What is the management approach for Eosinophilic (EOS) esophagitis?

Management of Eosinophilic Esophagitis

For initial treatment of eosinophilic esophagitis, use topical corticosteroids as first-line therapy, with proton pump inhibitors (PPIs) or empiric dietary elimination as alternative options depending on patient preference and clinical context. 1

Initial Treatment Options

Topical Corticosteroids (First-Line)

• Topical glucocorticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over 4-12 weeks with moderate certainty of evidence. 1
• Newer formulations (effervescent orodispersible tablets and viscous preparations) designed to coat the esophageal mucosa provide increased effectiveness at reduced doses compared to asthma formulations. 2
• Systemic side effects have not been documented during long-term treatment, though monitoring of bone mineral density and adrenal suppression is recommended in children and adolescents. 1
• Candida infection may occur in a small proportion of patients and should be managed with topical antifungals while continuing topical steroids. 1

Proton Pump Inhibitors (Alternative First-Line)

• PPIs are the most commonly prescribed first-line therapy due to accessibility, low cost, and safety profile, though they only induce remission in approximately 50% of patients at double doses. 2
• The anti-inflammatory effects are independent of gastric acid secretion inhibition. 2
• Evidence quality is very low for PPIs in patients with esophageal eosinophilia. 1
• If PPIs cause unwanted side effects (diarrhea, gastrointestinal infections, or magnesium deficiency), switch to alternative treatments such as diet or topical steroids. 1

Dietary Therapy (Alternative First-Line)

Step-up dietary approaches starting with 2-food elimination diets are preferred over restrictive 6-food elimination diets to reduce endoscopic procedures, shorten diagnostic time, and avoid unnecessary restrictions. 2, 3, 4

Dietary Options by Evidence Quality:

• Elemental diets: Moderate certainty evidence, highly effective but impractical in most patients 1, 2
• Empiric 6-food elimination diet: Low certainty evidence, 68% histologic response rate 1
• Empiric 2- and 4-food elimination diets: Low certainty evidence, more practical step-up approach 1
• Allergy testing-directed elimination: Very low certainty evidence with higher failure rates compared to empiric elimination 1

Critical caveat: Dietary elimination should only be conducted under supervision of an experienced dietitian due to risk of nutritional deficiencies and potential development of de novo IgE-mediated food allergy upon reintroduction. 1, 5

Maintenance Therapy

For patients achieving remission with topical corticosteroids, continue maintenance therapy rather than discontinuation to prevent recurrent dysphagia, food impaction, and esophageal stricture formation. 1

• Evidence for maintenance topical corticosteroids is very low certainty, but the recommendation favors continuation. 1
• Medical treatment with topical steroids likely reduces stricture development (moderate evidence, strong recommendation). 1
• Most PPI responders effectively maintain long-term remission with standard doses. 2

Management of Fibrostenotic Disease

In adult patients with dysphagia from EoE-associated strictures, perform endoscopic dilation in addition to anti-inflammatory therapy. 1

• Endoscopic dilation is safe and effective for improving symptoms in fibrostenotic disease (high certainty evidence for safety, moderate for efficacy). 1
• Both balloon and bougie dilators can be used safely. 1
• Critical principle: Dilation does not address esophageal inflammation and must be combined with effective anti-inflammatory therapy (topical steroids preferred) for optimal outcomes. 1
• Endoscopists often underestimate the frequency of strictures and narrow lumen esophagus in EoE (moderate evidence). 1

Refractory Disease

Patients with EoE refractory to treatment and/or significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist. 1

Therapies NOT Recommended for Routine Use

The following should only be used in clinical trial contexts due to insufficient evidence:

• Anti-IL-5 therapy (knowledge gap) 1
• Anti-IL-13 or anti-IL-4 receptor α therapy (knowledge gap) 1
• Anti-IgE therapy (conditional recommendation against, very low quality) 1
• Montelukast, cromolyn sodium, immunomodulators, and anti-TNF therapy (knowledge gap) 1

Monitoring and Follow-up

• Treatment duration should be at least 8-12 weeks before evaluating histological response. 5
• Endoscopy with biopsy is required while on treatment to evaluate histological response, as symptoms do not always correlate with histological activity. 5
• Inflammatory phenotype (rather than stricturing) and treatment duration up to 12 weeks increase chances of achieving remission. 2

Psychosocial Considerations

The psychological impact of dietary therapy should be discussed with patients, including anxiety and depression related to persistent symptoms and social restrictions, which are alleviated by effective therapy. 1