Medical therapy versus dietary avoidance in eosinophilic esophagitis: Which approach is better?

BACKGROUND: Eosinophilic esophagitis (EoE) is a chronic immune-mediated esophageal disease characterized by esophageal symptoms and esophageal eosinophilia. It is induced by food triggers and by environmental allergens in some patients. No U.S. Food and Drug Administration approved therapies exist for patients with EoE. Common therapies include topical corticosteroids (TCS) and dietary restriction.

METHODS: This article reviewed the pros and cons of a medical versus dietary approach in treating EoE in children and adults. Available data on short- and long-term efficacy, ease of implementation, cost, adverse effects, and quality of life (QoL) were summarized.

RESULTS: Although no comparative studies of TCS versus dietary restrictions exist, they seemed to be equivalent from an efficacy standpoint. However, each therapy offers different advantages and disadvantages. TCS allow ingestion of multiple food triggers and improve QoL of patients with EoE. However, TCS have the potential for topical and/or systemic adverse effects and can be costly in the long run. Dietary restriction therapies allow identification of food triggers and are less costly in the long run. However, they are more challenging to implement because they require a team approach with a dietitian and an allergist. In addition, they decrease the QoL of some children with EoE, often require extensive allergy testing and multiple endoscopies, and are not effective when environmental allergens trigger EoE. Therefore, the choice of medical versus dietary therapy needs to be individualized based on a thorough medical evaluation and discussion with patients with EoE and their families.

CONCLUSION: Research is needed to establish the lowest most effective and safe dose of TCS and the extent of adherence needed when eliminating foods for EoE, and to find less-invasive ways to monitor histologic disease activity. Potential results from this research may allow more tailored therapies or specific combination therapies that would take advantage of each treatment modality to maximize benefits to the patient while maintaining disease remission.