What is the recommended maintenance dose of topical steroids, such as fluticasone (Flovent) or budesonide (Pulmicort), for eosinophilic esophagitis?

Maintenance Dose of Topical Steroids for Eosinophilic Esophagitis

For maintenance therapy of eosinophilic esophagitis, orodispersible budesonide at 0.5-1.0 mg twice daily for adults or oral viscous budesonide at 1-2 mg daily for children is recommended based on the most recent high-quality evidence. 1

Topical Steroid Formulations and Dosing

Adults:

• First choice: Orodispersible budesonide tablets

  • Maintenance dose: 0.5-1.0 mg twice daily 1
  • Superior efficacy compared to other formulations (73.5-75% maintained remission vs 4.4% with placebo over 48 weeks) 1

• Alternative: Swallowed fluticasone

  • Maintenance dose: 440-880 mcg twice daily 1, 2
  • Less effective for maintenance (only 35.7% maintained histological remission after 1 year) 1

Children:

• Recommended: Oral viscous budesonide (OVB)

  • Maintenance dose: 1 mg/day if <150 cm or 2 mg/day if >150 cm 1
  • Can be given as a single dose or divided into two doses per day 1
  • For older/larger children not responding to standard dosage, up to 4 mg/day may be used 1

• Alternative: Swallowed fluticasone

  • Maintenance dose: 88-440 mcg twice to four times daily 2

Administration Technique

Proper administration is crucial for efficacy:

• For MDI formulations (fluticasone):

  • Spray the inhaler in the mouth with lips sealed around the device 1, 2
  • Swallow immediately without using a spacer 1
  • Avoid eating, drinking, or rinsing for 30 minutes after administration 1, 2

• For budesonide orodispersible tablets:

  • Place on tongue and allow to dissolve
  • Swallow saliva containing medication
  • Avoid eating or drinking for 30 minutes 1

Evidence for Maintenance Therapy

The need for maintenance therapy is well-established:

• Clinical and histological relapse rates are high after withdrawal of topical steroid treatment 1
• In a phase-3 randomized controlled trial, orodispersible budesonide maintained remission in 73.5-75% of patients compared to only 4.4% with placebo 1
• Median time to relapse was >350 days with budesonide versus 87 days with placebo 1
• Without maintenance therapy, 87.5% of patients experience symptom recurrence and 100% experience histological recurrence 1

Potential Side Effects and Monitoring

• Common side effects:

  • Esophageal candidiasis (occurs in up to 22% of patients) 1, 2
  • Dry mouth 2

• Long-term concerns:

  • Growth suppression in children
  • Adrenal suppression
  • Bone density effects 2

• Monitoring recommendations:

  • Regular clinical follow-up to assess symptom control
  • Periodic endoscopy to confirm histological remission
  • Growth monitoring in children

Important Considerations

1. Maintenance therapy should be tailored according to individual response and surveillance of potential side effects 1

2. The high risk of relapse after stopping therapy justifies long-term maintenance treatment 1

3. Budesonide orodispersible tablets have shown superior efficacy compared to other formulations in recent studies 1, 3

4. Systemic steroids are not recommended for maintenance therapy due to significant adverse effects 1

5. Immunomodulators (azathioprine, mercaptopurine) are not currently recommended for maintenance therapy of EoE 1

The evidence strongly supports the use of topical steroids for maintenance therapy in eosinophilic esophagitis, with orodispersible budesonide showing the most promising results for sustained remission in adults and oral viscous budesonide being preferred for children.