Management of eosinophilic oesophagitis in adults
All adults with eosinophilic oesophagitis should be managed by, or in consultation with, a gastroenterologist. Management involves dietary, pharmacological and, in some cases, endoscopic interventions. Management varies widely, ranging from largely symptomatic management to intensive therapy with frequent endoscopic monitoring to minimise inflammation. Dietary or pharmacological therapy should not be adjusted without specialist advice.
Dietary therapy has been shown to be effective for eosinophilic oesophagitis; however, this involves a major lifestyle change and is difficult to adhere to, especially for adults. A variety of dietary protocols are used; some involve multiple and frequent upper gastrointestinal endoscopic procedures to assess the impact of dietary changes.
Elimination diets may be difficult to follow, and there is a risk that the diet may not be nutritionally adequate or be associated with unhealthy eating habits. Therefore, elimination diets require education and supervision by an accredited practising dietitian; 2-food (milk and wheat), 4-food (wheat, egg, dairy, soy), or 6-food (wheat, egg, dairy, soy, nuts, seafood) elimination diets are commonly trialledWolf, 2014. If the patient responds to the diet, foods should be gradually re-introduced to identify trigger foods (on a symptomatic or endoscopic basis, depending on the management philosophy); dairy and wheat are the most common triggers. Limiting specific foods may improve symptoms, but this should only be continued if effective; advise patients to avoid food restrictions that do not improve symptoms.
Drug therapy for eosinophilic oesophagitis may include proton pump inhibitors (PPI) with or without topical corticosteroids. Eosinophilic oesophagitis may be seasonal, so symptomatic treatment may only be required at certain times of year (usually during spring or summer). Gastro-oesophageal reflux can be a contributing factor in the pathogenesis of eosinophilic oesophagitis, and PPIs may have additional anti-inflammatory effects. First-line drug therapy is a PPI at the standard dose; seek advice from a gastroenterologist about the duration of therapy. Use:
1esomeprazole 20 mg orally, daily, half to one hour before a meal esomeprazole esomeprazole esomeprazole
OR
1lansoprazole 30 mg orally, daily, half to one hour before a meal lansoprazole lansoprazole lansoprazole
OR
1omeprazole 20 mg orally, daily, half to one hour before a meal omeprazole omeprazole omeprazole
OR
1pantoprazole 40 mg orally, daily, half to one hour before a meal pantoprazole pantoprazole pantoprazole
OR
1rabeprazole 20 mg orally, daily, half to one hour before a meal. rabeprazole rabeprazole rabeprazole
Higher PPI doses may be required for some patients. Dose adjustment should not be made without consulting the treating specialist.
If symptoms do not resolve with PPI therapy, a topical corticosteroid may be added. Seek advice from a gastroenterologist about the dosage and duration of therapy. Suitable regimens include:
budesonide 1 mg orally (disintegrating tablet), at least 30 minutes after a meal, twice daily1. budesonide budesonide budesonide
Alternatively, use:
1fluticasone propionate 250 to 500 micrograms by metered dose inhaler, sprayed into the throat during a breath hold and swallowed, once or twice daily depending on symptom severity2Kuchen, 2014 fluticasone propionate fluticasone propionate fluticasone propionate
OR
2budesonide slurry (1 mg/2 mL nebuliser solution mixed with 3 to 5 g sucralose powder [Splenda]) swallowed, twice dailyDellon, 2014Dellon, 20123. budesonide budesonide budesonide
When using fluticasone propionate metered dose inhaler, the corticosteroid must be swallowed to coat the oesophagus (rather than inhaled into the lungs, as for asthma therapy).
To maximise the effectiveness of topical corticosteroids, instruct the patient not to rinse their mouth, or eat or drink for 30 minutes after the dose. This may increase the risk of oropharyngeal or oesophageal candidiasis.
Following the initial treatment course, the gastroenterologist may reduce the dose or stop the topical corticosteroid. Monitor the patient for relapse. Repeat treatment may be required—seek expert advice.
For refractory cases, oral prednisolone may be required—seek expert advice.
Endoscopic oesophageal dilatation may be required if oesophageal fibrosis or remodelling has occurred. Although dilatation is associated with sometimes dramatic tearing of the oesophageal mucosa, when performed carefully there does not appear to be a significantly increased risk of oesophageal perforationMoawad, 2013.