Management of Eosinophilic Esophagitis

SUMMARY:

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease of the esophagus characterized by symptoms of dysphagia, food impaction, and gastroesophageal reflux disease (GERD). EoE is commonly present in patients with atopic disease, such as asthma and allergic rhinitis. The management of EoE involves a combination of dietary and pharmacological interventions. EoE was first described as a distinct disease in the 1990s and has been increasing in incidence since then, primarily in children and young adults. Management of EoE continues to evolve as our understanding of the disease grows.

Management

Medical Management

PPI: Can induce remission in 42% of patients | Well tolerated | Choice of PPI depends on cost and patient preference | Assess for improvement after 8 weeks | When remission is achieved dosing can be decreased to lowest effective dose | Discuss rationale for use especially when reflux symptoms are absent
- Lansoprazole (Prevacid): 30 mg twice daily
- Omeprazole (Prilosec): 20 mg twice daily
- Pantoprazole (Protonix): 40 mg twice daily
- Esomeprazole (Nexium): 20 to 40 mg twice daily
Topical steroids: Preferred over systemic steroids to reduce risk of adverse effects | Can cause oral candidiasis | Administer after meals or before bedtime with 30-60 mins of post administration NPO time | Patients who will respond generally improve within days | Repeat endoscopy should be done following induction phase
- Fluticasone (Flovent): Administer via MDI without spacer | Instruct patient to swallow instead of inhale | 220 mcg/spray, 440 to 880 mcg twice daily | Induction therapy lasts 4 to 8 weeks
- Budesonide (Pulmicort): Swallow oral budesonide viscous liquid/suspension instead of using inhaler | 2 mg/day slowly swallowed over 5 to 10 minutes | Induction therapy can last up to 12 weeks
- Attention to possible adrenal insufficiency in patients on topical steroids and systemic steroids for other conditions
Biologic agents
- Dupilumab (Dupixent): IL-4 Receptor Antagonist | 300mg weekly subq | FDA approved in 2023 | Increases histologic remission compared to placebo in patients who have failed PPI trial | Recommended for patients who do not respond to other therapies or patients with other atopic indications
- Clinical trials are underway for other biologic agents including: Mepolizumab (Nucala) | Reslizumab (Cinqair) | Tezepelumab (Tezspire)

Dietary Therapies

Dietary therapy is a first line treatment for EoE based on the observation that many EoE patients have food allergies and other evidence of atopy
If possible, dietary therapy should be a multidisciplinary process with the assistance of allergists and dietitians with experience in EoE
Currently no testing exists that accurately identifies food triggers in EoE and dietary therapy depends on elimination diets with the slow reintroduction of possible food triggers
- Test-directed elimination diet (TDED) is guided by combined results of food-specific skin prick and atopy patch testing, but has not yet been validated in patients with EoE and remains an area of study
While generally well tolerated and effective, risks of dietary therapy include: Impacts on nutritional status | Decreased quality of life | Unfavorable weight changes | Development of food aversions | De-novo IgE-mediated food allergy
Elimination diets:
- Six food elimination therapy: Eliminates the 6 most common food allergens (e.g., milk, wheat, egg, soy, nuts, and fish/shellfish)
- Four food elimination diet: Eliminates the four most implicated allergens in adults (e.g., milk, egg, wheat, and legumes)
- ACG 2025 guidelines suggest offering to start with 1FED i.e., eliminating dairy only or 2FED i.e., eliminating dairy and wheat, per patient preference as 6FED and 4FED diets can be more restrictive and challenging to complete
- Escalation to 4FED and 6FED diets if no response to 1FED or 2FED
Elemental diet:
- Uses an amino acid-based formula (AAF) free from intact proteins or peptides and can result in EoE remission in a majority of patients
- Formula may be a financial burden on patients
- Difficult to maintain long term and can lead to social isolation
Following successful elimination diets (e.g., EoE remission is achieved), foods should be reintroduced to the diet sequentially with close assessment of recurrent symptoms clinically and/or endoscopically
- Higher risk foods (e.g., milk, wheat) should be added back last
- Serial tissue biopsies are the only way to be certain whether a reintroduced food is an EoE trigger, but may not be feasible or desired by the patient

Endoscopic Management

Useful for addressing symptoms and complications of EoE, but not effective at treating the underlying inflammation
Guidelines recommend evaluation of efficacy of medications or dietary changes via endoscopy and not with symptoms alone
Dilation
- Done for patients with EoE associated stricture who present with dysphagia or dietary avoidance/modification behavior
- Gradual dilation over multiple endoscopic sessions may be needed to achieve a target esophageal diameter (typically ≥ 16 mm)
- Patients undergoing dilation should be treated with medical therapy as well to decrease inflammation and reduce the risk of recurrent stricture
- EoE leads to subepithelial fibrous remodeling, and dilation may be useful in treating dysphagia in the absence of stricture in select patients
- Perforation is a rare complication of esophageal dilation and is generally medically managed by keeping patient NPO and administering empiric antibiotics to cover oral flora (e.g., Unasyn)

Follow Up

EoE is a chronic and progressive disease without a cure, and patients who reach histologic remission should continue to receive regular monitoring to assess disease activity with endoscopy (<15 eos/hpf) not only symptom description
Despite its chronic nature, there is no evidence that EoE shortens lifespans
Anti-inflammatory maintenance therapy should be continued after reaching remission to prevent relapse
Any clearly identified dietary triggers should be avoided for life
Patients with EoE may have minimal symptoms in the setting of ongoing or worsening inflammation, so regular endoscopic assessment with biopsies is recommended for disease monitoring
- At least annual clinical and endoscopic assessment is recommended in patient with well controlled disease

KEY POINTS:

EoE is a chronic immune mediated disease that is treated with dietary, pharmacologic, and endoscopic therapies
First line therapy for EoE includes PPIs, topical glucocorticoids, and food elimination diets
Endoscopy is an important tool both in the diagnosis and management of EoE complications such as dysphagia and strictures, but does not treat the underlying disease process
Therapies that are successful in helping a patient achieve clinical remission should be continued long term to prevent relapse