The treatment of patients suffering from EoE is occasionally complex and several options, from drugs to diets, and even endoscopic dilation, may be considered. The relative position of each therapy in a current therapeutic algorithm is discussed here, together with the potential benefits of each treatment option.
The recent recognition of proton pump inhibitor (PPI)-responsive esophageal eosinophilia (PPI-REE) as a particular variety of a true eosinophilic esophagitis (EoE) instead of a differentiated entity, has open the possibility of using PPIs (mainly including omeprazole, lansoprazole and esomeprazole) to treat patients with EoE. Despite the favorable safety profile of these drugs, demonstrated after 30 years of use for reducing gastric acid secretion, PPIs are effective in achieving histologic remission of EoE in only a half of patients, which means that the other half should be submitted to other alternatives. In order to achieve disease remission, PPIs in EoE are usually used at a double dose, which should be better distributed in two takings. At the present we lack of a method to identify which patients will respond to PPIs and which not, so disease remission needs to be assessed with endoscopy and biopsies, after 8 weeks of PPI use. If remission is achieved and checked, it will be maintained in the long term with standard PPI doses in both child and adult patients, but up to one out of four patient will require the initial high doses in order to maintain disease remission.
Regarding to steroids, at the present only formulas mainly designed to treat asthma or other allergic diseases are been used to treat the esophageal eosinophilic inflammation, either administered from inhaler systems of suspended in viscous solutions. No specifically-designed formula to be released and coat the esophageal mucosa is commercially available, but randomized controlled trials are ongoing, and drugs will be available in few years.
Dietary treatment for EoE
Regarding dietary treatment of EoE, elemental diet is not feasible at all for a chronic disease as EoE, so we do not recommend it except for selected pediatric cases attended in specialized centers. Despite having been widely used in multiple settings, allergy test-driven food elimination provides quite limited success in children but especially in adult patients. As a result, empiric elimination diets constitute the mainstay of this therapeutic option. Six food elimination diet was the demonstration that a drug-free and sustained remission of EoE could be achieved in most (75%) of EoE children and adult patients. However, many authors have misinterpreted the true sense of such as diet, which means not to eliminate indefinitely the 6 food groups more commonly involved in triggering food allergy, but only doing so for a 6 week period. This diet is thus instituted to achieve and document remission of EoE, as an starting point to reintroduce the several foods previously avoided, in order to identify the specific food trigger of the disease by the reappearance of the eosinophilic inflammation and symptoms. By doing so, a single food has been demonstrated to be responsible of EoE in about half of patients, and most of the remaining will have only two foods. Sustained remission of the disease after exclusively avoiding the offending one or two foods has been demonstrated for up to 5 years, with no recurrence of the disease and no need of using drugs.
However, it is sad to realize that many gastroenterologists put their EoE patients on continuous long term 6-food elimination diet, leading them to an unacceptable restriction o their diets and severe deterioration in quality of life. This is an evidence of large efforts in medical education and communication must be done.
Several research groups are currently involved in ongoing research with more simple and convenient dietary strategies to simplify empiric schemes in EoE: After demonstrating the advantages of a four-food elimination diet by an Spanish multicentre research team, another multicentre prospective trial with a two-food elimination diet, followed by 4-FED and with a final rescue option with 6-FED is currently undergoing in several Spanish and Italian centers. Preliminary results show that the efficacy of a 2-FED is around 48% (the same as PPIs as initial therapy of EoE), and one single food (mainly milk) is involved in most of the cases.
The chronic inflammatory phenomena that characterize EoE may cause collagen deposition and fibrous remodeling in patients, which increases with patients’ age and years of untreated disease. The result is esophageal narrowing and strictures, which limit the ability in ingesting solid food and cause repeated food impactions. Esophageal dilation by means of through-the-endoscope balloons or bougies has thus constituted a treatment option for EoE since its earliest descriptions. The goals of mechanical dilation are 2-fold: first, to relieve dysphagia, and, second, to achieve an esophageal caliber that allows for proper swallowing of solid foods. However, and because esophageal dilation has no effect on the underlying inflammatory process, it should not be used as the sole therapy in treating EoE patients. Despite some degree of symptomatic improvement resulting from dilation occurs in up to 75% of patients, this effect persist only in the short term. Dilation should thus be offered to symptomatic EoE patients with significant esophageal strictures or persistence of symptoms after adequate control of eosinophilic inflammation, which might be caused by a narrow esophagus. According to a recent randomized controlled trial, in patients with no severe strictures at the moment of diagnosis of EoE, esophageal dilation did not result in additional improvements in the dysphagia score when compared with treatment with either PPIs or fluticasone alone. The long-term efficacy of esophageal dilation has been assessed in at least 1 retrospective series, in which 13 patients treated with both esophageal dilation and daily antacids were evaluated over a mean follow-up period of 13.6 years. Patients initially underwent an average of 3.2 dilations during the first year; after that, regular dilations were needed about every 2 years, depending on symptom recurrence, to maintain symptom remission.
Drugs or diets, what to choose first?
Since various dietary and pharmacological options have proven effective in achieving remission of EoE, simultaneously combining different treatment modalities in the same patient is not justified. Thus, it is unnecessary to impose dietary restrictions in all cases, as they generally add no benefit to effective therapy with swallowed topical corticosteroids or PPIs, but have a negative impact on a patient’s quality of life. In fact, when several therapeutic modalities are applied simultaneously, it makes it more difficult to discern which is the most effective in controlling the disease and should therefore be maintained in the long term.
The comparative effects or advantages of dietary treatment versus drug therapy (including PPIs and topic steroids) on EoE-related symptoms and health related quality of life are currently unknown. Therefore, several expert clinicians agree in proposing the 3 therapies (PPIs, diets and topic steroids) in a same level. Regarding to endoscopic dilation it should be done in case of esophageal strictures and narrow caliber, and always accompanied with other drug of dietary measure with anti-inflammatory capacity.
The selection of the primary treatment should be thus individualized, taken into account patient’s preferences and values, local resources availability and the experience of health care providers. Having well-informed patients facilitates joint decision-making with your doctor, and result in a better outcome of treatment chosen.
Finally, and since EoE is a chronic disease, the patient’s needs may evolve over time. This means that the preferred therapeutic option may need to be modified to satisfy a given patient’s characteristics at different moments.