Eosinophilic esophagitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Ajay Gade MD[2]];Rithish Nimmagadda,MBBS.[3]

Overview

The optimal treatment of eosinophilic esophagitis remains uncertain. An eight-week course of therapy with topical corticosteroids (fluticasone or budesonide) may be used as the first-line pharmacologic therapy. Allergen elimination usually leads to improvement in dysphagia and reduction of eosinophil infiltration. Esophageal dilation of is generally reserved for refractory cases with esophageal stricture.

Medical Therapy

• The medical therapy of the EoE is as follows:
• The optimal treatment of eosinophilic esophagitis remains uncertain.

Steroid Therapy

• The endpoints of therapy of eosinophilic esophagitis include improvements in clinical symptoms and esophageal eosinophilic inflammation.
• An eight-week course of therapy with topical corticosteroids fluticasone or budesonide may be used as the first-line pharmacologic therapy.
• Children
  • 88–440 mcg/day fluticasone
  • 1 mg/day budesonide
• Adults
  • 880–1760 mcg/day fluticasone
  • 2 mg/day budesonide
• Patients without symptomatic and histologic improvement after topical steroids may be indicated for
  • Monoclonal Antibody Therapy with Dupilumab
  • Long course or higher doses of topical steroids
  • Systemic steroids with prednisone
  • Dietary elimination
  • Endoscopic dilation
• Oropharyngeal and esophageal candidiasis have been reported in patients treated with oral fluticasone.
• Evaluation by an allergist for coexisting atopic disorders, food, and environmental allergens is advisable.
• Allergen elimination usually leads to improvement in dysphagia and reduction of eosinophil infiltration.
• Graduated dilation of esophageal stricture should be performed with caution to minimize the risk of iatrogenic perforation.

Monoclonal Antibody Therapy

• Dupilumab blocks IL-4 and IL-13 cytokine signaling, which is critical for T helper type 2 (Th2) cell-mediated inflammation production and related to several inflammatory illnesses (ie, asthma, atopic dermatitis). Dupilumab is used to treat eosinophilic esophagitis in adults and pediatric patients one year of age and up. It is injected subcutaneously, and the dosage is determined by weight.

• Patients weighing 40 kg or more should take 300 mg once a week
• patients weighing 30 to <40 kg should take 300 mg once every other week
• patients weighing 15 to <30 kg should take 200 mg once every other week

Dietary Modification

• The dietary strategies are as follows:

• Elemental diet- highly effective in both adults and children, but it is limited by patient tolerability.
• Empiric six-food elimination diet (SFED)- the most common foods that trigger EoE are: soy, fish, cow milk, nuts, eggs, wheat.
• Limited diet driven by allergy testing and patient history- The allergy testing directs diet approach, although effective in the pediatric group has only moderate success in adults.
• The goal of dietary therapy is identification and removal of food antigens and consequently remove the sensitization.
• Diet therapy gives patients an alternative to control their disease, many patients find the idea of managing their sickness by means of removing the nutritional trigger more appealing than taking a drug to counteract the downstream inflammatory response.
• It is far vital to emphasize that the stern dietary elimination of multiple foods is only for a limited time but the long-term goal is the identify and remove the triggering dietary elements.
• Prolonged deviation from the elimination diet can be managed via the intermittent use of quick courses of topical steroids.

Esophageal Dilation

• Dilation is considered safe and effective in relieving the dysphagia in patients with EoE.
• Esophageal dilation has a very good acceptance in patients and it does not influence eosinophilic inflammation.
• Patients with esophageal strictures can be treated by esophageal dilation.
• Esophageal dilation is contraindicated in patients with endoscopic signs of acute inflammation.
• Postprocedural pain is very common in patients with esophageal dilation.
• The use of swallowed topical steroids before dilation reduces the risk of endoscopic complications such as bleeding, perforation, and postprocedural pain.
• Delaying the procedure in patients with strictures can lead to acute food bolus impactions.
• Food impactions should be dealt with carefully as they can cause spontaneous esophageal perforation and procedure-induced complications.