Current and Future Treatments of EoE

Diet. Elimination of food allergy triggers that promote an inflammatory response in the esophageal mucosa is the goal of dietary management strategies.⁴ There are three main dietary approaches to eliminating potential triggers⁴:

• Elemental diet. This is the most effective at bringing symptom remission, with a response rate of over 90%. This approach uses amino acid-based formulas (AAF) for intake, along with some treats. Elemental diets can interfere with development of feeding skills in babies, however, and a feeding tube may become necessary.
• Empiric dietary elimination. This diet follows the 6 Food Elimination Diet (SFED): dairy, wheat, eggs, soy, nuts and seafood. While less restrictive than the elemental diet, it only has a 60% to 70% response rate. Due to the restrictive nature of SFED, versions have been created that eliminate one (dairy), two (dairy and wheat), and four foods (dairy, wheat, egg, soy).
• Test-directed dietary modification: This diet eliminates food triggers  identified skin prick testing (SPT) and/or atopy patch testing (ATP). It the least efficacious with response rates in approximately 40% of patients. Because of this low efficacy, IgE blood testing and SPT/APT no longer suffice to identify food triggers for patients with EoE.⁵ This test approach is also cumbersome, as patients must have metal disks in contact with skin for 48 hours.⁴

Patients treated with elimination diets should be referred to a registered dietitian if they experience excessive weight change, poor adherence, poor nutritional quality, and negative impact on quality of life. .¹ Poor adherence to elimination diets, such as SFED, are influenced by effectiveness, social situations, and diet-related anxiety.⁶

Pharmacologic Therapy

There are  two traditional choices of drug class: proton pump inhibitors (PPI) and oral formulations of topical corticosteroids.⁷ An initial trial of PPI therapy was standard of care until updated diagnostic guidelines in 2018. Now they are considered as one option for initial care.⁸ This approach is inexpensive and tolerable with a favorable safety profile.⁷

Swallowed topical corticosteroids have been routinely used in the treatment of EoE, with budesonide oral suspension receiving approval in 2024 for 12 weeks of treatment in those 11 years and older with EoE.⁹ A systematic review of double-blind clinical trials demonstrated that patients treated with topical corticosteroids for 2 to 12 weeks have approximately 3 times the rate of histological remission than placebo-treated patients (RR 0.39, 95% CI, 0.85 – 1.19). Topical steroids are well tolerated although Candida infections (12% to 15% of patients) can be a complication. There is no indication that adrenal insufficiency is a common side effect of topical steroid treatment (0.9%).¹⁰

Newer, targeted agents show promise for treating patients with EoE due to the type 2 (Th2) inflammation that drives its pathophysiology. In June of 2022, the FDA approved the first dupilumab for use in patients with EoE who are 12 years and older.¹¹  Dupilumab has since received expanded approval in 2024, with approved indications for use in patients 1 year and older weighing at least 15kg.¹² It binds to the interleukin (IL)-4 receptor α and suppresses the action of Th2 and type 2 innate lymphoid cells (ILC2) in response to IL-4 and IL-13 (Figure 2).⁷ Please see the animations using the menu for a more in-depth discussion of EoE pathophysiology and targeted agents.