What is the treatment for eosinophilic enteritis?

Treatment of Eosinophilic Enteritis

Corticosteroids are the first-line treatment for eosinophilic enteritis, with systemic steroids being most effective for inducing remission, requiring treatment for at least 8-12 weeks before evaluating histological response. 1, 2

Primary Treatment Approach

Corticosteroid Therapy

• Systemic corticosteroids remain the most effective agents for controlling symptoms in eosinophilic enteritis, with documented success in the majority of patients 3, 2, 4
• Treatment duration should be at least 8-12 weeks before assessing histological response through endoscopy with biopsy 1
• Oral prednisone at 1-2 mg/kg/day (maximum 60 mg) is the typical dosing regimen 5
• Corticosteroids are efficient in inducing remission in most patients, though the disease has a relapsing nature that may require prolonged use 2, 4

Important caveat: While corticosteroids are highly effective, approximately half of patients may experience unpredictable relapses and develop a chronic course requiring ongoing management 2

Proton Pump Inhibitors (PPIs)

• PPIs may be considered as complementary therapy, with omeprazole 20 mg twice daily for 8-12 weeks being the recommended approach 1
• PPIs have shown efficacy in eosinophilic gastrointestinal disorders, though evidence specific to enteritis is limited 1
• If PPIs cause unwanted side effects (diarrhea, gastrointestinal infections, magnesium deficiency), switch to alternative treatments 6, 5

Dietary Management

Elimination Diet Strategy

• Dietary elimination should only be conducted under supervision of an experienced dietitian throughout both elimination and reintroduction phases 1, 7
• A two-food elimination diet (TFED) is the recommended initial approach, eliminating milk +/- wheat or egg for 8-12 weeks 1
• If TFED fails, step up to more restrictive diets (four-food or six-food elimination) under dietitian guidance 1
• Endoscopic and histological assessment must be performed between 8-12 weeks after each dietary change to evaluate effectiveness 1

Critical consideration: The psychological impact of dietary therapy should be discussed with patients, as anxiety and depression can result from persistent symptoms and social restrictions 6, 1, 7

Treatment Monitoring

Response Assessment

• Endoscopy with biopsy while on treatment is mandatory to assess response, as symptoms do not always correlate with histological activity 1, 7, 5
• If symptoms recur during treatment, repeat endoscopy immediately for evaluation and additional histology 1, 5
• Clinical symptoms typically improve within 7 days, with histological improvement within 4 weeks of corticosteroid therapy 5

Refractory Disease Management

Second-Line Options

• For steroid-refractory patients, vedolizumab (anti-integrin therapy) has shown promise, inducing clinical and histological improvement in 3 of 4 refractory cases in one study 3
• Joint management by a gastroenterologist and allergist specialist is recommended for refractory cases and patients with significant concomitant atopic disease 1, 7, 5
• Novel biologics (dupilumab, cendakimab, benralizumab) have shown promising results in other eosinophilic disorders, though evidence specific to eosinophilic enteritis is limited 1

Treatments NOT Recommended

• Anti-TNF and anti-integrin monoclonal antibodies are not recommended as routine treatment 1
• Immunomodulators, sodium cromoglycate, montelukast, and antihistamines are not recommended for primary management, though they may have a role in concomitant atopic disease 7, 5

Special Monitoring Considerations

• Peripheral eosinophilia is present in approximately two-thirds of patients and can be used as an adjunctive monitoring parameter 4
• The patchy nature of the disease and involvement of multiple GI segments necessitates structured biopsy sampling from multiple sites 3, 2
• Long-term corticosteroid use carries risks including growth abnormalities, bone abnormalities, mood disturbances, and adrenal axis suppression, particularly in children 5

Common pitfall: The highly variable clinical presentation and subtle endoscopic abnormalities make diagnosis challenging; maintain high clinical suspicion and obtain biopsies from multiple segments even when endoscopy appears normal 3, 2