What is the initial treatment for eosinophilic esophagitis using inhaler puffs (inhalation corticosteroids)?

Initial Treatment for Eosinophilic Esophagitis Using Inhaler Puffs

For initial treatment of eosinophilic esophagitis (EoE), swallowed topical corticosteroids are the first-line therapy, with fluticasone 440-880 mcg twice daily for adults and 88-440 mcg twice to four times daily for children, administered by puffing into the mouth and swallowing. 1

Recommended Corticosteroid Regimens

Fluticasone Protocol:

• Adults: 440-880 mcg twice daily
• Children: 88-440 mcg twice to four times daily (not exceeding adult dose)
• Administration method:
  • Spray the metered dose inhaler in the mouth with lips sealed around the device
  • Swallow the medication (do not inhale)
  • Do not eat, drink, or rinse for 30 minutes after administration
  • Treatment duration: 4-8 weeks for initial therapy 1

Alternative Option - Budesonide:

• Adults and older children: 2 mg daily (divided doses)
• Children <10 years: 1 mg daily
• Administration: As a viscous suspension 1

Efficacy and Response Rates

Topical corticosteroids have demonstrated effectiveness in both symptom improvement and histologic resolution:

• Clinical symptoms improve in approximately 75-91% of patients 1, 2
• Histologic improvement occurs in a majority of patients, though complete histologic response (<15 eosinophils/high-power field) is seen in only about 57% of cases 3
• Endoscopic improvement may also be observed 4

Predictors of Response

Several factors may predict response to topical corticosteroid therapy:

• Patients with abdominal pain as a presenting symptom may have better response rates
• Patients requiring esophageal dilation at baseline may be less likely to respond
• Higher baseline levels of tryptase and eotaxin-3 are associated with better steroid response 3

Potential Side Effects and Monitoring

• Common side effect: Esophageal candidiasis (fungal infection)
• Less common: Dry mouth
• Long-term concerns: When used chronically, monitor for:
  • Growth (in children)
  • Adrenal suppression
  • Bone density effects 1

Disease Course and Maintenance Therapy

EoE is a chronic disease with high relapse rates after discontinuation of therapy:

• Approximately 91% of patients experience symptom recurrence after stopping treatment
• Mean time to recurrence: 8.8 months after completing initial treatment
• 69% of patients require repeated treatment courses 2

After induction of remission, maintenance therapy with topical corticosteroids may be needed, though long-term therapy should be individualized based on disease severity, patient lifestyle, medication adherence capability, and family resources 1.

Important Considerations

1. No FDA-approved medications: Currently, there are no FDA-approved medications specifically for EoE treatment 5, 6

2. Proper administration technique: Correct administration is crucial for efficacy - patients must be instructed to swallow (not inhale) the medication and avoid eating/drinking for 30 minutes afterward 1

3. Alternative treatments: For patients who don't respond to topical corticosteroids:

   • Dietary therapy (elimination diets)
   • Systemic corticosteroids (for severe cases with dysphagia requiring hospitalization, dehydration, or weight loss)
   • Esophageal dilation (for fixed strictures) 1

4. Avoid ineffective treatments: Cromolyn sodium and leukotriene receptor antagonists are not recommended for EoE treatment 1

Topical corticosteroids remain the cornerstone of initial EoE treatment, providing effective symptom relief and histologic improvement for most patients, though long-term management is often necessary due to the chronic nature of the disease.