Proton Pump Inhibitors (PPIs) / Steroids / Biologics / Procedures

• Dietary changes alone don’t work for everyone with eosinophilic esophagitis (EoE).
• There are several categories of medications that may improve your EoE symptoms.
• Esophageal dilation can be a treatment option, but it may involve a series of dilation procedures over time.

Eosinophilic esophagitis is a condition that affects the esophagus — the tube that carries food from the throat to the stomach. It may be triggered by allergens, certain foods, or acid reflux. These triggers can cause the lining of the esophagus to fill with immune cells called eosinophils. These white blood cells can lead to inflammation, damage, and pain within the esophagus.

Treatment plans may include dietary changes, medication, procedures, or a combination of these. An elimination diet (avoiding certain foods) may be the only treatment needed for some people. However, this approach doesn’t work for everyone. It’s not always effective, it can be frustrating to stick to a diet, and it can be hard to get all of the necessary nutrients. Medication and procedures may help when dietary therapy isn’t a good fit.

Several types of medication can boost your quality of life and treat EoE symptoms like difficulty swallowing and food impaction.

EoE Medications

Several types of medication can boost your quality of life and treat EoE symptoms like difficulty swallowing and food impaction (when food gets stuck in the esophagus). People with this condition may be able to take proton pump inhibitors (PPIs), steroids, or biologics.

Proton Pump Inhibitors

PPIs are often the first treatment recommended for EoE. These medications reduce the amount of acid the stomach makes. PPIs can help prevent inflammation in the esophagus, which may ease EoE symptoms. These medications are also used to treat gastroesophageal reflux disease (GERD), a related condition that causes similar symptoms such as heartburn.

PPIs are often tablets or capsules that you take every day. Doctors usually suggest taking these medications in the morning, before any food is in your stomach.

PPIs improve symptoms of EoE for many people. However, different studies have reported different success rates. A review of studies found PPIs helped decrease the number of eosinophils in the esophagus for between 33 percent and 61 percent of people. Additionally, 25 percent to 80 percent of people who use PPIs have fewer symptoms. One recent study found that, among people who experienced a drop in eosinophils after taking PPIs, 64 percent still had reduced symptoms after a couple of years.

PPIs can sometimes cause side effects such as infection or vitamin or mineral deficiencies.

Steroids for EoE

If your EoE symptoms persist after trying a PPI, your gastroenterologist may recommend a steroid medication. Steroids help calm the immune system and lower inflammation levels.

The first drug in this class you’ll likely try is a topical corticosteroid. These medications are swallowed, allowing them to reach the esophagus lining. Your doctor may tell you to take high doses of these steroids at first. If they work well to reduce your symptoms, your doctor may recommend continuing to take them while using the smallest dose needed to maintain positive effects. This may help you avoid side effects.

One topical steroid is fluticasone (Flovent). This medication can be swallowed from an inhaler that dispenses the correct dose. Another topical steroid, budesonide (Entocort EC), needs to be mixed with a thickening agent such as Splenda, applesauce, or honey to form a slurry. Your doctor may recommend taking these medications twice per day.

In 2024, the U.S. Food and Drug Administration (FDA) approved budesonide oral suspension (Eohilia) as a specially formulated preparation of the steroid. Eohilia can be taken for 12 weeks by adults and children 11 years and older who have been diagnosed with EoE.

Each of these medications works equally well to treat EoE. In a recent study, budesonide decreased eosinophil counts for 71 percent of people, and fluticasone lowered eosinophil levels for 64 percent.

In some cases, doctors may also recommend systemic steroids — steroid medications that come in the form of a pill or tablet and travel throughout the bloodstream to the whole body. Oral systemic steroids may be a good choice for those who can’t use topical steroids because of severe swallowing problems or for those who try topical steroids and find them ineffective. However, these medicines often cause a lot of side effects, and doctors discourage using oral systemic steroids long term.

Biologics for EoE

Biologics are medications that come from living organisms. In the case of EoE treatments, biologics are usually monoclonal antibodies — proteins that can recognize and block certain parts of the immune system.

One biologic, dupilumab (Dupixent), became the first treatment approved by the FDA to treat EoE in 2022. Doctors may still recommend using other biologics off-label, however. Many of these other biologics have been approved to treat similar health conditions and may help people with EoE.

Dupilumab

Dupilumab works by blocking the immune system’s inflammatory response. It’s approved to treat EoE in adults and children ages 1 year and older who weigh at least 33 pounds (15 kilograms). This drug is given as a shot in the upper arm, thigh, or abdomen.

A clinical trial found dupilumab to be effective for more than half of the people with EoE who took it. About 60 percent of people who used dupilumab had significantly fewer eosinophils in their esophagus, while only 5 percent of people who took a placebo (sugar pill) experienced the same result.

Side effects of dupilumab may include the following issues:

• Dry, burning, or very watery eyes
• Pain, swelling, or redness of the eye or eyelid
• Skin reactions leading to discoloration, blistering, or scaling
• Tiredness
• Chest pain or cough
• Sore throat
• Bleeding or bruising problems

Other Biologics

Researchers are developing and testing other biologics, some of which have shown in early studies that they might help with EoE. You may be able to try these potential new treatments by participating in a clinical trial, however, none are approved by the FDA at this time to treat EoE specifically.

Procedures To Treat EoE

In some cases, EoE can cause the esophagus to swell and become more narrow. This narrow place in the throat is called a stricture. A procedure called esophageal dilation can help stretch the tissue, opening the esophagus more fully. This may help ease swallowing problems.

Often, doctors recommend a series of dilations in which the esophagus is gradually widened over time.

Esophageal dilation may be a good choice when medication is ineffective or when you don’t want to take medications due to side effects or other difficulties. This procedure can help improve EoE symptoms for 19 out of 20 people.

To prepare for an esophageal dilation, you will likely have to avoid eating or drinking for several hours before the procedure. Make sure to follow the instructions from your health care provider.

There are different ways to carry out esophageal dilation. Your doctor may perform an endoscopic procedure, in which a tube is passed down your esophagus and into your stomach and small intestine. During an endoscopy, your doctor may use other tools to stretch out the tissue, such as balloons that are gradually filled with air or thin tubes that are wider on one end. Alternatively, your doctor may guide a weighted, cone-shaped dilator instrument down your esophagus, which helps increase the size of the tunnel.

Esophageal dilation occasionally comes with medical complications. It’s possible the procedure will leave a small hole or tear in your esophagus. If your esophagus isn’t already narrowed, the risk of perforation during this procedure is increased.

You may also experience side effects from any sleep-inducing or pain-relieving medications used during the procedure. However, these complications are rare.

If your esophagus is very narrow, it may be hard for the doctor to sufficiently widen it all at once. Often, doctors recommend a series of dilations in which the esophagus is gradually widened over time. In some cases, additional dilations may be needed in the future if your esophagus begins to shrink again. One study found that people with EoE who used esophageal dilation needed an average of three procedures.

Which EoE Treatment Is Best for You?

There are multiple risks and benefits to each potential treatment for EoE. Talk to your physician to explore treatment options, and ask questions about any concerns you have. Deciding on treatments together can help you find an approach that works best for you and your lifestyle. If you experience health changes, you may need to work with your doctor to change your treatment dose or try a different type of therapy.

Talk With Others Who Understand

On myEoEcenter, the site for people with eosinophilic esophagitis and their loved ones, people come together to gain a new understanding of EoE and share their stories with others who understand life with EoE.

What treatments have you tried for eosinophilic esophagitis? Share your experience in the comments below.