Management of Eosinophilic Esophagitis
Start with twice-daily proton pump inhibitor (PPI) therapy for 8-12 weeks as first-line treatment, and if this fails to achieve histological remission (<15 eosinophils/hpf), switch to topical corticosteroids as second-line therapy. 1
First-Line Treatment: Proton Pump Inhibitors
Initiate PPI therapy at twice-daily dosing (e.g., omeprazole 20-40 mg twice daily) for a minimum of 8-12 weeks before assessing histological response via endoscopy with biopsy. 1
PPIs are effective in inducing both histological and clinical remission in approximately 50% of EoE patients, with moderate-grade evidence supporting this approach. 1
For patients who achieve histological response to PPIs, continue maintenance therapy, potentially at reduced doses, as this effectively maintains long-term remission. 1, 2
The anti-inflammatory effects of PPIs in EoE are independent of gastric acid suppression, making them distinct from their use in GERD. 3
Second-Line Treatment: Topical Corticosteroids
When PPIs fail to achieve adequate response after 8-12 weeks, switch to topical corticosteroids, which have high-grade evidence for inducing both histological and clinical remission. 1
Topical steroids demonstrate a large histological improvement (63% higher response rate compared to placebo, with number needed to treat = 3). 4
Topical corticosteroids are strongly preferred over systemic corticosteroids due to superior safety profile and reduced systemic adverse effects. 1
Following successful induction of remission, maintenance treatment with topical steroids should be recommended, as clinical and histological relapse rates are high after withdrawal. 1
Topical steroid therapy likely reduces the development of strictures in EoE patients, providing long-term structural benefit. 1
Dietary Elimination Therapy
Consider empirical elimination diets after inadequate response to medication or as an alternative first-line approach for motivated patients, particularly those preferring to avoid long-term pharmacotherapy. 1, 2
Start with a two-food elimination diet (TFED) removing milk plus wheat or egg for 8-12 weeks, then step up to more restrictive diets (four-food or six-food elimination) only if needed. 1, 5
Step-up dietary strategies reduce the number of endoscopic procedures required, shorten diagnostic time, and avoid unnecessary food restrictions compared to starting with six-food elimination. 3, 5
Dietary elimination must be conducted under supervision of an experienced dietitian throughout both elimination and reintroduction phases to prevent nutritional deficiencies and ensure proper implementation. 1, 5
Allergy testing (skin prick, specific IgE, patch testing) is NOT recommended for choosing dietary restrictions, as these tests do not reliably predict food triggers in EoE. 1
Exclusive elemental diets have the highest efficacy but lowest compliance rates and should be reserved only for patients refractory to all other treatments. 1
Management of Fibrostenotic Disease and Strictures
Endoscopic dilation is effective and safe for improving symptoms in patients with strictures or reduced esophageal caliber, and can be performed using either balloon or bougie dilators. 1
Best clinical outcomes occur when endoscopic dilation is combined with effective anti-inflammatory therapy using topical steroids, rather than dilation alone. 1
Consider endoscopic dilation in patients with persistent dysphagia despite achieving histological remission, as structural changes may persist. 3
The perforation rate with endoscopic dilation is approximately 0.4%, with most complications occurring before 2009 when techniques were less refined. 2
Be aware that endoscopists frequently underestimate the presence of strictures and narrow lumen esophagus in EoE patients during endoscopy. 1
Treatment of Refractory Disease
For patients refractory to PPIs, topical steroids, and dietary therapy, consider novel biologics such as dupilumab, cendakimab, or benralizumab, though these currently have weak recommendation strength. 1
Biologics result in better histological improvement (55% higher response rate, NNTB = 2) when compared to placebo, with moderate-certainty evidence. 4
Patients with refractory EoE and/or significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist to optimize treatment. 1
Do NOT use immunomodulators (azathioprine, 6-mercaptopurine) or anti-TNF/anti-integrin therapies typically used for inflammatory bowel disease, as these are not effective for EoE. 1
Do NOT use sodium cromoglycate, montelukast, or antihistamines for EoE management, though these may have a role in treating concomitant atopic diseases. 1
Monitoring and Follow-Up
If symptoms recur while on treatment, repeat endoscopy with biopsy to assess histological activity, as symptoms do not always correlate with histological disease activity. 1
Perform endoscopy with biopsy at 8-12 weeks after initiating any new therapy (PPI, topical steroid, or dietary change) to assess histological response while on treatment. 1
Combining elimination diets with pharmacological treatment is not routinely recommended but can be considered in cases of drug treatment failure. 1
Common Pitfalls to Avoid
Do not stop treatment after achieving initial remission, as EoE is a chronic disease requiring long-term maintenance therapy to prevent disease progression and fibrostenotic complications. 3, 4
Do not rely on symptom improvement alone to assess treatment response; always confirm histological remission with endoscopy and biopsy. 1
Do not use allergy testing to guide dietary elimination choices, as this approach has been shown to be suboptimal and unreliable. 1
Inflammatory phenotype and treatment duration up to 12 weeks increase chances of achieving remission; do not assess response too early. 3