Eosinophilic Esophagitis Treatment Guidelines

First-Line Treatment Options

Topical corticosteroids are the first-line treatment for eosinophilic esophagitis symptoms, with high-quality evidence supporting their effectiveness in achieving both clinical and histological improvement, as recommended by the American Gastroenterological Association 1
Administration technique is crucial: patients should spray the metered dose inhaler in the mouth with lips sealed around the device, then not eat, drink, or rinse for 30 minutes, according to the American College of Gastroenterology 2
Clinical symptoms typically improve within 7 days, with histological improvement within 4 weeks, as reported by the American Gastroenterological Association 2
If PPIs cause unwanted side effects, consider switching to topical steroids or dietary therapy, as suggested by the European Society of Gastrointestinal Endoscopy 1

Dietary elimination may be effective when food allergies are identified as triggers, and should be conducted under supervision of an experienced dietitian, as recommended by the American Academy of Allergy, Asthma, and Immunology 3
The psychological impact of dietary therapy should be discussed with patients, according to the American Gastroenterological Association 1
Endoscopic dilation is effective for improving symptoms in patients with fibrostenotic disease, and can be performed safely using either balloon or bougie dilators, as reported by the American Society for Gastrointestinal Endoscopy 1
Clinical outcomes are better when combined with effective anti-inflammatory therapy with topical steroids, as suggested by the European Society of Gastrointestinal Endoscopy 1

Systemic corticosteroids are reserved for patients requiring urgent symptom relief, and are indicated for severe dysphagia, dehydration, significant weight loss, or esophageal strictures, as recommended by the American College of Gastroenterology 2
Dosage: 1-2 mg/kg/day of prednisone (maximum 60 mg), according to the American Gastroenterological Association 2
Risk factors with long-term use include growth abnormalities, bone abnormalities, mood disturbances, and adrenal axis suppression, as reported by the American Academy of Pediatrics 2

Clinical and histological relapse is high after withdrawal of topical steroid treatment, making maintenance therapy necessary, as suggested by the European Society of Gastrointestinal Endoscopy 1
The duration of treatment should be at least 8-12 weeks before evaluating histological response, according to the American Gastroenterological Association 3
Medical treatment with topical steroids likely reduces the development of strictures, as reported by the American Society for Gastrointestinal Endoscopy 1

If symptoms recur while on treatment, endoscopy should be repeated for assessment and to obtain further histology, as recommended by the American College of Gastroenterology 1
Endoscopists should be aware they may underestimate the frequency of strictures and narrow lumen esophagus, according to the American Society for Gastrointestinal Endoscopy 1
Candida infection may occur in a small proportion of patients treated with topical corticosteroids and should be managed with topical antifungals while continuing topical steroids, as suggested by the Infectious Diseases Society of America 1

Patients with refractory disease and/or significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist, as recommended by the American Academy of Allergy, Asthma, and Immunology 1
Novel biologics used in other allergic conditions have shown promise in treatment-resistant cases, according to the American Gastroenterological Association 1
Immunomodulators, anti-TNF, and anti-integrin therapies are not recommended, as reported by the European Society of Gastrointestinal Endoscopy 1