Eosinophilic esophagitis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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:[1][2][3]
- 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
- Children
- 88–440 mcg/day fluticasone
- 1 mg/day budesonide
- Adults
- 880–1760 mcg/day fluticasone
- 2 mg/day budesonide may be used as the first-line pharmacologic therapy.
- Patients without symptomatic and histologic improvement after topical steroids
- 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 and 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.
Dietary Modification
- The goal of dietary therapy is identification and elimination of food antigens to consequently remove the trigger for allergic sensitization.
- Diet therapy offers patients a non-pharmacologic alternative to controlling their disease. In a broader context, studies across disciplines have demonstrated the widespread patient use of alternative medicine to many medical conditions, in spite of available conventional therapies.
- Many patients find the concept of remedying their disease by eliminating a dietary trigger more appealing than taking a drug to counteract the downstream inflammatory response.
- Furthermore, when discussing the diet approach, it is important to emphasize that the strict dietary removal of multiple foods is for a limited period of time. The long-term goal is the identification and long-term elimination of one or a few dietary factors.
- In addition, the notion by patients that they will “never” be able to eat an identified trigger food is incorrect. In contrast to food-related anaphylaxis, occasional dietary indiscretion is likely not a major concern.
- Prolonged deviation from the elimination diet can be managed by intermittent use of short courses of topical steroids. Moreover, as progress is made in the understanding of the pathogenesis of EoE, newer
- The three most commonly utilized diet strategies are the
- Elemental diet- highly effective in both adults and chlidren, but it is limited by patient tolerability.
- Empiric six-food elimination diet (SFED)- six most common foods that trigger EoE are as follows: soy, fish, cow milk,nuts, eggs, wheat.
- Limited diet driven by allergy testing and patient history- The allergy testing directed diet approach, although effective in the pediadric group has only moderate success in adults.
References
- ↑ Dellon, Evan S.; Gonsalves, Nirmala; Hirano, Ikuo; Furuta, Glenn T.; Liacouras, Chris A.; Katzka, David A.; American College of Gastroenterology (2013-05). "ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE)". The American Journal of Gastroenterology. 108 (5): 679–692, quiz 693. doi:10.1038/ajg.2013.71. ISSN 1572-0241. PMID 23567357. Check date values in:
|date=(help) - ↑ de Vernejoul P, Mestan J, Delaloye B (1971). "The application of radiocardiography in measuring pulmonary pressures and resistances". Helv Med Acta. 36 (1): 67–78. PMID 4946566.
- ↑ Liacouras CA, Spergel JM, Ruchelli E, Verma R, Mascarenhas M, Semeao E, Flick J, Kelly J, Brown-Whitehorn T, Mamula P, Markowitz JE (2005). "Eosinophilic esophagitis: a 10-year experience in 381 children". Clin. Gastroenterol. Hepatol. 3 (12): 1198–206. PMID 16361045.