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Eosinophilic Esophagitis: Questions on Management

Q: A 15 year-old girl with a recent diagnosis of eosinophilic esophagitis (EoE) was referred by a pediatric gastroenterologist for evaluation of possible food allergies contributing to her EoE. She presented initially with recurrent abdominal pain. Endoscopy with biopsies shows >30 eosinophils/high power field in the mid- and distal esophagus, along with basal zone hyperplasia. She has not had any symptoms of GERD or difficulty swallowing, and never received PPI therapy, but rather has been placed on swallowed fluticasone alone.


 Does any evidence indicate a specific duration to treat with swallowed steroids? Is it reasonable to perform only dietary changes and observe?

A: Eosinophilic esophagitis has posed many challenges with regard to treatment strategy. In current consensus guidelines, there is no definitive duration of initial or ongoing treatment recommended with regard to swallowed/topical steroids. The decision to initiate or stop steroid therapy should be based on clinical judgment weighing the risks and benefits of initiation or continuation of therapy. These guidelines also mention that topical steroids have been shown to be effective short term with good safety (except local fungal infections), but longer-term safety studies are lacking and the disease often recurs upon discontinuation of steroid therapy.

On this subject, one of the recent guidelines indicates “Clinical experience and concern for ongoing symptoms, esophageal inflammation, and complications of untreated disease have led to the recommendation that after induction of clinicopathologic remission, topical corticosteroid therapy might need to be maintained; however, long-term therapy must be individualized for each patient. When topical steroids are used chronically, in addition to observing for side effects, growth should be carefully monitored in children."

Another consideration should be made for possible PPI-responsive esophageal eosinophilia. In the recent article in JACI: In Practice July/August 2013 (referenced below), an 8 week trial of PPI therapy was recommended prior to a diagnostic esophageal biopsy, and concurrent treatment with PPI is suggested. This article also provides a helpful schematic algorithm (in Figure 1) for clinical management of eosinophilic esophagitis.

With regard to your second question, it would be reasonable to attempt either dietary therapy (empiric elimination diet or targeted diet) or topical steroid therapy alone - or both at the same time. There is currently no data regarding which intervention (topical steroid or dietary therapy) is more effective; therefore, the decision is left to your discretion. Please take into consideration that if both strategies are initiated concurrently, it may be difficult to identify respective treatment effect.

References: 1. Liacouras CA, et al., Eosinophilic esophagitis: Updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011 (July); 128(1):3-20 (E6).
2. Greenhawt M, Aceves SS, Spergel JM, Rothenberg ME., The management of eosinophilic esophagitis. J Allergy Clin Immunol: In Practice 2013;1:332-40.

 
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