From the Guidelines
Acute management of difficulty swallowing (dysphagia) in eosinophilic esophagitis (EoE) should begin with proton pump inhibitors (PPIs) such as omeprazole 20-40mg twice daily or esomeprazole 40mg once daily for 8-12 weeks, as well as topical steroids, either fluticasone 440-880mcg twice daily or budesonide oral suspension 1mg twice daily for 8-12 weeks, according to the most recent guidelines 1.
Key Recommendations
- For patients with severe symptoms, topical steroids are recommended as first-line treatment, in addition to PPIs, to reduce eosinophilic inflammation in the esophagus 1.
- During acute episodes, a soft or liquid diet can help minimize food impactions while medications take effect, and patients should be advised to eat slowly, chew thoroughly, and stay upright for 30 minutes after meals to reduce the risk of food becoming lodged in the esophagus.
- For immediate relief of food impactions, patients should go to the emergency department for possible endoscopic removal.
- Dietary modifications, particularly elimination diets removing common trigger foods (dairy, wheat, eggs, soy, nuts, fish/shellfish), can be effective but should be implemented under professional guidance 1.
Rationale
The use of PPIs and topical steroids is supported by the most recent guidelines, which suggest that these treatments can effectively reduce symptoms and eosinophilic inflammation in the esophagus 1. The guidelines also recommend dietary modifications, such as elimination diets, as a potential treatment option for patients with EoE 1. Esophageal dilation may be considered in patients with dysphagia from a stricture associated with EoE, but it does not address the underlying esophageal inflammation and should be used in conjunction with other treatments 1.
Additional Considerations
- Patients with EoE should be closely monitored for the development of clinical symptoms and esophageal morphologic abnormalities, such as rings, strictures, or narrowing 1.
- The decision to advance treatment should be based on the degree of symptoms, the age of the patient, and the presence of esophageal morphologic abnormalities, as well as the patient's values and preferences 1.
From the Research
Management of Difficulty Swallowing with EoE Acutely
- The management of eosinophilic esophagitis (EoE) involves a multidisciplinary approach, including dietary modifications, medications, and esophageal dilation 2, 3, 4, 5.
- Dietary modifications, such as elimination diets, can be effective in inducing remission in EoE patients 2, 3, 4, 5.
- Topical corticosteroids, such as fluticasone and budesonide, are commonly used to treat EoE and have been shown to be effective in reducing eosinophilic inflammation 2, 6.
- Proton pump inhibitors (PPIs) may also be used to treat EoE, particularly in patients with PPI-responsive esophageal eosinophilia (PPI-REE) 2, 5.
- Esophageal dilation may be necessary for patients with reduced esophageal caliber or persistent dysphagia despite histological remission 2, 4.
Treatment Options
- Swallowed topical corticosteroids (STCs) are recommended as initial options to induce and maintain long-term disease remission 2.
- Empirical elimination diets, such as two- and four-food elimination diets, can be effective in inducing EoE remission and allow for identification of specific food triggers 2, 3.
- PPIs are commonly prescribed as first-line therapy for EoE due to their accessibility, low cost, and safety profile 2.
- Dupilumab, a humanized monoclonal antibody, has shown promising results in clinical trials and was approved by the Food and Drug Administration in 2022 for use in EoE 3.
Considerations
- Symptom alleviation is not the sole end point of treatment in EoE, as persistent inflammation can lead to esophageal fibrosis and stricture formation over time 3.
- Maintenance therapy is necessary in patients with EoE after initial remission is achieved, as the disease is chronic and prone to relapse 2, 3, 6.