Eosinophilic Esophagitis: Effective Lifestyle, Medications, and Procedures
Health ConditionsDigestive Health

Eosinophilic Esophagitis Treatment: A Complete Guide

Eosinophilic Esophagitis Treatment: A Complete Guide
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Published on August 1, 2024
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Eosinophilic esophagitis (EoE) is a chronic immune system disease that occurs due to an allergic reaction to certain foods that causes a certain type of white blood cells (eosinophils) to build-up in the esophagus, causing it to become inflamed.

This inflammation can make it difficult to swallow or cause food to get caught in the esophagus after swallowing. It can also trigger acid reflux, chest pain that does not go away with antacids, and regurgitation.

Because EoE is a chronic condition, most people require ongoing treatment to manage their symptoms. After a doctor rules out other conditions that cause similar symptoms, and perhaps tests for food allergies, they will likely work with a team to develop a specialized diet depending on a person’s individual triggers. Aside from diet changes, some people might need medications or to undergo a procedure (such as endoscopy) that dilates the esophagus if it is narrowed.

Eosinophilic Esophagitis Medication

An essential part of managing EoE is taking certain medications, some of which can help lower the immune response that occurs with EoE. Other medications may prevent triggers, such as acid reflux. There are a few your doctor can choose from.

Proton Pump Inhibitors (PPIs)

Proton pump inhibitors (PPIs) work by decreasing the amount of stomach acid the stomach produces. They’re often prescribed for acid reflux, GERD, and EoE, but many people with EoE do not have their symptoms improve with PPIs.

Since EoE is a chronic condition, most people would likely need to take PPIs long-term.

Common PPIs include:

  • omeprazole (Prilosec OTC, Zegerid, and OmePPi)
  • esomeprazole (Nexium)

Steroids

For years, steroids have been used-off label for EoE, mostly budesonide and fluticasone.

Budesonide Oral Suspension In 2024, the U.S. Food and Drug Administration (FDA) approved the first EoE-specific corticosteroid, or steroid, called budesonide oral suspension (Eohilia). The drug, a liquid that is taken twice a day at least 30 minutes before or after eating or drinking, is currently only approved in the United States for a 12 week course in people 11 years and older.

Steroids are used to treat inflammation and reduce the immune system’s activity. Oral budesonide specifically works by decreasing the number of eosinophils, the type of white blood cells that cause EoE, that build up on the esophagus.

Some people might experience side effects while taking oral budesonide. Also, not everyone can take it — the FDA recommends people with liver failure not take oral budesonide. It can also be dangerous and potentially fatal for someone who has measles, chickenpox, or shingles to take the drug. Budesonide also comes in a liquid form that is taken by mouth.

Fluticasone Fluticasone, which is typically used to treat asthma, is also used off-label to treat EoE. The medication is prescribed as an an inhaler but has to be mixed into an oral slurry (such as with apple sauce) and swallowed. It used to be sold as Flovent, but now is only available under its generic name.

Since it’s a steroid, the same precautions about infection susceptibility apply to people taking fluticasone as well.

Any steroid causes immune suppression, which means people taking these drugs are more prone to infections, including bacterial, fungal, and viral infections.

Monoclonal Antibodies 

As part of a class of drugs called biologics, monoclonal antibodies contain lab-made molecules that behave like antibodies. They can be made from mouse proteins, human proteins, or a combination of both. In the case of EoE treatment, monoclonal antibodies block or reduce immune-regulating proteins that have been shown to cause EoE.

Dupilumab The FDA approved an injectable monoclonal antibody called dupilumab (Dupixent) for the treatment of EoE in early 2024. The antibody blocks signaling from two proteins — interleukin-4 and interleukin-13 — which play key roles in triggering and sustaining EoE. It can be used in patients as young as 1 year old, who weigh at least 33 pounds. It is an injection that is given weekly.

Dupilumab is the only monoclonal antibody currently approved by the FDA for EoE, but researchers are investigating other monoclonal antibodies for the treatment of EoE, including:


  • cendakimab
  • dectrekumab
  • mepolizumab (Nucala)
  • reslizumab (Xolair)
  • benralizumab (Fasenra)
  • tezepelumab (Tezspire)
  • lirentelimab
Drug Type
What They Do
Proton pump inhibitors (PPIs)

Reduce the amount of acid the stomach produces, which can treat acid reflux

Steroids

Treat inflammation by reducing the immune system’s response

Monoclonal antibodies

Behave like antibodies that block or reduce immune-regulating proteins that have been shown to cause EoE

Eosinophilic Esophagitis Procedures

Some people with EoE may develop a stricture, in which the esophagus narrows. This can make it difficult to swallow or cause food to get stuck in the esophagus when you do. A procedure called esophageal dilation can correct this narrowing and make it easier to swallow.

During an esophageal dilation, a patient is usually not under full anesthesia. During the dilation, a doctor guides a scope with a specialized balloon into the esophagus and gently inflates the balloon, stretching the esophagus and widening the stricture. People often need repeat dilations depending on how narrow the esophagus is.

It’s important to understand that dilation does not address the underlying inflammation associated with EoE. The procedure is used in tandem with dietary changes and drugs to help manage EoE.

Eosinophilic Esophagitis Lifestyle Changes

Identifying food allergies and triggers, often through an elimination diet, is sometimes the first line of treatment for EoE. This means removing a particular food from your diet for a few weeks at a time, then adding it back in and assessing whether it triggers symptoms or if the eosinophils have returned on the endoscopy as some patients have no symptoms despite active inflammation. If it does, studies have shown that permanently eliminating trigger foods can significantly help relieve EoE symptoms. The most common EoE food triggers are milk, wheat, soy, eggs, nuts, and seafood, but which individual foods, or which combination of foods, is a trigger will be different for everyone. Milk is a very common trigger for children who have EoE, so it’s likely a pediatric care team will start with eliminating milk.

Some people may also do an elemental diet. This is more intense than an elimination diet and is usually reserved for severe cases. People do not eat any usual food for six weeks. Instead, they get all their nutrients from liquid aminoacid-based nutrition. Studies have shown that an elemental diet can put people with EoE into remission.

Eosinophilic Esophagitis and Mental Health

Mental health issues are common in anyone living with a chronic condition. It can be a long road to determining what your triggers are and what medications work for you, and people with EoE may experience anxiety or depression.

If you’re worried about the toll EoE is taking on your mental health, talk with your healthcare provider to connect with someone who specializes in helping people cope with chronic illness. Cognitive behavioral therapy (CBT), mindfulness, and meditation have been shown to help people cope with living with a chronic condition.

The Takeaway

Eosinophilic Esophagitis is a complex condition and what causes EoE is different from person to person — so is treatment. Treatment usually requires a multi-pronged approach that starts with identifying food triggers. It may also require different types of medications — PPIs, steroids, or biologics — or dilation procedures. With a holistic approach, the condition is manageable, and researchers are working to develop new drugs to stop EoE triggers. 

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Yuying Luo, MD

Medical Reviewer

Yuying Luo, MD, is an assistant professor of medicine at Mount Sinai West and Morningside in New York City. She aims to deliver evidence-based, patient-centered, and holistic care for her patients.

Her clinical and research focus includes patients with disorders of gut-brain interaction such as irritable bowel syndrome and functional dyspepsia; patients with lower gastrointestinal motility (constipation) disorders and defecatory and anorectal disorders (such as dyssynergic defecation); and women’s gastrointestinal health.

She graduated from Harvard with a bachelor's degree in molecular and cellular biology and received her MD from the NYU Grossman School of Medicine. She completed her residency in internal medicine at the Icahn School of Medicine at Mount Sinai, where she was also chief resident. She completed her gastroenterology fellowship at Mount Sinai Hospital and was also chief fellow.

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Kaitlin Sullivan

Kaitlin Sullivan

Author
Kaitlin Sullivan reports on health, science, and the environment from Colorado. She has a master's in health and science journalism from the City University of New York.
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