What is the treatment for eosinophilic esophagitis?

Treatment of Eosinophilic Esophagitis

Begin treatment with either topical corticosteroids or proton pump inhibitors (PPIs) as first-line therapy, followed by endoscopic assessment at 8-12 weeks to confirm histological response. 1

First-Line Treatment Options

Topical Corticosteroids (Preferred First-Line)

• Topical corticosteroids are the most effective first-line treatment, achieving histological remission in 64.9% of patients compared to 13.3% with placebo 1, 2, 3
• Administer for 8-12 weeks before assessing histological response via endoscopy with biopsy 1, 2
• Administration technique is critical for efficacy: spray the metered dose inhaler in the mouth with lips sealed around the device, then avoid eating, drinking, or rinsing for 30 minutes 4
• Clinical symptoms typically improve within 7 days, with histological improvement within 4 weeks 4
• New effervescent orodispersible tablets and viscous formulations designed to coat the esophageal mucosa provide increased effectiveness at reduced doses compared to asthma formulations 5

Proton Pump Inhibitors (Alternative First-Line)

• PPIs achieve histological response in 41.7% of patients versus 13.3% with placebo 1, 3
• Administer twice daily for at least 8-12 weeks prior to assessment of histological response 2
• The anti-inflammatory effects of PPIs in EoE are independent from gastric acid secretion inhibition 5
• PPIs should first be used diagnostically to exclude PPI-responsive esophageal eosinophilia, which may represent GERD or a distinct PPI-responsive phenotype rather than true EoE 1
• Patients achieving complete remission with PPIs alone are reclassified as having PPI-responsive esophageal eosinophilia rather than EoE 1
• For omeprazole specifically: 20 mg once daily for 4-8 weeks in adults and weight-based dosing in children (10 mg for 10-20 kg, 20 mg for >20 kg) 6
• PPIs are particularly useful when GERD coexists with EoE as a comorbid condition 1

Dietary Therapy

Empirical Elimination Diets

• Elimination diets achieve clinico-histological remission in both adults and children, with six-food elimination diet (SFED) producing the highest histological remission rates (79%) but lower compliance 1, 7
• Step-up strategies are preferred: two-food elimination diet achieves 43% remission, four-food achieves 60%, and six-food achieves 79% 7
• Two- and four-food elimination diets should be considered as initial approaches as they reduce the need for endoscopic procedures, shorten diagnostic processing time, and avoid unnecessary restrictions 5
• Mandatory dietitian involvement throughout elimination and reintroduction phases is strongly recommended to ensure nutritional adequacy and proper execution 1, 2
• The psychological impact of dietary therapy should be appreciated and discussed with patients 2, 4
• Among patients who respond to elimination diet, food triggers can be identified in approximately 87% during reintroduction 8
• Practical limitation: only 55% of patients who initially respond to elimination diet remain compliant and sustain remission at 9 months 8

Elemental Diet

• Entirely amino acid-based diet leads to histological remission in over 90% of patients but can only be performed for a limited time 7

Treatment Monitoring

Mandatory Endoscopic Assessment

• Endoscopy with biopsy while on treatment is mandatory to assess response, as symptoms do not reliably correlate with histological activity 1, 2, 4
• Perform endoscopy no sooner than 4 weeks after the last therapeutic intervention 9
• Histological remission is defined as <15 eosinophils per 0.3 mm² (high-power field) in any biopsy specimen 1
• If symptoms recur while on treatment, repeat endoscopy for assessment and obtain further histology 4

Management of Fibrostenotic Disease

• Endoscopic dilation is effective for symptomatic strictures, improving dysphagia in patients with established fibrosis 1, 2
• Can be performed using either balloon or bougie dilators 2, 4
• Clinical outcomes are better when therapeutic dilation is combined with effective anti-inflammatory therapy with topical steroids 2, 4
• Patients with EoE are at increased risk for esophageal tears and perforation during endoscopy 9
• Endoscopists may underestimate the frequency of strictures and narrow lumen esophagus 4

Systemic Corticosteroids (Reserved for Urgent Cases)

• Reserved for patients requiring urgent symptom relief: severe dysphagia, dehydration, significant weight loss, or esophageal strictures 4
• Dosage: 1-2 mg/kg/day of prednisone (maximum 60 mg) 4
• Risk factors with long-term use include growth abnormalities, bone abnormalities, mood disturbances, and adrenal axis suppression 4

Maintenance Therapy

• Long-term maintenance therapy is necessary given the chronic nature and high recurrence rates of EoE 1, 4
• Clinical and histological relapse is high after withdrawal of topical steroid treatment 4
• Patients should continue the effective therapy (PPI, topical steroid, or diet) indefinitely 1
• Controlled studies do not extend beyond 12 months 1, 6
• Medical treatment with topical steroids likely reduces the development of strictures 4

Refractory Disease

• Combining dietary elimination with pharmacological treatment can be considered for patients failing initial therapy, though this is not routinely recommended 1
• Patients with refractory disease and/or significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 2, 4
• Novel biologics (such as dupilumab) show promise for refractory cases, achieving histological remission in 60-86% of patients who have failed standard therapies 1, 7
• Immunomodulators, anti-TNF, and anti-integrin therapies are not recommended 2, 4
• Sodium cromoglycate, montelukast, and antihistamines are not recommended but may have a role in concomitant atopic disease 2

Common Pitfalls and Caveats

• Do not rely on symptoms alone to guide treatment decisions: symptoms may not correlate with histological activity 1, 2
• Candida infection may occur in a small proportion of patients treated with topical corticosteroids and should be managed with topical antifungals while continuing topical steroids 4
• If a patient does not respond to 8 weeks of treatment, an additional 4 weeks of treatment may be given 6
• Among patients who fail dual therapy with omeprazole and clarithromycin, clarithromycin resistance is more likely compared with triple therapy; susceptibility testing should be done 6
• Inflammatory rather than stricturing EoE phenotype and treatment duration up to 12 weeks increase chances of achieving remission 5