Can Flovent (fluticasone) be used with honey for the treatment of Eosinophilic Esophagitis (EOE)?

Flovent (Fluticasone) with Honey for Eosinophilic Esophagitis (EOE)

Topical fluticasone (Flovent) can be effectively administered with honey as a vehicle for the treatment of eosinophilic esophagitis, as this delivery method may improve medication adherence and esophageal contact time compared to standard inhaler administration. 1

Treatment Options for EOE

First-Line Treatments

• Topical steroids are highly effective for inducing histological and clinical remission in EOE with strong evidence supporting their use 1
• Proton pump inhibitors (PPIs) are also effective first-line therapy, given twice daily for 8-12 weeks before assessing response 1
• Dietary approaches, including elimination diets, can be effective but have compliance challenges 1

Topical Steroid Administration Methods

Standard Administration

• Traditional method involves swallowing puffs from a metered dose inhaler (MDI) without inhaling 1
• For fluticasone (Flovent), typical dosing:
  • Adults: 440-880 μg twice daily (880-1760 μg/day) 1
  • Children: 110-440 μg twice daily based on age 1, 2
• After administration, patients should not eat, drink, or rinse for 30 minutes 1

Viscous Preparations

• Mixing topical steroids with viscous carriers (like honey) can improve:
  • Esophageal contact time 1, 3
  • Medication delivery to the esophageal mucosa 1, 3
  • Patient adherence, especially in children 3, 4

Evidence for Fluticasone in EOE

• Swallowed fluticasone has been shown to induce histologic remission in 50% of patients compared to 9% with placebo 2
• Long-term maintenance therapy with swallowed fluticasone demonstrates sustained reduction in esophageal eosinophils and improvement in clinical symptoms 4
• Fluticasone is particularly effective in the proximal esophagus and in younger, non-allergic individuals 2
• Compounded fluticasone suspensions have shown efficacy even in treatment-refractory EOE populations 3

Practical Administration with Honey

1. Empty fluticasone MDI puffs into a small amount of honey (approximately 1-2 teaspoons) 1, 3
2. Swallow the mixture without chewing to maximize esophageal contact time 1
3. Avoid eating, drinking, or rinsing for 30 minutes after administration 1
4. Administer twice daily for optimal effect 1, 4

Efficacy and Safety Considerations

Efficacy

• Histologic response (defined as <15 eosinophils/high-power field) occurs in 64-71% of patients 5
• Clinical symptoms typically improve within 4-8 weeks of treatment 4, 6
• Endoscopic features (furrows, rings, exudates) also improve with treatment 4, 6

Safety Considerations

• Local side effects include esophageal candidiasis (12-16% of patients) 5
• Oral thrush occurs in 2-3% of patients 5
• Systemic side effects are minimal at recommended doses 7
• Growth is not impeded with long-term use in children 4

Treatment Monitoring

• Repeat endoscopy with biopsies is recommended to assess histologic response 1
• If symptoms recur while on treatment, repeat endoscopy is indicated 1
• Clinical and histological relapse is high after withdrawal of topical steroid treatment, so maintenance therapy is often needed 1

Important Caveats

• Fluticasone is not FDA-approved specifically for EOE treatment in the United States (off-label use) 1
• Patients with significant strictures may require endoscopic dilation in addition to anti-inflammatory therapy 1
• Patients with refractory disease or significant concomitant atopic disease should be jointly managed by gastroenterology and allergy specialists 1
• Medical treatment with topical steroids may reduce the development of strictures in EOE 1