5 Eosinophilic Esophagitis Treatment Options

There are several treatments that can improve the quality of life for people with eosinophilic esophagitis (EoE). Doctors may recommend diet changes, medication, and procedures and many use a combination of therapies. The treatment plan that works best can vary from person to person and over time, so you may have to try several approaches before you find something that works for you.

EoE is a chronic condition that often requires lifelong treatment. It is caused by the accumulation of eosinophils, a type of white blood cell, in the esophagus that leads to inflammation and damage. People with EoE have difficulty swallowing (dysphagia) and can have food get stuck in the esophagus (food impaction). EoE is diagnosed with an endoscopy (a camera that looks at your esophagus) performed by a gastroenterologist. The appearance of your esophagus will support the diagnosis, and tissue samples (biopsies taken during endoscopy) of your esophagus are needed to confirm the diagnosis.

Doctors may recommend diet changes, medication, and procedures. Many people use a combination of therapies.

Treatments might change as your symptoms evolve, so it’s important to work closely with your healthcare team to manage your condition. Below, we describe some of the treatment options for EoE.

1. Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are medications that reduce how much stomach acid you make. They’re also widely used to treat gastroesophageal reflux disease (GERD), a common condition that causes heartburn. PPIs can be over-the-counter or prescription drugs. Usually, people with EoE start with high-dose PPIs.

PPIs are often the first-line treatment for EoE, but they don’t work for everyone. If you’ve tried these drugs and continue to have symptoms, your doctor may recommend other medications or dietary therapy.

2. Dietary Therapy

Sometimes, EoE can be managed by avoiding foods that trigger allergic reactions, known as food allergens. This approach can be used if someone isn’t responding to proton pump inhibitors, but it can also be the first treatment someone with EoE tries. If changing your diet is helpful, you may be able to avoid taking medications that could cause side effects. On the other hand, it may be difficult to get proper nutrition and keep your body healthy if you need to eliminate too many foods.

Diets for EoE include:

• Empiric elimination diet without an allergy test — This diet includes avoiding the categories of foods and drinks that most often cause allergic reactions, such as wheat, dairy, eggs, peanuts, tree nuts, soy, fish, and shellfish.
• Allergy test-directed elimination diet — You undergo allergy testing to figure out which foods you are allergic to, then eliminate those items from your diet.
• Elemental diet — The most restrictive type of diet, it involves avoiding any foods or drinks that contain proteins, and drinking a liquid containing amino acids (the building blocks of proteins).

Often, your healthcare provider will suggest a less-restrictive diet first, and then remove foods if symptoms don’t improve.

It may be helpful to work with other healthcare providers, like an allergist or a dietitian, when planning a new diet. An allergist can perform testing to help determine your food allergies. A registered dietitian can help build a food elimination diet that meets your nutritional needs and makes sure you aren’t missing any important vitamins or minerals. Your gastroenterologist (digestive system specialist) can refer you to these other providers.

It may be helpful to work with other healthcare providers, like an allergist or a dietitian, when planning a new diet.

When following a dietary plan, you’ll likely need several endoscopies. These check whether the inflammation goes away after removing a certain food group and make sure it doesn’t come back when that food group is added again.

3. Topical Corticosteroids

Steroid medications, also called corticosteroids, reduce inflammation in your body. Topical steroids are applied directly to the affected area. In the case of EoE, topical steroids are used in the esophagus by swallowing medication. Budesonide (Eohilia) is a topical steroid approved for children aged 11 and up and adults with EoE. It’s a liquid that you swallow daily, usually twice a day. Budesonide can help with dysphagia (difficulty swallowing) and has been shown in clinical trials to improve EoE in about 30 percent to 50 percent of people.

Another steroid that’s often used for EoE is fluticasone. Although it’s not specifically approved for EoE, fluticasone has been used for years to treat this condition. Fluticasone is often sprayed into the mouth using an inhaler and swallowed. For children, it’s also possible to mix the medication into a slurry to make it easier to take.

4. Dupilumab

The biologic medication dupilumab (Dupixent) is approved by the U.S. Food and Drug Administration (FDA) to treat EoE in adults and children 1 year old and up. It’s a monoclonal antibody, a type of protein that blocks the overactive immune response in the esophagus and reduces inflammation and damage. It is an injection you give yourself once a week.

One study found a 64 percent reduction of EoE symptoms in people who took dupilumab. The condition was also 10 times more likely to go into remission — a period of improved symptoms and fewer signs of EoE — for people who took dupilumab compared to those who received a placebo (sugar pill).

The current guidelines for treatment of EoE recommend that people who haven’t responded to PPIs try dupilumab. However, your provider might suggest earlier use of this medication if you have other conditions that can also be treated with dupilumab, such as severe asthma or eczema.

5. Esophageal Dilation

EoE often leads to fibrosis (buildup of scar tissue) and stricture (narrowing) of the esophagus. This can make it more difficult for food to pass through and can lead to food impaction (when food gets stuck in the esophagus).

Esophageal dilation is a procedure that can help widen the stricture and make eating easier. It is often performed at the same time as an upper endoscopy.

It may take some trial and error before you find the right treatment plan.

Dilation endoscopy is usually only used if medications are not helping with dysphagia, because there’s a risk of esophageal damage and chest pain, but it can also be used together with medications if symptoms are severe. It often takes several sessions of endoscopy to open the esophagus wide enough to make a difference. Even if you choose to have esophageal dilation, you’ll still need to continue taking anti-inflammatory medications like steroids or biologics to prevent new strictures from forming due to the inflammation.

What’s the First-Line Treatment for Eosinophilic Esophagitis?

The most recent guidelines on treating EoE suggest that people with EoE and their providers make a shared decision about which treatments to try first. In general, you can start with PPI medication for a trial period of several weeks, or you can make diet changes first. However, other therapies can be chosen first depending on the severity of your symptoms, history of food impactions, your endoscopy findings, other comorbid conditions, and your preference. If the first type of treatment isn’t helping EoE symptoms, your healthcare team will work with you to plan the next steps.

Deciding on a Treatment Plan

To find the best approach for treating your EoE, you’ll want to talk over the options with your healthcare team. It may take some trial and error before you find the right treatment plan. It’s important to follow up with your providers and let them know if treatments don’t seem to be working well, or if you experience any health changes.

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