If you have a new diagnosis of eosinophilic esophagitis (EoE), you’ll want to know what the best treatment is for you. The mainstays of treatment for EoE are proton pump inhibitors, steroids, diet changes, and a procedure called esophageal dilation.
But it’s hard to say whether one therapy is better than the other. There are no head-to-head trials comparing them. That’s why doctors often rely on other things – like patient preferences, how easy it is to get medications, how severe the disease is, and its impact on a patient’s life – to figure out the best treatment for their particular case of EoE.
Here are some things your doctor may consider before they recommend a treatment.
A history of allergies. If you already have known allergies, your doctor will be more likely to refer you to an allergist. Food allergies can often make EoE worse. The most common culprits are:
If you have EoE, there’s no one-size-fits-all approach to food allergies. Some patients have a problem with just one food, while others have symptoms after they consume several foods.
It’s also trickier to identify these problem foods. Typical allergy tests, such as skin prick tests, or blood tests aren’t as accurate when it comes to identifying triggers of EoE. Skin testing, for example, has a high rate of false positives, which can lead to cutting out foods that you aren’t necessarily allergic to.
Instead of using traditional allergy testing to identify food allergies that may be causing EoE, doctors might try one of the following.
Elimination diet. This is when you do not eat or drink certain foods, like milk, soy, eggs, wheat, nuts, and seafood, for several weeks. Then you gradually add them back in, one at a time, to see if you can pinpoint the food that triggers the allergic reaction.
Elemental diet. This is a much more restrictive eating plan. It’s essentially a liquid meal replacement diet during which you do not consume any protein. You drink an amino acid instead. As you do with the elimination diet, you slowly reintroduce foods, one at a time, to identify the offending food or foods.
Research shows that the elemental diet is the most effective approach, but since it’s so restrictive, it’s very hard for people, especially adults, to stick to. There may also be other reasons that your doctor recommends an elimination diet instead of an elemental diet. For example, your insurance may not cover the amino acid formula used in the elemental diet.
But dietary approaches are not for everyone. If a person with EoE already has trouble getting proper nutrition, either because they have a condition called failure to thrive or are already on a very restrictive diet, then doctors will try a different approach.
Disease severity. If you have early-stage disease, treatment with a proton pump inhibitor (PPI), such as omeprazole, is often a good choice. The main function of these drugs is to keep stomach acid out of the esophagus in people who have acid reflux disease. But, because PPIs ramp down inflammation and help repair the damaged lining of the esophagus, they can also help people with EoE.
PPIs are easy to use and easy to get since many are available over the counter. They may be a safer option for children, since steroids (another mainstay of EoE therapy) can have side effects like slow growth, more risk of infection, and higher blood sugar. But research does suggest that they are less effective for people with narrowing of the esophagus, which can happen when the disease is more advanced.
If your disease is more severe and PPIs aren’t enough, your doctor might recommend a new treatment called Dupixent, which recently earned FDA approval to treat EoE in people ages 12 and older. It comes in the form of a weekly shot, so it’s not for the squeamish. But research show it eases inflammation – and the symptoms that come with it – with minimal side effects.
Past treatment history. If you’ve already tried proton pump inhibitors, doctors may recommend that you try steroids. This medication, which you swallow, reduces inflammation in the esophagus. Research suggests that about two out of three people with EoE who use them go into remission. But insurance doesn’t always pay for them. They also come with side effects, such as a higher risk of yeast infections, which is why doctors may try other treatments first.
Your doctor may also recommend that you use steroids along with PPIs if you have another GI condition, such as severe heartburn, erosive esophagitis, or Barrett’s esophagus.
Age. If you got your EoE diagnosis at an older age, it’s likely that you had the condition for a while before you found out. As a result, you may have gotten an esophageal stricture, a narrowing or tightening of the esophagus. This is one of the most severe complications of EoE. Research shows that for every 10-year increase in a patient’s age, the odds of having one of these strictures doubles.
If your esophagus has narrowed, you’re a candidate for a procedure called esophageal dilation. In this treatment, your doctor stretches your esophagus to widen it back out. Though very effective, it’s generally reserved for older people with strictures who haven’t responded to treatment with medicine. That’s because this procedure carries risks, such as esophageal tears, chest pain, and bleeding. To be safe, your doctor may do the procedure across several sessions to dilate the esophagus a little each time. They may also prescribe medications alongside this procedure.
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UpToDate: “Treatment of Eosinophilic Esophagitis.”
Cleveland Clinic: “Eosinophilic Esophagitis.”
Journal of Allergy and Clinical Immunology: “Diagnosis and Treatment of Eosinophilic Esophagitis.”
American College of Gastroenterology: “Eosinophilic Esophagitis.”
GI & Hepatology News: “Eosinophilic Esophagitis: Frequently Asked Questions and Answers for the Early-Career Gastroenterologist.”
News release, FDA.
Mayo Clinic: “Eosinophilic esophagitis.”
American Society for Gastrointestinal Endoscopy: “Understanding Esophageal Dilation.”