The role of maintenance therapy in eosinophilic esophagitis: who, why, and how?

In patients with eosinophilic esophagitis (EoE) who do not respond to proton pump inhibitors, initial anti-inflammatory/anti-eosinophilic treatment is with either topical corticosteroids or dietary elimination. A large body of literature supports the efficacy of these approaches, with histologic response rates in the 50-90% range for steroids and 70% range for the six-food elimination diet. However, these studies are almost all short-term and data evaluating long-term safety and efficacy of either treatment are limited. Nevertheless, because EoE is chronic, symptomatic, endoscopic, and histologic disease activity recurs when successful treatments are stopped. An emerging body of data also suggest that left untreated, persistent eosinophilic esophageal inflammation may progress to fibrostenosis over time. Therefore, maintenance therapy in EoE is intuitively attractive. This paper reviews the rationale for maintenance treatment in EoE, the available long-term pharmacologic and dietary response data for EoE, and discusses who may benefit the most from ongoing treatment. While all patients with EoE can be offered maintenance treatment, this option should be strongly recommended in patients with severe disease phenotypes or complications, including malnutrition or failure to thrive, esophageal fibrostenosis, strictures requiring dilation, recurrent food bolus impaction, history of perforation, and symptoms that recur quickly after treatment discontinuation. In all EoE patients, regular follow-up is also advised.