and represent an emerging option for patients who have failed standard therapies. 2, 4
• Joint management with a gastroenterologist and allergist is recommended for refractory cases or those with significant atopic comorbidities. 2

Maintenance Therapy

Long-term maintenance therapy is necessary given the chronic nature and high recurrence rates of EoE. 4 Once remission is achieved:

• Continue the effective therapy (PPI, topical steroid, or diet) indefinitely. 1, 2
• Controlled studies support maintenance therapy for up to 12 months, though many patients require lifelong treatment. 1
• Periodic endoscopic surveillance may be needed to confirm sustained histological remission. 1

Treatments NOT Recommended

Immunomodulators, monoclonal antibodies (other than dupilumab), sodium cromoglycate, montelukast, and antihistamines are not recommended for routine EoE management. 2 These agents lack sufficient evidence for efficacy in EoE, though they may have roles in managing concomitant atopic diseases. 2