What is the optimal first‑line therapy for a breastfeeding mother with eosinophilic esophagitis?

Management of Eosinophilic Esophagitis in a Breastfeeding Mother

For a breastfeeding mother with eosinophilic esophagitis, topical corticosteroids (specifically swallowed budesonide or fluticasone) are the optimal first-line therapy, as they achieve minimal systemic absorption and pose negligible risk to the nursing infant while providing the highest efficacy for inducing clinical and histological remission. 1, 2

First-Line Treatment: Topical Corticosteroids

Topical corticosteroids should be initiated as first-line therapy because they achieve histological remission in 64.9% of patients compared to 13.3% with placebo, representing the most effective pharmacologic option. 1, 3

Specific Regimens for Breastfeeding Mothers:

• Budesonide orodispersible tablets (1 mg twice daily) are the most effective formulation, achieving clinicopathological remission in 57.6% at 6 weeks and 84% at 12 weeks. 1, 4
• Swallowed fluticasone propionate (880 mcg [four puffs] twice daily) is an alternative, achieving histological response in 62% of patients. 1
• Oral viscous budesonide (2 mg daily for adults) achieves 64% histological remission versus 27% with fluticasone in comparative studies. 1

Administration Technique (Critical for Efficacy):

• Spray the metered-dose inhaler in the mouth with lips sealed around the device 2
• Do not eat, drink, or rinse for 30 minutes after administration 2
• Clinical symptoms typically improve within 7 days, with histological improvement within 4 weeks 2

Safety in Breastfeeding:

Topical corticosteroids have minimal systemic absorption when swallowed, making them safe during breastfeeding. 1 The only significant adverse effects are local fungal infections (primarily oral candidiasis), which occur in a small proportion of patients and should be managed with topical antifungals while continuing topical steroids. 2

Alternative First-Line Option: Proton Pump Inhibitors

PPIs can be considered as an alternative first-line therapy if the patient prefers to avoid corticosteroids or experiences intolerable side effects. 1, 3

• Dosing: High-dose PPI (e.g., omeprazole 20-40 mg twice daily) for 8-12 weeks 1, 3
• Efficacy: Achieves histological response in 42% of patients overall, though with high variability 1, 3
• Safety in breastfeeding: PPIs are generally considered compatible with breastfeeding and have a long-standing safety profile 1

Important caveat: PPIs are less effective than topical corticosteroids for confirmed EoE (41.7% vs 64.9% histological remission), but they are easier to administer and may be preferred by some patients. 3

Mandatory Monitoring Protocol

Endoscopy with biopsy at 8-12 weeks is mandatory to assess histological response, as symptoms do not reliably correlate with mucosal healing in approximately 41% of patients. 1, 3, 5

• Histological remission is defined as <15 eosinophils per high-power field in all biopsy specimens 3
• If symptoms recur while on treatment, repeat endoscopy should be performed for assessment and further histology 2

Maintenance Therapy (Essential)

Long-term maintenance therapy is necessary because clinical and histological relapse rates are high after withdrawal of treatment. 1, 2

• Continue the same topical corticosteroid regimen indefinitely that achieved remission 1, 3
• Maintenance PPI therapy achieves sustained histological remission in 70-73% of responders at 12 months 1
• Do not discontinue therapy after achieving remission, as 87.5% of patients who stop treatment experience symptom recurrence and 100% exhibit histological recurrence 1

Treatments to Avoid During Breastfeeding

Systemic corticosteroids should be avoided except for emergency cases (severe dysphagia, hospitalization, significant weight loss) due to potential systemic effects on both mother and infant. 1, 2

The following are not recommended:

• Cromolyn sodium, leukotriene receptor antagonists, immunosuppressive agents (azathioprine, 6-mercaptopurine), anti-TNF agents, and anti-integrin therapies have no demonstrated benefit 1, 3, 5

Dietary Therapy Considerations

Elimination diets are not recommended as first-line therapy in breastfeeding mothers due to:

• The need for significant patient commitment and mandatory dietitian supervision 3, 5
• Risk of nutritional deficiencies that could affect milk production 3
• Requirement for multiple repeat endoscopies during food reintroduction 3
• Lower adherence rates compared to pharmacologic therapy 5

If dietary therapy is pursued (typically after pharmacologic failure), it should only be conducted under supervision of an experienced dietitian with attention to calcium and vitamin D supplementation. 3, 5

Management of Fibrostenotic Complications

If the patient presents with dysphagia from established strictures, endoscopic dilation should be performed in combination with anti-inflammatory therapy (topical steroids) for optimal outcomes. 1, 2

• Dilation improves symptoms in 87% of patients but does not address underlying inflammation 1
• Perforation risk is 0.4%, hospitalization 1.2%, and significant hemorrhage 0.1% 1

Common Pitfalls to Avoid

• Do not assume symptom resolution equals histologic healing—mandatory endoscopic reassessment at 8-12 weeks is essential 3
• Do not use allergy testing (skin-prick, specific IgE, patch testing) to guide treatment decisions, as predictive value is only ~45.5% in this non-IgE-mediated disease 3
• Do not discontinue maintenance therapy after achieving remission, as relapse rates approach 100% 1
• Monitor for oral candidiasis in patients on topical corticosteroids and treat with topical antifungals while continuing EoE therapy 2