Refractory Eosinophilic Esophagitis: What to do When the Patient has not Responded to Proton Pump Inhibitors, Steroids and Diet

Alexandra L. Strauss; Gary W. Falk


Curr Opin Gastroenterol. 2022;38(4):395-401. 

In This Article

What are Other Treatment Options for Patients With Refractory Eosinophilic Esophagitis?

There are a number of options for patients who fail all of the first-line therapeutic options, each with limitations. Systemic corticosteroids are effective, but have multiple adverse effects for long-term administration and have similar response rates to topical corticosteroids.[36] Systemic corticosteroids should be limited to short-term use.[4] Elemental formulas are hypoallergenic formulations of amino acids, simple carbohydrates and medium-chain triglycerides with a high response rate of 93.9%.[6,37,38] However, elemental diets are expensive and difficult to tolerate, occasionally requiring feeding tubes to maintain adequate nutrition. There are limited data to support the use of montelukast, cromolyn, immune modulators, anti-IgE or anti-TNFs, and none are currently recommended by the AGA/JTF.[6,39]

Oesophageal dilation should be considered as an acute or additional therapy, as intervention can improve swallowing dysfunction.[6] A systematic review and meta-analysis found 95% clinical improvement with dilation and low rates (<1%) of major complications.[8] Dilation is an option for managing fibrostenotic disease and can provide symptomatic relief for 15–17 months regardless of medical therapy.[9,40,41] Work from the Northwestern group in a group of patients with severe strictures (oesophageal lumen <10 mm) managed with serial dilations found that 89.4% of patients experienced improvement in oesophageal diameter to at least 13 mm and 65.2% to at least 15 mm. Of note, 85.5% of these patients achieved histologic remission, and only one patient was managed with dilation alone.[42]