Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disorder characterized by inflammation of the esophagus, typically triggered by food allergens or environmental factors. The incidence and prevalence of EoE are rising rapidly, making it a common condition in gastroenterology, allergy, emergency, and primary care settings.
Symptoms of EoE include dysphagia, food impaction and heartburn. The condition is marked by an elevated presence of eosinophils in the esophageal tissue, reflecting a type 2 inflammatory response. It is often managed through dietary modifications, medications, and sometimes esophageal dilation to alleviate symptoms and prevent complications.
In this analysis, we have compared the guidelines provided by the American College of Gastroenterology (ACG), versus the American Gastroenterological Association (AGA) and Joint Task Force on Allergy-Immunology Practice Parameters (JTF). [Note: the JTF is composed of the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI)].
This article will examine how the recommendations on the Management of Eosinophilic Esophagitis in each guideline agree, contradict, or otherwise differ. By juxtaposing these recommendations, our goal is to equip healthcare professionals with valuable insights and optimal strategies for treating eosinophilic esophagitis. This evidence-based approach aims to enhance patient outcomes by facilitating appropriate intervention and management, while also balancing the risks of recurrence and complications with the necessary follow-up care.
Titles of Comparison
| Titles | Clinical Guidelines for the Management of Eosinophilic Esophagitis - 2020 | Diagnosis and Management of Eosinophilic Esophagitis - 2025 |
|---|---|---|
| Society | American Gastroenterological Association (AGA), American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) | American College of Gastroenterology (ACG) |
| Publication Year | 2020 | 2025 |
| Objective | Provide updated recommendations from 2020 on the clinical management of EoE for both pediatric and adult allergists and gastroenterologists. | Provide updated recommendations from 2013 for diagnosis, treatment, response monitoring and assessment of EoE in adults, with considerations specific to pediatric care. |
| Primary Audience | Allergists and Gastroenterologists | Gastroenterologists |
| Methodology | Evidence-based review and expert consensus | Evidence-based review and expert consensus |
| Graded Strength of Recommendations | Yes | Yes |
| Graded Level of Evidence | Yes | Yes |
| Systematic Review | Yes | Yes |
| Literature Review | Yes | Yes |
| Full Text | Management of Eosinophilic Esophagitis | Diagnosis and Management of Eosinophilic Esophagitis |
| Summary | Summary | Summary |
Key Points: Treatment and Management
| Therapies | AGA/ACAAI/AAAAI 2020 | ACG 2025 |
|---|---|---|
| Proton Pump Inhibitors (PPIs) | Conditional recommendation for symptomatic EoE over no treatment (very low-quality evidence) | Conditional recommendation for use as treatment (low-quality evidence) |
| Swallowed Topical Steroids (Fluticasone & Budesonide) | Strong recommendation for use over no treatment (moderate-quality evidence) | Strong recommendation as treatment (moderate-quality evidence) |
| Swallowed Topical vs.Systemic Steroids | Suggests swallowed topical steroids over systemic steroids (moderate-quality evidence) | Not specifically addressed; focus on swallowed topical steroids |
| Elemental Diet | Elemental diet is recommended over no treatment (moderate-quality evidence) | Not specifically addressed as primary therapy |
| Empiric Elimination Diet | Suggests a 6-food elimination diet (6FED) over no treatment (low-quality evidence) | Suggests an empiric food elimination diet (low-quality evidence); Suggested starting with a less restrictive 1-food (1FED) or 2- food (2FED) elimination diet. |
| Allergy-Testing Based Elimination Diet | Conditional recommendation for allergy-testing based elimination diet over no treatment (very low-quality evidence) | Conditional recommendation against guided elimination diets based on allergy testing (very low-quality evidence) Currently available allergy tests detect food allergens, but not necessarily EoE triggers |
| Biologics | Suggests anti-IL-13 and anti-IL-4 receptor therapy only in clinical trials (not graded, knowledge gap) | Suggests dupilumab treatment for adult and pediatric patients unresponsive to PPIs (moderate-quality in adults and low-quality evidence in children) |
| Recommends anti-IL-5 therapy only in clinical trials (not graded, knowledge gap) | No recommendation for or against the following biologics:-benralizumab, -mepolizumab-reslizumab-cendakimab-lirentelimab | |
| Suggests against anti-IgE therapy for EoE (very low-quality evidence) | Suggests against omalizumab for EoE (low-quality evidence) | |
| Small Molecules | Suggests montelukast and cromolyn only in clinical trials (not graded, knowledge gap) | Suggests against montelukast and cromolyn as treatment (very low-quality evidence) |
| Esophageal Dilation | Suggests esophageal dilation for patients with dysphagia from a stricture (very low-quality evidence) | Suggests esophageal dilation for patients with dysphagia from a stricture (low-quality evidence) |
| Maintenance Therapy | Suggests continuing swallowed topical steroids after remission over discontinuation (very low-quality evidence) | Suggests continuation of effective therapy to prevent recurrence (low-quality evidence) |
| Monitoring and Evaluation | Uses symptomatic, endoscopic and histologic assessments (not graded) | Recommends symptomatic, endoscopic and histologic assessments(very low-quality evidence) |
Treatment Approach
| Therapeutic Sequence | AGA/ACAAI/AAAAI 2020 | ACG 2025 |
|---|---|---|
| First-line | PPIs Swallowed Topical Steroids Elemental Diet Elimination Diet | PPIs Swallowed Topical Steroids Elimination Diet |
| Second-lines | Biologics Endoscopic Dilation | Biologics Endoscopic Dilation |
Key Comparisons from Guidelines
First-Line Therapies
- Both guidelines recommended PPIs
- Both guidelines strongly recommended swallowed topical steroid treatment
- Both guidelines recommended empiric elimination diets; but AGA/ACAAI/AAAAI recommended a 6-food elimination diet while ACG suggested starting with a 1-food or 2-food elimination diet initially.
- AGA/ACAAI/AAAAI recommended an allergy testing-based elimination diet, while ACG recommended against it.
Second-Line Therapies
- Biologics
- Both guidelines recommended anti-IL-13 and anti-IL-4 receptor treatment as second-line treatments; however, AGA/ACAAI/AAAAI recommended it in the context of clinical trials.
- AGA/ACAAI/AAAAI recommended anti-IL-5 therapy in the context of clinical trials, while ACG had no recommendation for or against it.
- Both guidelines recommended against anti-IgE therapy.
- Small Molecules
- AGA/ACAAI/AAAAI recommended montelukast and cromolyn (in the context of clinical trials) as second-line treatments, while ACG recommended against using these drugs for treatment.
- Endoscopic Dilation
- Both guidelines recommended endoscopic dilation for patients with dysphagia from a stricture.
The guidelines provided by AGA/ACAAI/AAAAI and ACG share commonalities in their approach to managing EoE, both stressing the importance of first-line treatment with anti-inflammatory medications (such as PPIs and swallowed topical steroids) and diet elimination therapy. While not completely aligned regarding biologic and small molecule therapies, both guidelines suggested certain biologics for patients unresponsive to PPIs. Esophageal dilation for patients with dysphagia due to strictures was also suggested by both. Finally, the AGA/ACAAI/AAAAI and ACG both endorsed using symptomatic, endoscopic and histologic assessments for monitoring and evaluation.
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