Evidence-based treatments for eosinophilic esophagitis: insights for the clinician

Abstract

Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. Left untreated, EoE progresses to fibrous remodeling and stricture formation that impairs quality of life. Therefore, EoE requires either repeated treatments or maintenance therapy. Current guidelines recommend swallowed topical corticosteroids (STCs), proton-pump inhibitors (PPIs), or dietary intervention as initial options to induce and maintain long-term disease remission. Impractical exclusive elemental diets and suboptimal allergy testing-directed food avoidance paved the way for empirical elimination diets. These are moderately effective and highly reproducible in inducing EoE remission and allow for identification of specific food triggers. Step-up strategies, including two- and four-food rather than six-food elimination diets, should be considered as initial approaches for dietary treatment in patients of all ages, as they reduce the need for endoscopic procedures, shorten diagnostic processing time, and avoid unnecessary restrictions. Formulations of STC originally designed for asthma therapy are suboptimal for EoE treatment, with new effervescent orodispersible tablets and viscose formulations designed to coat the esophageal mucosa providing increased effectiveness at reduced doses. The anti-inflammatory effects of PPI in EoE are independent from gastric acid secretion inhibition; despite evidence from observational research, PPIs are the most commonly prescribed first-line therapy for EoE due to their accessibility, low cost, and safety profile. Double doses of PPI only induce remission in half of EoE patients, irrespective of the drug used or patients’ age. Inflammatory rather than stricturing EoE phenotype and treatment duration up to 12 weeks increase chances of achieving EoE remission. Most responders effectively maintain long-term remission with standard PPI doses. Finally, endoscopic dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission. This article provides a state-of-the-art review and updated discussion of current therapies and newly developed options for EoE.

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“…They also restore the integrity of the esophageal mucosa and reverse remodeling. (ORTEGA, 2022) PPIs are inexpensive, readily available, well tolerated, and easy to administer. Because of this, they are often chosen as the initial therapy.…”

“…Because of this, they are often chosen as the initial therapy. Their use causes symptomatic and histological remission, and they are also effective as maintenance therapy (ORTEGA, 2022). (ORTEGA, 2022) Treatment should be given for at least 8 weeks, with starting doses of 20-40mg in adults and 1-2mg/kg/dose in children, twice daily.…”

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“…In addition to administration by multidoses inhalers or nasal drops, fluticasone has also demonstrated benefits by disintegrating tablets. (ORTEGA, 2022) Studies suggest that the topical ECs budesonide, fluticasone, ciclesonide, or mometasone have optimal effects on clinical and histological improvement in adult and pediatric patients. (BIEDERMANN, 2021) Initially, the recommended treatment is at a dose of 1mg of budesonide or 880mcg of fluticasone, twice daily.…”

“…(STEINBACH, 2019) However, cortisol monitoring is recommended for children receiving high doses of EC for long periods or joint use of EC by other routes. (ORTEGA, 2022) Eyes on health sciences V.01 -Eosinophilic Esophagitis…”

“…(ORTEGA, 2022) Treatment should be given for at least 8 weeks, with starting doses of 20-40mg in adults and 1-2mg/kg/dose in children, twice daily. (ORTEGA, 2022) In the long term, one aims to use the lowest effective dose possible to achieve remission. (ORTEGA, 2022) Studies have shown a greater chance of remission in patients who used higher doses of the drug and in those who had treatment extended to 12 weeks.…”