Track eosinophil counts at every biopsy and consider treating with PPIs, steroids, diet and some biologics, the American College of Gastroenterology says.
The American College of Gastroenterology has updated its clinical guidelines for eosinophilic oesophagitis the first time since 2013, reflecting major advances in the understanding and treatment of the disease.
These updated guidelines now include recommendations for children with EoE, and include new information on risk factors, how it develops, diagnosis, treatment and how to assess outcomes.
Diagnosis
The ACG recommended that EoE is diagnosed using a combination of oesophageal dysfunction as well as 15 or more eosinophils per high-power field on an oesophageal biopsy – only after other disorders that cause or could contribute to EoE have been evaluated and ruled out.
The College recommended using a systematic scoring system (such as the EoE Endoscopic Reference Score) every time an endoscopy is undertaken, and that at least six biopsies should be performed at two different levels to determine whether the histological features are consistent with EoE. Eosinophil counts from each biopsy should be quantified.
“We advise performing endoscopy on no treatment (e.g., no dietary restriction and no proton pump inhibitors) when EoE is suspected to maximise diagnostic sensitivity. Diet and medications, including intranasal or inhaled steroids for rhinitis, sinusitis or asthma may partially or completely treat EoE and lead to a falsely negative examination,” Dr Evan Dellon, academic gastroenterologist at the University of North Carolina, and colleagues wrote in the guidelines.
Treatment
Swallowed topical steroids were the treatment option with the highest quality evidence, and the authors recommended fluticasone propionate or budesonide specifically. PPIs and empiric food elimination diets were also recommended as potential treatments – albeit on a more conditional basis.
“We advise administration of steroids after meals or before bedtime with nothing to eat or drink after 30-60 minutes to help maximise medication dwell time in the oesophagus. If patients eat or drink right after medication administration, the medication will be cleared from the oesophagus and will be less effective,” the panel wrote.
Related
Dupilumab was also suggested as a potential treatment for patients of all ages who are non-responsive to PPI therapy, with the panel advising that the biologic should be considered in patients with both EoE and other atopic conditions that would also meet requirements for dupilumab use.
Oesophageal dilation was recommended as an adjunct to pharmacological therapies, particularly if patients are experiencing dysphagia from oesophageal strictures.
In contrast, the panel recommended that omalizumab, cromolyn and montelukast should not be used to treat EoE. The panel also recommended against the use of allergy testing to direct food elimination diets.
The panel was unable to make recommendations regarding the use of other biologics such as cendakimab, benralizumab, lirentelimab, mepolizumab or reslizumab as potential treatments for EoE.
The importance of ongoing monitoring and evaluation was also made clear.
“We advise providers no to monitor symptoms alone in patients with EoE to assess [the] treatment response… as symptoms do not strongly correlate with endoscopic or histological features of disease activity,” the authors wrote.
“Providers may consider using a histologic response threshold of less than 15 eosinophils per high-powered field, [although] the improvement in eosinophil count should be considered in the context of improvement of other histologic features, endoscopic findings and symptoms.”
Paediatric-specific considerations were also highlighted, with the College suggesting that an oesophagram should be undertaken to check for fibrostenotic disease – and that a feeding therapist and/or dietician could serve as an additional therapeutic intervention – in children with EoE and dysphagia.
In 2014 the Australasian Society for Clinical Immunology and Allergy estimated that EoE affects one in 100 adults and one in 10,000 children. The Society’s latest fact sheet on the condition, released in 2024, notes that the incidence of EoE appears to be increasing but does not report any specific numbers.
ASCIA has developed action plans for the treatment and management of EoE, along with dietary guidelines. These resources are available on the Society’s website.
