Management of proton pump inhibitor responsive-esophageal eosinophilia and eosinophilic esophagitis: controversies in treatment approaches

Abstract

Eosinophilic esophagitis (EoE) is a chronic immune-mediated clinicopathologic disease. The prevalence of EoE is approximately 1/2000 persons, EoE is now the most common cause of food impactions, with healthcare expenditures approaching US$ 1 billion annually. This article will discuss challenges related to proton pump inhibitor responsive esophageal eosinophilia, including distinguishing this condition from EoE and understanding the mechanisms behind the PPI response. For EoE, we will review multiple ongoing debates about treatment and monitoring strategies, including selecting treatment outcomes, optimizing medication formulations, approaching the steroid-refractory patient, conducting dietary elimination, prescribing long-term maintenance therapy and performing esophageal dilation.

Keywords:

• challenges
• endoscopy
• eosinophilic esophagitis
• management
• proton pump inhibitor responsive esophageal eosinophilia

Financial & competing interests disclosure

The authors were supported in part by NIH awards T32DK007634 (to B. Kochar), K23DK090073 and R01DK101856 (to E.S. Dellon), and U54AI117804 (CEGIR), which is part of the Rare Disease Clinical Research Network (RDCRN), an initiative of the Office of Rare Disease Research (ORDR), NCATS, and is funded through collaboration between NIAID, NIDDK, and NCATS. ES Dellon has received research funding from Miraca Life Sciences, Meritage, Receptos, and Regeneron, has received an educational grant from Diagnovus, and has been a consultant for Aptalis, Novartis, Receptos, Regeneron, and Roche. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• PPI-responsive esophageal eosinophilia and eosinophilic esophagitis (EoE) may be a spectrum of the same disease.

• Topical corticosteroids are first-line therapy for the management of EoE.

• Dietary therapies can also be first-line agents for the management of EoE or can be used as second-line treatment or adjunctively with steroid therapy.

• Esophageal dilation is a safe and effective adjunctive tool in the management of EoE.

• Maintenance therapy is typically required for EoE.

• Many novel therapeutics are being studied for the treatment of EoE.

• Treatment endpoints need to be better defined.