What is the recommended treatment for Eosinophilic Esophagitis (EoE) with steroids?

Treatment of Eosinophilic Esophagitis (EoE) with Steroids

Topical corticosteroids are the first-line pharmacological treatment for eosinophilic esophagitis, with high-quality evidence supporting their efficacy for inducing both clinical and histological remission. 1

Types of Steroid Therapy for EoE

First-Line Treatment: Topical Corticosteroids

Topical corticosteroids have demonstrated superior efficacy compared to placebo with the following options:

1. Budesonide (preferred option):

   • Adults: 2 mg/day divided into twice daily doses 1
   • Children:
     • <10 years: 1 mg daily

     • 10 years: 2 mg daily 1

   • Formulations:
     • Orodispersible tablets (most effective formulation with OR 18.9 for achieving clinical-histological remission) 2
     • Oral viscous solution (prepared by pharmacist)

2. Fluticasone:

   • Adults: 880-1760 μg/day divided into twice daily doses 1
   • Children: 88-440 μg twice to four times daily (not exceeding adult dose) 1
   • Administration: Puffed and swallowed through metered-dose inhaler

Administration Technique for Topical Steroids

For optimal efficacy:

• Spray the metered dose inhaler in the mouth with lips sealed around the device
• Do not eat, drink, or rinse for 30 minutes after administration 1
• For budesonide orodispersible tablets, allow to dissolve on tongue and swallow saliva

Second-Line Treatment: Systemic Corticosteroids

Systemic corticosteroids should be reserved for severe cases requiring urgent symptom relief:

• Indications: Severe dysphagia, dehydration, significant weight loss, hospitalization, or esophageal strictures 1
• Dosage: Prednisone 1-2 mg/kg/day (maximum 60 mg) 1
• Duration: Short-term use only due to potential toxicity

Treatment Efficacy

1. Topical Corticosteroids:

   • Histological remission rates: 68-77% 3
   • Clinical symptom improvement: 82-88% 3
   • Higher doses (≥0.8 mg/day) provide superior clinical-histological remission rates (65%) compared to lower doses 2

2. Formulation Comparison:

   • Budesonide orodispersible tablets demonstrate superior efficacy (OR 18.9) compared to other formulations 2
   • Viscous preparations have better esophageal contact time than nebulized preparations 1

Duration of Treatment

• Initial treatment: 4-8 weeks for induction of remission 4
• Maintenance therapy: Strongly recommended due to high relapse rates after discontinuation 1
  • Clinical and histological relapse is high after withdrawal of topical steroid treatment 1

Monitoring and Follow-up

• Repeat endoscopy with biopsies to assess histological response after initial treatment
• If symptoms recur while on treatment, repeat endoscopy for assessment 1
• In children, monitor growth when topical steroids are used chronically 1

Potential Adverse Effects

• Topical corticosteroids:

  • Esophageal candidiasis (most common side effect, occurs in approximately 5-15% of patients) 1
  • Oral candidiasis
  • Dry mouth (rare)
  • Manage candida infections with topical antifungals while continuing topical steroids 1

• Systemic corticosteroids:

  • Growth abnormalities
  • Bone abnormalities
  • Mood disturbances
  • Adrenal axis suppression 1

Clinical Pearls and Pitfalls

1. Key pitfall: Inadequate administration technique can reduce efficacy

   • Ensure proper swallowing technique and post-administration fasting period

2. Important consideration: Medical treatment with topical steroids may reduce the development of strictures in EoE 1

3. Common mistake: Discontinuing treatment after symptom improvement

   • Maintenance therapy is crucial due to high relapse rates

4. Treatment resistance: For patients with refractory disease, consider:

   • Consultation with a specialist allergist 1
   • Dietary therapy as an alternative or adjunct
   • Endoscopic dilation for fibrostenotic disease 1

Topical corticosteroids represent the cornerstone of pharmacological therapy for EoE, with budesonide orodispersible tablets emerging as the most effective formulation based on the most recent evidence 2. Long-term maintenance therapy should be recommended for most patients due to the chronic nature of the disease and high relapse rates after discontinuation 1.