What is the management approach for Eosinophilic Esophagitis?

Management of Eosinophilic Esophagitis

First-line treatment for eosinophilic esophagitis should be either swallowed topical corticosteroids (strong recommendation) or proton pump inhibitors (conditional recommendation), with topical steroids achieving approximately 65% histological remission compared to 42% with PPIs. 1, 2

Initial Treatment Selection

Topical Corticosteroids (Preferred First-Line)

• Topical steroids are the most effective initial therapy, inducing histological remission (<15 eosinophils/high-power field) in approximately 65% of patients versus 13% with placebo. 2
• Treatment duration should be 8-12 weeks before assessing response with repeat endoscopy and biopsy. 1
• New effervescent orodispersible tablets and viscous formulations designed to coat the esophageal mucosa provide increased effectiveness at reduced doses compared to older asthma-based formulations. 3
• Maintenance therapy with topical steroids is necessary after achieving remission, as clinical and histological relapse is high after withdrawal. 1

Proton Pump Inhibitors (Alternative First-Line)

• PPIs should be given at double doses (e.g., esomeprazole 40 mg twice daily) for at least 8-12 weeks prior to histological reassessment. 1, 2
• Overall histological response rate is approximately 42%, with the anti-inflammatory effects independent of acid suppression. 2, 3
• In patients who achieve histological response, PPI therapy is effective in maintaining remission. 1
• Approximately 23% of patients initially diagnosed with EoE will respond to PPI alone and should be reclassified as PPI-responsive esophageal eosinophilia. 4

Dietary Therapy Options

Empirical Elimination Diets

• A two-food elimination diet (TFED) eliminating milk +/- wheat or egg is the recommended initial dietary approach for 8-12 weeks. 5
• Step-up strategies (starting with 2-food, then 4-food, then 6-food elimination) reduce endoscopic procedures and avoid unnecessary restrictions. 3
• Elemental diets have high efficacy but low compliance rates and should be reserved for patients refractory to other treatments. 1
• Dietary elimination must be conducted under supervision of an experienced dietitian throughout both elimination and reintroduction phases. 5, 6
• Only 52% achieve complete remission with 6-food elimination diet plus PPI, and only 55% maintain remission at 9 months due to poor adherence. 4

Treatment Monitoring

Mandatory Endoscopic Reassessment

• Endoscopy with biopsy while on treatment is mandatory after 8-12 weeks to assess histological response, as symptoms do not always correlate with histological activity. 1, 5
• A meta-analysis found only moderate association between symptomatic and histological response, with 41% of patients reporting symptomatic improvement without histological response. 1
• The target is achieving <15 eosinophils/high-power field to define adequate therapeutic response. 1

Management of Treatment Failure

Sequential Treatment Algorithm

• If initial therapy fails, switch to the alternative pharmacological option (PPI to topical steroid or vice versa) or initiate dietary elimination. 1, 2
• Consider combination treatment modalities (e.g., PPI plus topical steroid) for refractory cases. 1
• Patients refractory to treatment and/or with significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist. 1, 5

Novel Biologic Therapies

• Dupilumab, cendakimab, and benralizumab have shown promise in treatment of EoE. 1
• Anti-TNF and anti-integrin therapies typically used for inflammatory bowel disease are not recommended. 1

Management of Complications

Strictures and Fibrostenotic Disease

• Medical treatment with topical steroids reduces the development of strictures. 1
• Endoscopic dilation is effective and safe in improving symptoms in patients with fibrostenotic disease or persistent dysphagia despite histological remission, using either balloon or bougie dilators. 1, 2
• Clinical outcomes are better if therapeutic dilation is combined with effective anti-inflammatory therapy with topical steroids. 1
• Endoscopists frequently underestimate the frequency of strictures and narrow lumen esophagus in EoE. 1

Esophageal Perforation

• EoE is the most common cause of spontaneous esophageal perforation, occurring at any age. 1
• CT contrast study should be performed to assess degree of extravasation. 1
• Limited extravasation should be managed conservatively with multidisciplinary input. 1

Important Caveats and Side Effects

PPI-Related Issues

• If PPI causes diarrhea, gastrointestinal infections, or magnesium deficiency, switch to topical steroids or dietary therapy. 1

Topical Steroid-Related Issues

• Candida infection may occur in a small proportion of patients and should be managed with topical antifungals while continuing topical steroids. 1
• Systemic side effects have not been documented during long-term treatment in adults, but continued monitoring of bone mineral density and adrenal suppression is recommended in children and adolescents. 1

Psychological Considerations

• Anxiety and depression affect patients due to persistent symptoms and social restrictions from dietary therapy and are alleviated by effective therapy. 1

Therapies NOT Recommended

• Immunomodulators (azathioprine, 6-mercaptopurine) are not recommended. 1
• Sodium cromoglycate, montelukast, and antihistamines are not recommended for EoE management but may have a role in concomitant atopic disease. 1