Evolving Management of Eosinophilic Esophagitis: From Diagnosis to Early Intervention - Episode 6
Choosing a First- Line Therapy for EoE
Panelists discuss how first-line eosinophilic esophagitis (EoE) treatment involves shared decision-making between proton pump inhibitors, topical swallowed steroids, or food elimination diets, with therapy selection based on patient preferences, lifestyle factors, developmental stage in children, and the understanding that treatment approaches can evolve over time as circumstances change.
Treatment selection for EoE follows a patient-centered, shared decision-making approach rather than a standardized protocol, as no single “best” first-line therapy has been definitively established. According to recent American College of Gastroenterology guidelines, 3 primary first-line treatment options exist: proton pump inhibitors (PPIs), topical swallowed steroids, and food elimination diets. Many practitioners begin with PPI therapy to assess patient responsiveness before considering alternative treatments, though the optimal choice varies significantly based on individual patient factors and circumstances.
The shared decision-making process involves comprehensive discussion of treatment trade-offs, patient values, lifestyle factors, and feasibility considerations. Each therapy option presents distinct advantages and challenges that must be weighed against patient preferences and capabilities. For instance, dietary therapy may be highly effective but requires significant lifestyle modifications and cooking abilities, whereas medications offer convenience but may have different acceptability profiles among patients and families. Busy young adults or university students may find dietary restrictions particularly challenging to implement effectively, whereas families with young children might have better control over dietary interventions.
Pediatric treatment considerations incorporate developmental stages, with 3 distinct age groups requiring different approaches: 0 to 6 years (family-controlled environment favoring dietary therapy), 7 to 12 years (increased socialization potentially complicating dietary restrictions), and 13+ years (requiring adolescent-appropriate strategies). Treatment selection should prioritize adherence potential and lifestyle integration, recognizing that optimal therapy choices may evolve as patients’ life circumstances change. The treatment landscape continues to expand, with 4 current categories and anticipated future options. Current limitations include the lack of reliable allergy testing to identify specific food triggers, necessitating trial-and-error approaches for dietary interventions. Ongoing research aims to develop better methods for identifying allergenic foods, potentially improving the precision and effectiveness of elimination diet strategies in the future.
