First of all, on behalf of all the authors of our study, we wish to express our gratitude to Dr. García-Compeán and Dr. Jiménez-Rodríguez for their comments, which enrich the discussion on the current landscape of eosinophilic esophagitis (EoE) in Latin America, a disease with an increasing number of patients.

In response to the comments on treatment, despite the recommendations in international guidelines,1–3 suggesting monotherapy with diet, proton pump inhibitors (PPIs), steroids, and more recently, dupilumab, we reported that over half of patients (55%) received combination treatment. However, this does not necessarily reflect their initial treatment, but rather the treatment they were receiving upon their inclusion in the study.4

Combination therapy in EoE has not been widely studied and has even been criticized because of its potential risk of combining adverse events, having a negative impact on quality of life, and in cases of response, not knowing which of the treatments were effective.5 The rationale for combination therapy in EoE is to target multiple pathophysiologic mechanisms rather than just one.

A review of the international literature reveals that combination therapy is not as uncommon as previously thought, in the management of EoE. In a recently published Chilean study on 62 patients with EoE, 40.3% received combination therapy with PPIs and steroids.6 A survey of 228 gastroenterologists from 18 European countries also showed that 9.2% preferred using combination therapy for treating EoE.7 A recent study demonstrated that of 12 patients who were nonresponders to monotherapy with elimination diet or PPIs, 11 achieved histologic remission with the combination of those two treatments.8

A recently published expert opinion9 proposed the concept of a therapeutic pyramid in the management of EoE, similar to the model we use for managing inflammatory bowel disease (IBD). Its base is treatment with monotherapy, with combination therapy as the next step, suggested when complete remission is not achieved with monotherapy, and carried out in a personalized manner, always taking the patient’s opinion into account. This may have been the case in our study, considering that histologic remission did not exceed 70% with the different monotherapies utilized. At the top of the pyramid is biologic therapy with dupilumab, which is proposed as a possible first-line (top-down) treatment in EoE patients who also present with other diseases, such as atopic dermatitis, or the fibrostricturing phenotype, similar to what we do in IBD.

In view of the fact that there are no reliable predictors of response to monotherapy with any treatment, selection is based on local availability, cost, and patient acceptance. In Colombia, obstacles to treating EoE are the unavailability of topical viscous steroids and the lack of approval of the regulatory authorities for the use of dupilumab in EoE, which favors greater use of PPIs and an exclusion diet as first-line therapies. A recent multicenter randomized study demonstrated that the sole exclusion of animal milk was comparable to the 6-food elimination diet, potentially bolstering dietary treatment and facilitating adherence to it.10

We agree that there is a need for a consensus on EoE developed by experts in Latin America. Because of the diagnostic, monitoring, and treatment limitations in the different countries of the continent, we must arrive at agreements for improving the quality of life of patients with this increasingly prevalent disease.