Is there treatment for eosinophilic esophagitis?

Treatment for Eosinophilic Esophagitis

Yes, eosinophilic esophagitis has multiple effective treatment options, with topical corticosteroids, proton pump inhibitors (PPIs), and elimination diets all serving as first-line therapies that can achieve both clinical and histological remission. 1

First-Line Treatment Options

You have three equally valid first-line approaches to choose from:

Topical Corticosteroids

• Topical corticosteroids are highly effective and achieve histological remission in approximately 63% more patients compared to placebo, with a number needed to treat of 3. 2
• These medications lead to large improvements in histological outcomes (reducing eosinophils to <15 per high-power field) and may provide clinical symptom improvement. 2
• New formulations including effervescent orodispersible tablets and viscous preparations designed to coat the esophageal mucosa provide increased effectiveness at reduced doses compared to older asthma-based formulations. 3
• The main adverse effect is esophageal candidiasis, which should be monitored. 4

Proton Pump Inhibitors (PPIs)

• PPIs should be given twice daily for at least 8-12 weeks prior to assessment of histological response. 1
• PPIs are the most commonly prescribed first-line therapy due to their accessibility, low cost, and safety profile. 3
• Double doses of PPI induce remission in approximately 50% of EoE patients, irrespective of the specific drug used or patient age. 3
• The anti-inflammatory effects of PPIs in EoE are independent from gastric acid secretion inhibition. 3
• For treatment of erosive esophagitis due to acid-mediated GERD, omeprazole 20 mg once daily for 4-8 weeks is FDA-approved. 5
• Most responders effectively maintain long-term remission with standard PPI doses. 3

Elimination Diets

• Six-food elimination diets result in higher histological remission rates (over 70% in adults) than two- or four-food elimination diets. 1, 6
• Step-up strategies starting with two-food or four-food elimination diets should be considered as initial approaches, as they reduce the need for endoscopic procedures, shorten diagnostic time, and avoid unnecessary restrictions. 3
• The most common food triggers are milk, wheat, egg, soy, peanuts/tree nuts, and fish/shellfish. 6
• Support from an experienced dietitian throughout both the elimination and reintroduction process is strongly recommended, and the psychological impact of dietary therapy should be discussed with patients. 1
• Elemental diets are highly effective but impractical in most patients due to poor palatability and often requiring enteral feeding via nasogastric or gastrostomy tube. 7

Treatment Selection Algorithm

Choose based on these patient-specific factors:

• For patients prioritizing medication-free approaches or with strong food allergy history: Start with empiric elimination diet (two-food or four-food step-up approach). 3, 8
• For patients seeking convenience and lowest cost: Start with twice-daily PPI for 8-12 weeks. 1, 3
• For patients with inflammatory phenotype and no significant strictures: Any first-line option is appropriate; inflammatory phenotype and treatment duration up to 12 weeks increase chances of achieving remission. 3
• For pediatric patients: All three options are effective; dietary therapy should consider family lifestyle, resources, and acceptance of repeated endoscopies. 7, 8

Management of Fibrostenotic Disease

• Endoscopic dilation is effective in improving symptoms in patients with fibrostenotic disease and can be performed using either balloon or bougie dilators. 1
• Clinical outcomes are better if therapeutic dilation is combined with effective anti-inflammatory therapy with topical steroids. 1
• Dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission. 3

Treatment Goals and Monitoring

The primary goal is symptomatic relief, ideally accompanied by resolution of esophageal eosinophilia (defined as <15 eosinophils per high-power field). 4

• After initiation of therapy, endoscopy with biopsy while on treatment is recommended to assess response, as symptoms may not always correlate with histological activity. 1
• A critical pitfall: substantial esophageal eosinophilia can persist in asymptomatic or minimally symptomatic patients because they modify their diet to compensate for symptoms, masking inflammatory activity. 4
• Therapeutic evaluation based solely on symptoms without endoscopy and biopsy is limited and often misleading. 4
• Prevention of progressive esophageal dysfunction and fibrostenotic remodeling is crucial, as retrospective studies suggest prolonged untreated disease is associated with increased prevalence of esophageal strictures. 4

Maintenance Therapy

• Controlled studies for maintenance therapy do not extend beyond 12 months. 5
• EoE requires either repeated treatments or maintenance therapy, as there is currently no cure. 2
• Most PPI responders effectively maintain long-term remission with standard doses. 3

Treatments NOT Recommended

• Immunomodulators and monoclonal antibody therapies are not recommended in routine management of EoE. 1
• Sodium cromoglycate, montelukast, and antihistamines are not recommended for EoE treatment (though they may have a role in concomitant atopic disease). 1
• Cromolyn showed no benefit in achieving histologic remission compared to placebo. 7

Refractory Disease

• Patients with EoE refractory to treatment and/or with significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist. 1
• Novel biologics have shown promise and should be considered for patients with refractory disease who have failed standard therapies. 1