What is the management approach for eosinophilic esophagitis?

Management of Eosinophilic Esophagitis

Topical corticosteroids are the first-line therapy for eosinophilic esophagitis, with strong evidence supporting their use over no treatment to reduce esophageal eosinophil counts and achieve remission. 1, 2

Initial Treatment Approach

Topical Corticosteroids (Preferred First-Line)

• Topical glucocorticosteroids are strongly recommended over no treatment with moderate quality evidence for reducing esophageal eosinophil counts to <15 per high-power field over 4-12 weeks 1, 2
• Topical formulations are preferred over oral glucocorticosteroids due to better safety profile and targeted delivery 1
• New effervescent orodispersible tablets and viscous formulations designed to coat the esophageal mucosa provide increased effectiveness at reduced doses compared to asthma-designed formulations 3
• 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 2
• Candida infection may occur in a small proportion of patients and should be managed with topical antifungals while continuing topical steroids 2

Proton Pump Inhibitors (Alternative First-Line)

• PPIs may be used as initial therapy, though they induce remission in only approximately 50% of patients regardless of drug used or patient age 3
• The anti-inflammatory effects are independent of gastric acid secretion inhibition 3
• PPIs are the most commonly prescribed first-line therapy due to accessibility, low cost, and safety profile 3
• Standard dosing is omeprazole 20 mg twice daily for 8-12 weeks 4

Dietary Therapy Options

Step-Up Empiric Elimination Approach (Recommended Strategy)

• A two-food elimination diet (milk +/- wheat or egg) stepping up to more restrictive diets if needed is the most practical initial dietary approach 2, 5, 6
• This step-up strategy reduces the need for endoscopic procedures, shortens diagnostic processing time, and avoids unnecessary restrictions compared to starting with six-food elimination 2, 5
• Four-food elimination diet can be used as an intermediate step if two-food elimination fails 2, 5
• Six-food elimination diet (avoiding milk, wheat, egg, soy, peanuts/tree nuts, and fish/shellfish) has low certainty evidence with 68% histologic response rate but is more restrictive 1, 2

Other Dietary Approaches

• Elemental diets have moderate certainty evidence and are highly effective but impractical in most patients due to adherence challenges and prolonged reintroduction process 1, 2
• Allergy testing-directed elimination has very low certainty evidence with higher failure rates compared to empiric elimination and should not be routinely used 1, 2

Critical Dietary Therapy Considerations

• Dietary elimination must 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 2
• The psychological impact including anxiety and depression related to persistent symptoms and social restrictions should be discussed with patients 2
• Treatment duration must be 8-12 weeks before evaluating histological response 2, 4

Maintenance Therapy

• For patients achieving remission with topical corticosteroids, continuation of maintenance therapy is recommended rather than discontinuation to prevent recurrent dysphagia, food impaction, and esophageal stricture formation 1, 2
• Medical treatment with topical steroids likely reduces stricture development with moderate evidence 2
• Most PPI responders effectively maintain long-term remission with standard PPI doses 3
• Inflammatory rather than stricturing EoE phenotype and treatment duration up to 12 weeks increase chances of achieving remission 3

Management of Fibrostenotic Disease

• In adult patients with dysphagia from EoE-associated strictures, endoscopic dilation in addition to anti-inflammatory therapy is recommended 2
• Endoscopic dilation is safe and effective for improving symptoms with high certainty evidence for safety and moderate for efficacy 2
• Dilation does not address esophageal inflammation and must be combined with effective anti-inflammatory therapy for optimal outcomes 2
• Dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission 3

Monitoring and Follow-Up

• Endoscopy with biopsy is required while on treatment to evaluate histological response, as symptoms do not always correlate with histological activity 2, 4
• Treatment duration should be at least 8-12 weeks before evaluating histological response 2, 6
• Endoscopic and histological assessment should be performed between 8-12 weeks after each dietary change 4

Refractory Disease

• Patients with EoE refractory to treatment and/or significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 2

Common Pitfalls to Avoid

• Do not rely on symptoms alone to assess treatment response; endoscopic evaluation with biopsy is mandatory 2
• Do not use allergy testing as the primary guide for dietary elimination due to poor concordance with actual food triggers 1, 2
• Do not start with highly restrictive six-food elimination diet when step-up approaches (two-food or four-food) are more practical and reduce unnecessary restrictions 2, 5
• Do not discontinue maintenance therapy after achieving remission, as this leads to disease recurrence 1, 2
• Do not attempt dietary therapy without dietitian supervision due to nutritional risks 2