What is the recommended treatment for eosinophilic esophagitis?

Treatment of Eosinophilic Esophagitis

The recommended first-line treatment for eosinophilic esophagitis is either topical corticosteroids or proton pump inhibitors (PPIs) given twice daily for 8-12 weeks, followed by mandatory endoscopic assessment with biopsy to confirm histological remission, as symptoms do not reliably correlate with mucosal healing. 1, 2

Initial Treatment Selection

You have three evidence-based first-line options, and the choice depends on patient preference and clinical context:

Option 1: Topical Corticosteroids (Preferred by Guidelines)

• Topical corticosteroids achieve the highest histological remission rates (64.9% vs. 13.3% placebo) and are recommended as the most effective first-line pharmacologic therapy. 1, 2, 3

• Administer fluticasone or budesonide as a swallowed formulation—patients should spray the metered-dose inhaler into the mouth with lips sealed around the device, then avoid eating, drinking, or rinsing for 30 minutes. 3

• Clinical symptoms typically improve within 7 days, with histological improvement by 4 weeks. 3

• Continue treatment for 8-12 weeks before performing endoscopy with biopsy to assess histological response. 1

Option 2: Proton Pump Inhibitors

• PPIs are effective as primary therapy for true EoE (not just PPI-responsive esophageal eosinophilia), achieving histological response in 41.7% of patients versus 13.3% with placebo. 2, 4

• Dose PPIs twice daily (e.g., omeprazole 20 mg twice daily) for at least 8-12 weeks before assessing histological response. 1, 4

• PPIs are particularly useful when GERD coexists with EoE as a comorbid condition, and they offer advantages of low cost, good safety profile, and convenience. 2, 4

• Patients achieving complete remission with PPIs alone may have PPI-responsive esophageal eosinophilia rather than classic EoE, but this distinction does not change the treatment approach—continue effective therapy. 2, 4

Option 3: Elimination Diets

• Elimination diets are effective in achieving clinico-histological remission in both adults and children, but require significant patient commitment and mandatory dietitian supervision throughout elimination and reintroduction phases. 1, 2

• A six-food elimination diet (SFED: milk, wheat, egg, soy, peanuts/tree nuts, fish/shellfish) produces the highest histological remission rates (72-79%) but has lower compliance and requires more endoscopies during food reintroduction. 1, 4

• A step-up approach starting with two-food elimination (milk + wheat, 43% remission) and escalating to four-food (60% remission) or six-food elimination only if needed reduces the number of required endoscopies by approximately 20%. 4

• Do not use allergy testing (skin prick, specific IgE, patch testing) to guide dietary elimination—these tests have limited predictive value (≈45.5% efficacy) because EoE is principally a non-IgE-mediated disorder. 1, 4

• The most common food triggers are cow's milk (≈42% of cases), eggs (≈21.5%), and wheat/gluten (≈10.9%). 4

Critical Monitoring Requirement

• After initiating any therapy (dietary or pharmacological), endoscopy with biopsy while on treatment is mandatory to assess response, as symptoms do not correlate with histological activity in approximately 41% of patients. 1, 2, 4

• Histological remission is defined as <15 eosinophils per 0.3 mm² (high-power field) in any biopsy specimen. 1, 2

• Failure to confirm mucosal healing despite symptomatic improvement allows persistent eosinophilic inflammation and risks progression to fibrosis and strictures. 4, 3

Maintenance Therapy

• Clinical and histological relapse is high after withdrawal of topical steroid treatment or PPIs—long-term maintenance therapy with the effective agent is necessary to prevent recurrent dysphagia, food impaction, and esophageal stricture formation. 1, 2, 3

• Continue the therapy that achieved remission (PPI, topical steroid, or diet) indefinitely. 2

• Medical treatment with topical steroids likely reduces the development of strictures over time. 3

Management of Fibrostenotic Disease

• Endoscopic dilation (balloon or bougie) is effective for symptomatic strictures and should be combined with anti-inflammatory therapy (topical steroids) for optimal outcomes. 2, 3

• Dilation improves dysphagia in patients with established fibrosis but does not address underlying inflammation. 1, 2

Refractory Disease

• Combining elimination diets with pharmacological treatment can be considered for patients failing initial monotherapy, though this is not routinely recommended. 1, 2

• Novel biologics such as dupilumab show promise for refractory cases and represent an emerging option for patients who have failed standard therapies. 1, 2

• Do not use immunomodulators (azathioprine, 6-mercaptopurine) or monoclonal antibodies typically used for inflammatory bowel disease (anti-TNF, anti-integrin therapies)—these are not effective for EoE. 1, 3

• Exclusive elemental diets (amino acid-based formulas) have high efficacy (90.8%) but poor compliance and should be reserved for patients refractory to other treatments. 1, 4

Common Pitfalls to Avoid

• Never assume symptom resolution equals histological healing—endoscopic assessment is necessary to prevent ongoing inflammation despite apparent clinical benefit. 2, 4, 3

• Do not discontinue maintenance therapy after achieving remission—recurrence rates are extremely high without continuous treatment. 1, 2

• Avoid using allergy tests to guide food elimination—empiric elimination based on the most common triggers is more effective. 1, 4

• Screen for candida infection in patients on topical corticosteroids (occurs in a small proportion) and manage with topical antifungals while continuing topical steroids. 3

• Ensure dietitian involvement for all elimination diets to prevent nutritional deficiencies, monitor growth in children, and assess need for micronutrient supplementation (calcium, vitamin D). 1, 4