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 for reducing esophageal eosinophil counts and inducing remission over 8-12 weeks. 1, 2

Initial Treatment Selection

Topical Corticosteroids (Preferred First-Line)

• The American Gastroenterological Association strongly recommends topical glucocorticosteroids over no treatment, with moderate quality evidence. 1
• Topical corticosteroids effectively reduce esophageal eosinophil counts to <15 per high-power field over 4-12 weeks with moderate certainty of evidence. 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 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 are suggested for patients with symptomatic esophageal eosinophilia, though with conditional recommendation and very low quality evidence. 1
• Double doses of PPI (e.g., omeprazole 20 mg twice daily) induce remission in approximately 50% of EoE patients, irrespective of the drug used or patient age. 3
• The anti-inflammatory effects of PPIs in EoE are independent from gastric acid secretion inhibition. 3
• PPIs are the most commonly prescribed first-line therapy due to their accessibility, low cost, and safety profile, despite limited evidence from observational research. 3
• Treatment duration should be 8-12 weeks before evaluating histological response. 2

Dietary Therapy Options (Ranked by Practicality)

Step-up approach starting with 2-food elimination diet is the most practical dietary strategy, avoiding unnecessary restrictions while maintaining effectiveness. 2, 4

Two-Food Elimination Diet (Most Practical)

• Eliminate milk +/- wheat or egg for 8-12 weeks as initial step. 2, 4
• This step-up approach reduces the need for endoscopic procedures, shortens diagnostic processing time, and avoids unnecessary restrictions compared to six-food elimination. 4
• Low certainty evidence but more practical than more restrictive diets. 2

Four-Food Elimination Diet (Intermediate Option)

• Step up to four-food elimination if two-food approach fails. 2, 4
• More restrictive but still more practical than six-food elimination. 4

Six-Food Elimination Diet (More Restrictive)

• Avoid milk, wheat, egg, soy, peanuts/tree nuts, and fish/shellfish. 1, 5
• Demonstrates 68% histologic response rate with low certainty evidence. 2
• Over 70% remission rate in adults but requires significant dietary restrictions. 5

Elemental Diet (Most Effective but Least Practical)

• Highly effective with moderate certainty evidence but impractical in most patients. 2, 3
• Patients who value avoiding the challenges of adherence to an elemental diet and prolonged reintroduction process may reasonably decline this option. 1

Allergy Testing-Based Elimination (Not Recommended)

• Very low certainty evidence with higher failure rates compared to empiric elimination. 2
• Low concordance with actual dietary causes of EoE, especially in adults. 6
• Due to limited accuracy of currently available allergy-based testing, patients may prefer alternative therapies. 1

Critical Dietary Therapy Requirements

• Dietary elimination should 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
• Endoscopic and histological assessment must be performed between 8-12 weeks after each dietary change to evaluate effectiveness. 2
• Multiple factors including demographics, nutritional status, patient and family lifestyles, social and financial support, and acceptance of repeated endoscopies influence dietary therapy results. 6

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. 2

• Conditional recommendation with very low quality evidence supports continuing topical glucocorticosteroids over discontinuation. 1
• Medical treatment with topical steroids likely reduces stricture development with moderate evidence and strong recommendation. 2
• Most PPI responders effectively maintain long-term remission with standard PPI doses. 3
• Early identification of responders with few food triggers may select best candidates for maintenance dietary therapy. 4

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 in fibrostenotic disease with high certainty evidence for safety and moderate for efficacy. 2
• Dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission. 3
• Dilation does not address esophageal inflammation and must be combined with effective anti-inflammatory therapy for optimal outcomes. 2
• Inflammatory rather than stricturing EoE phenotype increases chances of achieving remission with medical therapy. 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

• Treatment duration should be at least 8-12 weeks before evaluating histological response. 2
• Treatment duration up to 12 weeks increases chances of achieving EoE remission. 3
• If symptoms recur during treatment, repeat endoscopy for evaluation and obtain additional histology. 2

Refractory Disease Management

• 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 and Caveats

• Do not rely on symptoms alone to assess treatment response—histological confirmation via endoscopy is mandatory. 2
• Avoid allergy testing-directed elimination as initial approach due to poor concordance with actual food triggers. 2, 6
• Do not start with six-food elimination diet when two-food or four-food step-up approaches are more practical and reduce unnecessary restrictions. 4
• The psychological impact of dietary therapy should be discussed with patients, including anxiety and depression related to persistent symptoms and social restrictions, which are alleviated by effective therapy. 2
• Left untreated, EoE progresses to fibrous remodeling and stricture formation that impairs quality of life, requiring either repeated treatments or maintenance therapy. 3