Emerging therapeutic strategies for eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is recognized as an increasingly common cause of chronic and recurrent esophageal symptoms that significantly impact quality of life and may occasionally result in severe complications in both pediatric and adult patients. The disease is triggered and maintained by exposure to food antigens in most patients, with an additional role proposed for airborne allergens. Different diet-based approaches focused on restricting potentially offending foods have proven to be effective long-term therapies for EoE. Dietary therapy is thus an attractive, yet challenging treatment option that should be considered for all pediatric and adult EoE patients. However, limitations related to food restriction, patient willingness to undergo repeated endoscopies and biopsies, and the variable results of allergy testing imply that dietary management is for the most part currently restricted to highly motivated healthcare providers treating highly motivated patients reluctant to utilize drug-based therapy on a chronic basis. Pharmacological therapies for EoE mainly comprise swallowed topical steroids, especially fluticasone propionate and budesonide, which were originally developed to treat bronchial asthma and are now extensively used "off label" in EoE patients. In fact, topical steroids currently constitute the prevailing therapeutic option and will probably continue to do so in the near future; indeed, several randomized clinical trials are currently underway to test these drugs for approval as the first pharmacological agents for EoE patients. Immunomodulators and several anti-allergic agents must be further assessed as therapeutic alternatives for refractory cases or patients with complications. Endoscopic dilation represents the third pillar in the therapeutic management of EoE patients, since they frequently present reductions in the esophageal caliber as a result of collagen deposition and a progressive fibrous remodeling process promoted by chronic eosinophilic infiltration. Dilation provides at least temporary symptom relief with similar complication rates to esophageal strictures from a different origin. However, although repeated endoscopic dilation has sometimes been used as the sole therapy for EoE, it best constitutes an adjuvant therapy along with dietary or pharmacological-based interventions, especially since dilation has no effect on the underlying esophageal inflammation. Current therapeutic management of EoE varies widely, with physician experience being a major explanatory factor. New evidence from ongoing research on EoE should thus seek to define a common treatment algorithm to optimize EoE patient management.