When discussing treatment for eosinophilic esophagitis (EoE), often the first-line treatment is a choice between diet and medication, Evan S. Dellon, MD, said during his presentation at the 2023 ACG Annual Scientific Meeting and Postgraduate Course on October 22, in Vancouver, Canada.

“And it doesn’t always have to be either/ or,” Dr Dellon said. “Ultimately, it all comes down to shared decision making and patient and provider preference.”

Dr Dellon is a professor of medicine and an adjunct professor of epidemiology for Center for Esophageal Diseases and Swallowing at the University of North Carolina School of Medicine, Chapel Hill, North Carolina.

Current EoE treatments include non-pharmacologic treatments and pharmacologic treatments. Non-pharmacologic treatments may further include dietary elimination and esophageal dilation. On the other hand, pharmacologic treatment may include proton pump inhibitors (PPIs), topical corticosteroids, mast cell stabilizers, immunomodulators, biologics and small molecules.

Dietary interventions have become the first-line treatment of EoE and are as effective as medication therapies, according to international guidelines.

Using the results of the research paper by Angel Arias and colleagues, published in Gastroenterology, elemental diets were found to be effective for 90.8% of the cases, 6-food elimination diets (SFEDs) were found to be effective for 72.1% of the cases, and allergy test result-directed food elimination for 45.5% of cases. Elemental diets and SFEDs were the most effective, “achieving <15 eosinophils/high-power field in 90.8% and 72.1% of patients, respectively,” Dr Dellon said.

Among topical corticosteroids, both fluticasone and budesonide have shown statistically significant decrease in eosinophil count. However, “fluticasone showed faster inset of action and greater immunologic improvement compared to budesonide.”

Dupilumab—a biologic approved for the treatment of multiple type 2 inflammatory diseases such as atopic dermatitis, asthma, chronic rhinosinusitis with nasal polyps—is indicated for EOE among patients 12 years and older, 40 kg and above with a dosing of 300 mg weekly.

“While both medication and diet therapies are effective,” Dr Dellon concluded, “they are both limited by several critical issues.”

Reference:
Dellon E. Eosinophilic esophagitis: Beyond PPI therapy. Session 2B: The esophagus and more: Elucidating the esophageal enigmas. Presented at: 2023 ACG Postgraduate Course. Vancouver, Canada. October 22, 2023.