Part 2: Therapy Fundamentals: PPI, Topical Steroids, Biologics and Diet

Video Transcription

Video Summary

This ASGE webinar focused on eosinophilic esophagitis (EOE) therapy fundamentals for advanced practice providers, covering treatment goals, medical therapy, biologics, diet, and maintenance care. Faculty Dr. Nirmala Gonsalves and Dr. Amanda Muir emphasized a treat-to-target approach: improve symptoms, achieve histologic remission, reduce endoscopic inflammation, and prevent fibrosis, strictures, and food impactions.<br /><br />They reviewed first-line options including proton pump inhibitors (PPIs) and swallowed topical steroids. PPIs are a reasonable initial therapy, with about 42% overall effectiveness, and are generally safe long term. Practical advice included twice-daily or equivalent dosing initially, repeat endoscopy after 8–12 weeks, and considering drug metabolism or switching PPIs if response is poor. Swallowed steroids, such as fluticasone and budesonide preparations, showed about 61% effectiveness and can be used long term, though clinicians should watch for candidiasis and possible adrenal suppression in higher-risk patients. Maintenance therapy is important because EOE is chronic and undertreatment increases the risk of scarring.<br /><br />Dupilumab, which blocks IL-4 and IL-13 signaling, was highlighted as an effective biologic for refractory disease and for patients with significant atopic comorbidity. Side effects include injection-site reactions and possible conjunctivitis.<br /><br />Diet therapy was discussed in depth, including elemental, empiric elimination, and step-up approaches. Empiric elimination diets remain preferred, with cow’s milk often the most common trigger. Food reintroduction should be followed by serial endoscopies to identify triggers and avoid prolonged unnecessary restriction.<br /><br />The session ended with a Q&A on dosing strategies, biopsy protocols, barium studies, dilation, and when to repeat endoscopy.

Keywords

eosinophilic esophagitis

EOE therapy

advanced practice providers

treat-to-target

proton pump inhibitors

swallowed topical steroids

dupilumab

biologic therapy

elimination diet

maintenance care

endoscopy