Eosinophilic Esophagitis Treatment Guidelines

First-Line Treatment Options

The American Gastroenterological Association recommends topical corticosteroids as the first-line treatment for eosinophilic esophagitis (EoE) due to their high efficacy in achieving both clinical and histological remission 1, 2
Topical steroids are highly effective for inducing histological and clinical remission in EoE, with high-quality evidence supporting their effectiveness and a strong recommendation level 1, 2
Proton pump inhibitors (PPIs) are effective in inducing histological and clinical remission in patients with EoE, and should be given twice daily for at least 8–12 weeks prior to assessment of histological response 1, 3

Elimination diets are effective in achieving clinico-histological remission in both adults and pediatric patients, with a six-food elimination diet resulting in higher histological remission rates than two or four food elimination diets 3
Support from an experienced dietitian throughout both the elimination and reintroduction process is strongly recommended, and the psychological impact of dietary therapy should be appreciated and discussed with patients 4, 3

Endoscopic dilation is effective in improving symptoms in patients with fibrostenotic disease due to EoE, and can be performed using either balloon or bougie dilators 1, 5, 6
Clinical outcomes of patients with stricture are better if therapeutic dilation is combined with effective anti-inflammatory therapy with topical steroids 1, 6

After initiation of therapy, endoscopy with biopsy while on treatment is recommended to assess response, as symptoms may not always correlate with histological activity 1, 4, 3
Patients with EoE refractory to treatment and/or with significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 1, 5

Immunomodulators and monoclonal antibody therapies are not recommended in the management of EoE, and sodium cromoglycate, montelukast, and antihistamines are not recommended but may have a role in concomitant atopic disease 1, 4, 5

Novel biologics have shown promise in the treatment of EoE, but are still considered emerging therapies and should be considered for patients with refractory disease who have failed standard therapies 1

The American Gastroenterological Association (AGA) guidelines recommend considering fluticasone as an alternative topical corticosteroid for patients allergic to budesonide, with eight double-blind placebo-controlled studies showing topical glucocorticosteroids (including fluticasone) failed to induce histologic remission in only approximately one-third of treated patients 7, 8, 9
Fluticasone formulation should be used as swallowed fluticasone propionate mixed with a viscous vehicle or administered as a metered-dose inhaler without spacer, swallowed rather than inhaled, with a recommended dosing of twice daily for 8-12 weeks before assessing histological response 7
The safety profile of fluticasone shows no increased risk of adverse events compared with placebo in short-term studies of ≤3 months, though local viral and fungal infections can occur 7, 8

The target histologic threshold for adequate therapeutic response is <15 eosinophils per high-power field, and repeat endoscopy with biopsy should be performed at 8-12 weeks after initiating treatment to assess histological response 10
It is critical to not rely on symptom improvement alone, and always confirm histological response with endoscopy, as symptoms may improve without adequate control of inflammation, potentially leading to progressive fibrosis 10