Eosinophilic Esophagitis: An Evidence-Based Approach to Therapy

Abstract

In recent years, several randomized controlled trials and meta-analyses have evaluated the efficacy of the various therapeutic options available for treating patients with eosinophilic esophagitis, including dietary modifications, proton pump inhibitors, topical corticosteroids, and endoscopic esophageal dilation. Proton pump inhibitors are currently considered the first-line treatment for eosinophilic esophagitis, achieving histological remission and improvement of symptoms in 50.5% and 60.8% of patients, respectively. The efficacy of topical corticosteroids in eosinophilic esophagitis has been assessed in several trials. Meta-analyses summarizing results indicate that budesonide and fluticasone propionate are significantly superior to placebo, both in decreasing eosinophil densities in the esophageal mucosa and in relieving symptoms. However, owing to differences in drug delivery, viscous budesonide seems to be the best pharmacological therapy for eosinophilic esophagitis. Results for dietary modifications have been mixed depending on the type of diet prescribed. Thus, while exclusive amino acid-based elemental diets are the most effective in inducing histological remission of eosinophilic esophagitis (90.8%), their severe drawbacks limit their implementation in clinical practice. Allergy testing-based food elimination provides a suboptimal remission rate of 45.5%, although this is lower in adults than in children (32.2% vs 47.9%, respectively). In addition, the various available studies are highly heterogeneous. Empirical 6-food elimination diets were shown to be the best diet-based therapy, with a homogeneous remission rate of 72%. Simpler, more convenient empirical schemes have also been evaluated. The aim of this review is to provide an evidence-based overview on the efficacy of the options available for treatment of eosinophilic esophagitis along with a practical management algorithm.

A Review of the Novel Application and Potential Adverse Effects of Proton Pump Inhibitors

“…Many such cases have been reported, as expected [7]. A systematic review containing 10 randomized clinical trials (RCTs) enrolling 437 patients was performed to assess the efficacy of topical steroids compared with placebo or PPIs for the management of EoE [8].…”

Assessing eosinophilic cationic protein as a biomarker for monitoring patients with eosinophilic esophagitis treated with specific exclusion diets

“…Recent studies [13] have further described the therapeutic management of patients with EoE. It is noteworthy that clinical and histological improvements can be achieved in 50.5 and 60.8% of patients, respectively, using PPIs alone.…”

Eosinophilic esophagitis in children: doubts and future perspectives

“…It is worth noting that in some cases EoE appears to be triggered not only by food but also by aeroallergens, although in a part of the cases no clear trigger can be identified [2, 8, 9].…”

“…Such therapy should aim not only for the resolution of clinical symptoms but also for the resolution of esophageal inflammation, in order to obtain mucosal healing, which would allow the avoidance of long-term complications related to subepithelial fibrosis and deterioration in health-related quality of life. Another important therapeutic goal is to prevent adverse effects and complications related to long-term therapy and to avoid nutritional deficiencies derived from dietary restriction, especially among paediatric populations [2].…”

“…Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disorder, usually considered part of the wide spectrum of food allergies defined symptomatically by esophageal dysfunction and histologically by eosinophil-predominant inflammation of the esophagus [1]. It is the leading cause of food impaction, the main cause of dysphagia among children and young adults in Europe and North America and the most prevalent cause of chronic or recurrent esophageal symptoms after gastroesophageal reflux disease [2].…”