There can be many ways to treat eosinophilic esophagitis (EoE). This is a chronic allergic inflammatory disease that affects the esophagus. Diagnosis involves having esophageal symptoms and finding 15 or more eosinophils per high power field on biopsy in the absence of other causes. The most classical symptom seen in adults is difficulty swallowing, other symptoms seen are heartburn, abdominal pain, failure to thrive, feeding difficulties or vomiting, which can be seen in the pediatric population. This can lead to strictures and narrowing of the esophagus and food can get stuck requiring intervention.
The goal of treatment of eosinophilic esophagitis include histological remission (less than 15 eosinophils/hpf) and relieving symptoms of esophageal dysfunction.
EoE is thought to be related to food antigens because elimination diets and elemental formulas can be effective treatments but identifying causative foods can be difficult.
Here we discuss different treatment options for eosinophilic esophagitis:
- Proton pump inhibitors-this was one of the earliest treatment options for eosinophilic esophagitis. High doses of omeprazole (40mg twice daily) have shown to be helpful. These are generally very safe options for all patients.
- Swallowed topical steroids-studies have shown response rates greater than 90% at 6 weeks. They are used off label to treat EoE. Initial treatment with oral viscous budesonide or Flovent MDI has been shown to be helpful. For adults effective dosing has been flovent 440-880 micrograms twice a day or 2 mg daily of budesonide. In pediatrics Flovent 88-440 twice a day or budesonide 1 mg daily. Side effects can limit its long term use. They remain an excellent option for eosinophilic esophagitis treatment and there some new formulations are undergoing FDA studies. If a patient is doing well, a dose reduction of 50% can be considered with follow up.
- Prednisone-Prednisone can induce histological and symptomatic remission. There is a risk though of long term systemic side effects.
- Dietary Therapies-The 6 Food Elimination Diet target the removal of the most common food allergens. (Dairy, Wheat, Eggs, Soy, Peanuts/Tree Nuts, and Fish/Shellfish). Dairy is the most common in pediatrics (50-70%) and wheat in adults (40-50%). Other ways to treat can be a 4, 2, or 1 food elimination diet. Overall this is a common and effective therapy. If a patient is on dietary elimination with more than 1 food, reintroduction of 1 or more foods can be considered.
- Dilation-the goal is to dilate 15-18 mm in patients with a clinically significant stricture. This is generally safe.
- Dupixent (dupilumab)-this is the first FDA approved medication for EoE, it is an antibody that blocks IL-4 and IL-13 receptors. There are no set guidelines when it should be used in the treatment algorithm, some suggest using it first line and others suggest using it in more severe cases after other treatments have failed.
- Other treatments being studied are other biological medications: Lirentelimab, Benralizumab, Mepolizumab, reslizumab, Omalizumab.
In a patient with newly diagnosed EoE, PPI, topical steroids, dietary therapy or Dupixent can all be used first line. There is currently no evidence supporting one over the other. Many treatment options may need to be lifelong though. After making changes, patient showed be reevaluated every 8-12 weeks until an effective therapy is determined. Repeat biopsies may be needed to check the response to treatment.