Treatment of Eosinophilic Enteritis: Anti-Allergic Approach
Sodium cromoglycate, montelukast, and antihistamines are NOT recommended for the primary treatment of eosinophilic enteritis, as they have shown no convincing clinical or histological benefit. 1
Why Anti-Allergic Agents Don't Work
The evidence against traditional anti-allergic medications is clear and consistent:
Sodium cromoglycate showed reduction in immunological response in laboratory studies but failed to demonstrate any clinical improvement in actual patients. In a study of 14 children treated for 4 weeks, there was no improvement in either symptoms or histological profiles. 1
Montelukast (leukotriene antagonist) was evaluated in a randomized, placebo-controlled trial at 20 mg/day for maintenance therapy. Only 40% of the treatment group versus 23.8% of controls achieved remission after 26 weeks, with no statistically significant difference (OR 0.48,95% CI 0.10-2.16, p=0.33). 1
Antihistamines have no demonstrated efficacy for eosinophilic gastrointestinal disorders and are not recommended for primary management. 1
What Actually Works: Recommended Treatment Algorithm
First-Line Therapy: Corticosteroids
Systemic corticosteroids remain the most effective treatment for eosinophilic enteritis, with good efficacy in the majority of patients. 2, 3
Dosing: Start with oral prednisolone 30 mg daily or dexamethasone 10 mg IV daily for acute cases, then taper by 5 mg per week over 6 weeks. 4
Duration: Treat for at least 8-12 weeks before evaluating histological response. 5
Efficacy: Corticosteroids were effective in 21/22 (95%) patients in one series, inducing both clinical and histological remission. 2
Second-Line Therapy: Proton Pump Inhibitors
- Consider PPIs as complementary therapy at omeprazole 20 mg twice daily for 8-12 weeks, particularly if there is any component of acid-related symptoms. 5
Dietary Management
Elimination diets should be conducted only under supervision of an experienced dietitian, starting with a two-food elimination diet (milk +/- wheat or egg) for 8-12 weeks if food allergy is suspected as a trigger. 5
Elemental diets have the highest efficacy but lowest compliance and should be reserved for refractory cases. 6
Novel Biologics: Limited Role
While traditional anti-allergic agents fail, newer biologic therapies show promise but are not yet standard:
Vedolizumab (anti-integrin therapy) induced clinical and histological improvement in 3/4 steroid-refractory eosinophilic gastroenteritis patients, suggesting potential benefit in refractory cases. 2
Dupilumab, cendakimab, and benralizumab show promise but are currently recommended only for patients with coexisting allergic diseases, not as primary therapy for eosinophilic enteritis alone. 1, 6
Anti-IL-5 agents (mepolizumab) reduced eosinophil counts but showed variable clinical response and are not recommended for routine use. 1
Critical Clinical Pitfalls
Do not rely on symptoms alone: Endoscopy with biopsy is essential while on treatment to evaluate histological response, as symptoms may not correlate with histological activity. 5
Expect relapses: Eosinophilic enteritis has an unpredictable natural history with frequent relapses after steroid discontinuation, requiring long-term monitoring. 3
Obtain multisite biopsies: Eosinophilic infiltration often involves multiple gastrointestinal segments, and subtle endoscopic abnormalities can be missed. 2
When to Refer
Patients refractory to corticosteroids and/or with significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist. 1, 7