What are the treatment plans for eosinophilic esophagitis?

Treatment Plans for Eosinophilic Esophagitis

First-Line Treatment Selection

Begin treatment with either topical corticosteroids or proton pump inhibitors (PPIs) as first-line therapy, with topical corticosteroids being the most effective option for confirmed EoE. 1

Diagnostic PPI Trial First

• Start with high-dose PPI therapy (omeprazole 20-40 mg twice daily) for 8-12 weeks to exclude PPI-responsive esophageal eosinophilia, which may represent GERD or a distinct phenotype rather than true EoE 1, 2
• Patients achieving complete clinical and histological remission with PPIs alone should be reclassified as having PPI-responsive esophageal eosinophilia rather than EoE 1
• PPIs achieve histological response (<15 eosinophils per high-power field) in 41.7% of patients versus 13.3% with placebo in confirmed EoE cases 1, 3
• Double-dose PPI induces remission in approximately 50% of EoE patients, with responders able to maintain long-term remission on standard doses 4

Topical Corticosteroids for Confirmed EoE

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. 1, 3

Administration Technique (Critical for Efficacy)

• Spray metered-dose inhaler in the mouth with lips sealed around the device, then avoid eating, drinking, or rinsing for 30 minutes 5
• Clinical symptoms typically improve within 7 days, with histological improvement within 4 weeks 5
• Continue therapy for 8-12 weeks before assessing histological response via endoscopy with biopsy 1, 5

Monitoring for Adverse Effects

• Candida infection may occur in a small proportion of patients and should be managed with topical antifungals while continuing topical steroids 5

Dietary Therapy

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

Step-Up Approach (Preferred)

• Begin with a two-food elimination diet (milk +/- wheat or egg) for 8-12 weeks under mandatory dietitian supervision 1
• The six-food elimination diet produces the highest histological remission rates (52% in one study) but has lower compliance and requires more endoscopies during food reintroduction 1, 6
• Endoscopic and histological assessment must be performed between 8-12 weeks after each dietary change 1

Important Caveats

• Only 36% of patients who attempt dietary elimination successfully identify food triggers 6
• At 9 months, only 55% of initial responders to elimination diet maintain sustained remission due to poor long-term compliance 6
• Discuss the psychological impact of dietary therapy with patients, including potential for anxiety and depression related to persistent symptoms and social restrictions 7, 5

Treatment Monitoring (Mandatory)

Endoscopy with biopsy while on treatment is mandatory to assess response, as symptoms do not reliably correlate with histological activity. 1, 5

• Histological remission is defined as <15 eosinophils per 0.3 mm² (high-power field) in any biopsy specimen 1
• Perform endoscopic assessment at 8-12 weeks after initiating any therapy 1
• If symptoms recur while on treatment, repeat endoscopy for assessment and obtain further histology 5

Management of Fibrostenotic Disease

Endoscopic dilation is effective for symptomatic strictures and should be combined with anti-inflammatory therapy (topical steroids) for optimal outcomes. 1, 5

• Dilation improves dysphagia in patients with established fibrosis 1
• Can be performed safely using either balloon or bougie dilators 5
• Endoscopists may underestimate the frequency of strictures and narrow lumen esophagus 5

Systemic Corticosteroids (Reserved for Urgent Cases)

Systemic corticosteroids are reserved for patients requiring urgent symptom relief: severe dysphagia, dehydration, significant weight loss, or esophageal strictures. 5

• Dosage: 1-2 mg/kg/day of prednisone (maximum 60 mg) 5
• Risk factors with long-term use include growth abnormalities, bone abnormalities, mood disturbances, and adrenal axis suppression 5

Refractory Disease

Patients with refractory disease should be jointly managed by a gastroenterologist and specialist allergist. 5

• Combining dietary elimination with pharmacological treatment can be considered for patients failing initial therapy 1
• Novel biologics (such as dupilumab) show promise for refractory cases and represent an emerging option for patients who have failed standard therapies 1, 5
• Immunomodulators, anti-TNF, and anti-integrin therapies are not recommended 5

Maintenance Therapy (Essential)

Long-term maintenance therapy is necessary given the chronic nature and high recurrence rates of EoE; patients should continue the effective therapy (PPI, topical steroid, or diet) indefinitely. 1, 5

• Clinical and histological relapse is high after withdrawal of topical steroid treatment 5
• Medical treatment with topical steroids likely reduces the development of strictures 5
• Controlled studies do not extend beyond 12 months 1

Treatment Algorithm Summary

1. Start high-dose PPI (omeprazole 40 mg twice daily) for 8-12 weeks 1, 2
2. Perform endoscopy with biopsy at 8-12 weeks 1
3. If histological remission achieved: Reclassify as PPI-responsive esophageal eosinophilia; continue PPI maintenance 1
4. If no response: Confirmed EoE—switch to topical corticosteroids (most effective) or elimination diet with dietitian support 1, 5
5. Continue chosen therapy for 8-12 weeks, then repeat endoscopy 1
6. If response achieved: Continue indefinite maintenance therapy 1, 5
7. If refractory: Consider combination therapy or biologics with specialist co-management 1, 5
8. If strictures present: Add endoscopic dilation to anti-inflammatory therapy 1, 5