Your treatment for eosinophilic esophagitis (EoE) typically begins with a prescription acid blocker called a proton pump inhibitor (PPI). If a PPI doesn’t work, your doctor may also prescribe a liquid steroid that you swallow. While you take medications, you might also go on an elimination diet -- where you stop eating certain foods for a while -- to help your doctor identify the foods that trigger your symptoms. For many people, these first-line dietary and medical treatments are enough to reduce symptoms and improve quality of life.
But for others, first-line treatments aren’t enough. About two-thirds of people on PPIs and one-third of people on steroids don’t get to remission of their EoE.
In these cases, doctors turn to these options:
Esophageal dilation. If your EoE that has gone undiagnosed and untreated for a while, the esophagus can become narrow and tight. This is called esophageal stricture. In this case, diet and medication may not help with symptoms. Instead, your doctor might suggest a procedure called esophageal dilation. It gently stretches out your esophagus muscles to create space for food to pass through.
Using an endoscope (a thin flexible tube with a light and camera on the end) and an expanding tool, your doctor gently pushes out the walls of your esophagus. The procedure requires that the doctor push the endoscope through your throat, your esophagus, and into the first part of your small intestine. For this reason, they typically use a numbing spray on your throat and a sedative to relax you. After the scope is in place, they’ll use a balloon or plastic dilator over a guiding wire to stretch the esophagus. It’s a safe procedure that doesn’t have many risks. It might cause a tear in the esophagus that requires surgery to fix, but this is rare. If you have severe narrowing, your doctor might do multiple dilation sessions to expand your esophagus over time.
Keep in mind, esophageal stricture is only a symptom of EoE, and dilation treats just this one symptom. It doesn’t address the ongoing inflammation that your EoE will continue to cause after dilation. You’ll likely still need other treatments such as elimination diets and medications to continue to keep the lining of your esophagus from closing. It’s also possible you’ll need additional dilations at a future date.
Biologic drugs. In May 2022, the FDA approved the first biologic drug, dupilumab (Dupixent), to treat EoE in people over 12. Dupilumab is a type of drug called a monoclonal antibody. You take it as an injection. It works by blocking the activity of two inflammatory substances in your body called interleukin 4 (IL-4) and interleukin 13 (IL-13). These substances drive the inflammation that causes EoE symptoms.
By blocking IL-4 and IL-13, dupilumab slows down the process that causes the overgrowth of eosinophils (white blood cells) in your esophagus. This eases inflammation and symptoms. A big difference in this drug compared to PPIs or steroids is that biologics work directly on the disease process that causes the inflammation in the first place instead of treating symptoms.
Dupilumab has some common side effects, including:
- Injection site reactions
- Upper respiratory tract infections
- Joint pain
- Herpes viral infections.
Doctors are studying whether they should give these drugs as first line treatments in the future.
Other biologic drugs for treating EoE are currently in phase II or III clinical trials. They’ll target different inflammatory proteins than dupilumab. They include:
- Mepolizumab and reslizumab: Lab-made antibodies that fight against interleukin-5 (IL-5).
- Benralizumab: Lab-made antibodies that interfere with the activity of IL-5.
- QAX576 and RPC4046: Drugs that target IL-13.
- AK002: An antibody that interferes with the activity of a specific protein, called Siglec-8, on the surface of eosinophils.
- Losartan: A blood pressure medication that may work to treat EoE as well.
- CALY-002: A lab-made antibody that fights against IL-15.
The only way to get these treatments right now is to take part in a clinical trial that uses them.
Photo Credit: Yuguang Zhang / Getty Images
Mayo Clinic: “Eosinophilic esophagitis.”
AJMC: “Patients With EoE Lack Effective, Targeted Therapies for Long-term Disease Control, Review Finds.”
ASGE: “Understanding Esophageal Dilation.”
Current Opinion in Gastroenterology: “Esophageal dilation in eosinophilic esophagitis: risks, benefits, and when to do it.”
Gastroenterology: “Efficacy of Dupilumab in a Phase 2 Randomized Trial of Adults With Active Eosinophilic Esophagitis.”
FDA: “FDA Approves First Treatment for Eosinophilic Esophagitis, a Chronic Immune Disorder.”
Journal of Allergy and Clinical Immunology: In Practice: “Controversies in Allergy: The Potential Role of Biologics as First-Line Therapy in Eosinophilic Disorders.”
Pharmacological Therapy: “Siglec-8 as a drugable target to treat eosinophil and mast cell-associated conditions.”
ClinicalTrials.gov: “Dose Escalation Study to Evaluate an Experimental New Treatment (CALY-002) in Healthy Subjects and Subjects With Celiac Disease and Eosinophilic Esophagitis.”
Mayo Clinic: “Dupilumab (Subcutaneous Route).”