Management of Eosinophilic Esophagitis

Publication Date: April 1, 2020
Last Updated: March 14, 2022

Recommendations 

In patients with symptomatic esophageal eosinophilia, the AGA/JTF suggests using proton pump inhibition over no treatment. ( Very Low , Conditional (weak) )
612
In patients with EoE, the AGA/JTF recommends topical glucocorticosteroids over no treatment. (Moderate, Strong)
612
In patients with EoE, the AGA/JTF suggests topical glucocorticosteroids rather than oral glucocorticosteroids. (Moderate, Conditional (weak))
612
In patients with EoE, the AGA/JTF suggests using elemental diet over no treatment. (Moderate, Conditional (weak))
  • Comment: Patients who put a higher value on avoiding the challenges of adherence to an elemental diet and the prolonged process of dietary reintroduction may reasonably decline this treatment option.
612
In patients with EoE, the AGA/JTF suggests using an empiric, 6-food elimination diet over no treatment. (Low, Conditional (weak))
Comment: Patients who put a higher value on avoiding the challenges of adherence to diet involving elimination of multiple common food staples and the prolonged process of dietary reintroduction may reasonably decline this treatment option.
612
In patients with EoE, the AGA/JTF suggests using an allergy testing-based elimination diet over no treatment. (Very Low, Conditional (weak))
  • Comment: Due to the potential limited accuracy of currently available, allergy-based testing for the identification of specific food triggers for EoE, patients may prefer alternative medical or dietary therapies to an exclusively testing-based elimination diet.
612
In patient with EoE in remission after short-term use of topical glucocorticosteroids, the AGA/JTF suggests continuation of topical glucocorticosteroids over discontinuation of treatment. ( Very Low , Conditional (weak) )
  • Patients who put a high value on the avoidance of long-term topical steroid use and its possible associated adverse effects, and/or place a lower value on the prevention of potential long-term undesirable outcomes (ie, recurrent dysphagia, food impaction, and esophageal stricture), could reasonably prefer cessation of treatment after initial remission is achieved, provided clinical follow-up is maintained.
612
In adult patients with dysphagia from a stricture associated with EoE, the AGA/JTF suggests endoscopic dilation over no dilation. ( Very Low , Conditional (weak) )
  • Esophageal dilation does not address the esophageal inflammation associated with EoE.
612
In patients with EoE, the AGA/JTF recommends using anti–IL-5 therapy for EoE only in the context of a clinical trial. ( Evidence Gap , No recommendation )
612
In patients with EoE, the AGA/JTF recommends using anti–IL-13 or anti–IL-4 receptor α therapy for EoE only in the context of a clinical trial. ( Evidence Gap , No recommendation )
612
In patients with EoE, the AGA/JTF suggests against the use of anti-IgE therapy for EoE. ( Very Low , Conditional (weak) )
612
In patients with EoE the AGA/JTF suggest using montelukast, cromolyn sodium, immunomodulators, and anti-TNF for EoE only in the context of a clinical trial. ( Evidence Gap , Conditional (weak) )
612

Recommendation Grading

Overview

Title

Management of Eosinophilic Esophagitis

Authoring Organizations

American College of Allergy, Asthma, and Immunology

American Academy of Allergy, Asthma & Immunology

American Gastroenterological Association

Publication Month/Year

April 1, 2020

Last Updated Month/Year

November 12, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This document presents the official recommendations of the American Gastroenterological Association (AGA) and the Joint Task Force on Allergy-Immunology Practice Parameters (JTF) on the management of eosinophilic esophagitis.

Target Patient Population

Patients with eosinophilic esophagitis

PICO Questions

  1. Should Repeat Esophagogastroduodenoscopy Be Used to Assess Patients With Eosinophilic Esophagitis After a Change in Treatment?

  2. What Is the Management of Patients Who Become Asymptomatic After Initial Proton Pump Inhibitor Treatment?

  3. Should Proton Pump Inhibitors Be Used in Patients With Esophageal Eosinophilia?

  4. Should Topical Glucocorticosteroids Be Used in Patients With Eosinophilic Esophagitis?

  5. Should Systemic Glucocorticosteroids Be Used in Patients With Eosinophilic Esophagitis?

  6. Should an Elemental Diet Be Used in Patients With Eosinophilic Esophagitis?

  7. Should an Empiric Food Elimination Diet Be Used in Patients With Eosinophilic Esophagitis?

  8. Should Allergy-Based Testing Be Used for the Purpose of Identifying Food Triggers in Patients With Eosinophilic Esophagitis?

  9. Should Maintenance Therapy Be Recommended in Patients With Eosinophilic Esophagitis?

  10. Should Esophageal Dilation Be Used in Patients With Eosinophilic Esophagitis?

  11. Should Anti–Interleukin-5 Therapy Be Used in Patients With Eosinophilic Esophagitis?

  12. Should Anti–Interleukin-13 Therapy Be Used in Patients With Eosinophilic Esophagitis?

  13. Should Anti-IgE Therapy Be Used in Patients With Eosinophilic Esophagitis?

  14. Should Montelukast, Cromolyn, Immunomodulators, or Anti-TNF Therapy Be Used in Patients With Eosinophilic Esophagitis?

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Childcare center, Emergency care, Hospital

Intended Users

Dietician nutritionist, nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D057765 - Eosinophilic Esophagitis

Keywords

asthma, interleukin, esophagogastroduodenoscopy (EGD), allergic rhinitis, eosinophilic esophagitis, proton pump inhibitor, eczema

Source Citation

Ikuo Hirano, Edmond S. Chan, Matthew A. Rank, Rajiv Sharaf, Neil H. Stollman, David R. Stukus, Kenneth Wang, Matthew Greenhawt, Yngve Falck-Ytter. American Gastroenterological Association and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis. Ann Allergy Asthma Immunol. 2020;124:416-423.

Supplemental Methodology Resources

Technical Review