What is the treatment for eosinophilic esophagitis?

Treatment of Eosinophilic Esophagitis

Begin treatment with either topical corticosteroids or proton pump inhibitors (PPIs) as first-line therapy, with topical corticosteroids being the most effective option for confirmed EoE, achieving histological remission in 64.9% of patients compared to 41.7% with PPIs. 1, 2, 3

Initial Diagnostic Step: PPI Trial

• Start with a PPI trial (e.g., esomeprazole 40 mg or omeprazole 20 mg twice daily) for 8-12 weeks to exclude PPI-responsive esophageal eosinophilia, which may represent GERD or a distinct phenotype rather than true EoE 1, 4
• Patients achieving complete clinical and histological remission (<15 eosinophils per high-power field) with PPIs alone should be reclassified as having PPI-responsive esophageal eosinophilia rather than EoE 1
• Approximately 23-48.8% of patients with esophageal eosinophilia will respond to PPI therapy alone 5, 4

First-Line Treatment for Confirmed EoE

Topical Corticosteroids (Preferred)

• Topical corticosteroids are the most effective first-line treatment, achieving histological remission in 64.9% of patients versus 13.3% with placebo 1, 2, 3
• Continue therapy for 8-12 weeks before assessing histological response via endoscopy with biopsy 1, 2
• Newer formulations (effervescent orodispersible tablets and viscous preparations) designed to coat the esophageal mucosa provide increased effectiveness at reduced doses compared to asthma formulations 6
• Budesonide 1 mg orally twice daily as an aqueous gel achieves remission in 92% of patients 5

PPI Therapy (Alternative First-Line)

• For true EoE patients who don't respond to initial PPI trial or prefer this option, continue PPI therapy at double doses (e.g., 40 mg twice daily) for 8-12 weeks 1, 2
• PPIs achieve histological response in 41.7% of true EoE patients versus 13.3% with placebo 1, 3
• Particularly useful when GERD coexists with EoE as a comorbid condition 1
• Inflammatory phenotype (rather than stricturing) and treatment duration of 12 weeks (versus 8 weeks) increase chances of achieving remission 6, 4

Dietary Therapy (Alternative First-Line)

• Elimination diets achieve clinico-histological remission in both adults and children but require significant patient commitment and mandatory dietitian involvement 1, 2
• Use a step-up approach: start with two-food elimination diet (milk +/- wheat or egg) for 8-12 weeks, then escalate to four-food or six-food elimination diet if needed 1, 6
• Six-food elimination diet produces the highest histological remission rates (52% in real-world practice) but has lower compliance and requires more endoscopies during food reintroduction 1, 5
• Dietitian support throughout elimination and reintroduction phases is mandatory to ensure nutritional adequacy and proper execution 1, 2

Treatment Monitoring

• Endoscopy with biopsy while on treatment is mandatory at 8-12 weeks to assess response, as symptoms do not reliably correlate with histological activity 1, 2
• Histological remission is defined as <15 eosinophils per 0.3 mm² (high-power field) in any biopsy specimen 1
• For dietary therapy, perform endoscopic and histological assessment between 8-12 weeks after each dietary change during food reintroduction 2

Management of Fibrostenotic Disease

• Perform endoscopic dilation (balloon or bougie) for symptomatic strictures or persistent dysphagia despite histological remission 1, 2
• Combine therapeutic dilation with anti-inflammatory therapy (topical steroids) for optimal outcomes, as clinical outcomes are better with combined treatment 1, 2

Refractory Disease

• For patients failing initial therapy, consider combining dietary elimination with pharmacological treatment 1
• Novel biologics (such as dupilumab) show promise for refractory cases and represent an emerging option for patients who have failed standard therapies 1, 2
• Patients with refractory EoE and/or significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 2

Maintenance Therapy

• Long-term maintenance therapy is necessary given the chronic nature and high recurrence rates of EoE; continue the effective therapy (PPI, topical steroid, or diet) indefinitely 1
• Most PPI responders effectively maintain long-term remission with standard PPI doses (single daily dose), though stricturing phenotype decreases long-term response rates 6, 4
• PPI dosage reduction after achieving remission is effectively maintained in 69.9% of patients 4
• Remission is sustained in >85% of patients at 3 months with all treatment modalities, but only 55% of dietary therapy patients remain compliant and in sustained remission at 9 months 5

Treatments NOT Recommended

• Immunomodulators and monoclonal antibody therapies (anti-TNF, anti-integrin) are not recommended in routine EoE management 2
• Sodium cromoglycate, montelukast, and antihistamines are not recommended for EoE treatment, though they may have a role in concomitant atopic disease 2

Common Pitfalls

• Do not rely on symptom improvement alone to assess treatment response; always perform endoscopy with biopsy, as symptoms poorly correlate with histological activity 1, 2
• Do not attempt dietary elimination without experienced dietitian support, as this risks nutritional inadequacy and poor execution 1, 2
• Discuss the psychological impact of dietary therapy with patients, including potential for anxiety, depression, and social restrictions 2
• Inflammatory phenotype responds better to all therapies than stricturing phenotype; adjust expectations and treatment intensity accordingly 6, 4