What is the initial treatment for eosinophilic esophagitis (eOE)?

Initial Treatment for Eosinophilic Esophagitis

High-dose proton pump inhibitor (PPI) therapy at 20-40 mg twice daily for 8-12 weeks is the recommended first-line treatment for eosinophilic esophagitis, with mandatory endoscopic reassessment after this period to confirm histological response. 1, 2

Why PPIs Are First-Line

The 2018 international consensus removed the outdated distinction between "PPI-responsive esophageal eosinophilia" and "true EoE," recognizing that PPIs are a legitimate anti-inflammatory treatment rather than merely a diagnostic tool. 2 PPIs work through multiple mechanisms beyond acid suppression:

• They directly inhibit Th2 cytokine-stimulated eotaxin-3 secretion by blocking STAT6 binding to the eotaxin-3 promoter 2
• They restore impaired esophageal mucosal barrier function and improve desmoglein-1 expression 2
• They achieve histologic remission in approximately 42% of patients 1, 3

Specific PPI Dosing Protocol

Adults: 20-40 mg twice daily for 8-12 weeks, taken 30-60 minutes before meals 1, 2

Children: 1 mg/kg per dose twice daily (maximum based on adult dosing) for 8-12 weeks 1, 2

Critical point: Twice-daily dosing is essential—it achieves significantly higher remission rates (52.8-54.3%) compared to once-daily dosing (10-11.8%), regardless of total daily dose. 4 A single daily dose is inadequate even at higher milligram amounts.

Mandatory Reassessment Timeline

You must perform endoscopy with biopsies at 8-12 weeks to assess histological response. 5, 1, 2 This is non-negotiable because:

• Symptom improvement does not correlate reliably with histological remission—41% of patients report symptomatic improvement without histological response 5
• Histological remission is defined as <15 eosinophils per high-power field (0.3 mm²) 1, 2
• Minimum of 6 biopsies from different esophageal sites are required 1, 2
• At least 8 weeks of treatment is necessary, as shorter durations are insufficient for complete response 2, 6

If PPIs Fail: Second-Line Options

Switch to topical corticosteroids if inadequate response after 8-12 weeks of PPI therapy. 5, 1

Topical Steroid Options:

Budesonide orodispersible tablet: 1 mg twice daily achieves clinicopathological remission in 57.6% at 6 weeks and 84% at 12 weeks 5

Oral viscous budesonide: 1 mg/day if <150 cm height or 2 mg/day if >150 cm height 5

Swallowed fluticasone: 880 mcg (four puffs) twice daily achieves histological remission in 62% versus 0% on placebo 5

Topical steroids achieve histologic remission in approximately 65% of patients overall. 1, 3 The budesonide orodispersible tablet represents the highest quality evidence with the most robust response rates. 5

Dietary Therapy as Alternative First-Line

Elimination diets can be considered as first-line treatment but only under mandatory supervision of an experienced dietitian. 5, 1

• Six-food elimination diet (SFED) achieves histological response in 72.1% of patients 5
• Start with two-food elimination diet (milk and wheat, or milk and egg), stepping up to four-food or six-food elimination if inadequate response 5
• Reassess with endoscopy and biopsies at 8-12 weeks 5

Major caveat: While dietary therapy has high initial response rates (52-69%), only 55% of responders maintain compliance and remission at 9 months. 1, 7 This requires significant patient commitment and is less practical than pharmacotherapy for most patients.

Critical Pitfalls to Avoid

• Never rely on symptom improvement alone—you must confirm histological remission endoscopically 5, 1
• Never use once-daily PPI dosing—twice-daily administration is essential for adequate response 4
• Never perform esophageal dilation as initial therapy unless urgent intervention is required for food bolus obstruction or severe dysphagia 1
• Never discontinue PPI after initial response without endoscopic confirmation—disease recurs in 87.5% of patients who stop maintenance therapy 5

Maintenance Therapy

Once histological remission is achieved, continue the same treatment indefinitely to maintain remission. 5, 2

• 70-73% of PPI responders maintain sustained histological remission on maintenance therapy 5
• Disease recurs in 87.5% of patients who discontinue treatment after achieving remission 5
• Repeat endoscopy if symptoms recur during maintenance therapy 5, 2

Special Scenario: Acute Presentation

For patients with severe dysphagia, dehydration, significant weight loss, or food bolus obstruction, systemic corticosteroids (prednisone 1-2 mg/kg/day, maximum 60 mg) provide rapid symptom relief within 7 days and can be used as bridge therapy before transitioning to maintenance treatment. 5