What is the treatment of choice for eosinophilic esophagitis?

Treatment of Choice for Eosinophilic Esophagitis

For most patients with eosinophilic esophagitis, topical corticosteroids or proton pump inhibitors (PPIs) should be initiated as first-line monotherapy, with topical steroids being the preferred option due to their superior efficacy in achieving histological remission. 1

First-Line Pharmacological Treatment Options

Topical Corticosteroids (Preferred)

• Topical steroids are highly effective for inducing both histological and clinical remission in EoE, with high-quality evidence supporting their use as first-line therapy. 2, 1
• Corticosteroids lead to a large histological improvement (63% higher than placebo), with a number needed to treat of 3 for achieving histological remission (RR 11.94,95% CI 6.56 to 21.75). 3
• Treatment should be administered for at least 8-12 weeks before assessing histological response through repeat endoscopy with biopsy while on treatment. 2, 1
• Clinical and histological relapse is high after withdrawal of topical steroid treatment, therefore maintenance treatment should be recommended following clinical review. 2

Proton Pump Inhibitors (Alternative First-Line)

• PPIs are effective in inducing histological and clinical remission in patients with EoE and should be given twice daily for at least 8-12 weeks prior to assessment of histological response. 2, 1
• The recommended dosing is omeprazole 20 mg twice daily for adults, with weight-based dosing for pediatric patients (10 mg for those 10-20 kg, 20 mg for those ≥20 kg). 4
• PPIs induce remission in approximately half of EoE patients, irrespective of the specific drug used or patient age, with their anti-inflammatory effects being independent of gastric acid secretion inhibition. 5
• In patients who achieve histological response, PPI therapy appears effective in maintaining remission. 2

Dietary Therapy as Alternative First-Line Treatment

Elimination Diet Approaches

• Elimination diets are effective in achieving clinico-histological remission in both adults and pediatric patients with EoE, with moderate-quality evidence supporting their use. 2
• A six-food elimination diet (removing milk, wheat, eggs, soy, nuts/peanuts, and fish/shellfish) results in higher histological remission rates than two or four food elimination diets, but is associated with lower compliance and an increased number of endoscopies. 2
• Support from an experienced dietitian throughout both the elimination and reintroduction process is strongly recommended, as dietary therapy requires motivation, multiple endoscopies, and careful nutritional monitoring. 2, 1

Important Dietary Therapy Caveats

• Allergy testing to foods (skin prick, specific IgE, patch testing) is not recommended for choosing the type of dietary restriction therapy, as targeted dietary elimination based on IgE testing is no more effective than empirical dietary elimination. 2
• Exclusive elemental diets have a limited role in EoE, with high efficacy but low compliance rates, and should be reserved for patients refractory to other treatments. 2

Treatment Selection Algorithm

For Most Patients

• Commence treatment with single modality therapy of either diet or pharmacotherapy; for most patients this will be pharmacotherapy (topical steroids or PPIs), which is easier to implement than dietary restriction. 2
• The choice between topical steroids and PPIs depends on accessibility, cost, and patient preference, though topical steroids demonstrate superior histological remission rates. 1, 3

For Refractory Cases

• Combining elimination diets with pharmacological treatment is not routinely recommended but can be considered in cases of treatment failure to monotherapy. 2
• Combination therapy should be reserved for selected patients who have access to a multiprofessional team including a dietitian to monitor response carefully. 2

Critical Monitoring Requirements

Endoscopic Assessment

• After initiation of therapy, endoscopy with biopsy while on treatment is recommended to assess response, as symptoms may not always correlate with histological activity. 2, 1
• The target histologic threshold for adequate therapeutic response is <15 eosinophils per high-power field. 1
• Repeat endoscopy should be performed at 8-12 weeks after initiating treatment to assess histological response. 1

Common Pitfall to Avoid

• Do not rely on symptom improvement alone—always confirm histological response with endoscopy, as symptoms may improve without adequate control of inflammation, potentially leading to progressive fibrosis. 1

Management of Fibrostenotic Disease

• Endoscopic dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission. 1, 5
• Clinical outcomes of patients with stricture are better if therapeutic dilation is combined with effective anti-inflammatory therapy with topical steroids. 1

Treatments NOT Recommended

• Immunomodulators (azathioprine, 6-mercaptopurine) are not recommended in the management of EoE. 2
• Monoclonal antibody therapies such as anti-TNF and anti-integrin therapies typically used for inflammatory bowel disease are not recommended. 2
• Sodium cromoglycate, montelukast, and antihistamines are not recommended for EoE management but may have a role in concomitant atopic disease. 2