How are topical steroids administered in eosinophilic esophagitis?

Administration of Topical Steroids in Eosinophilic Esophagitis

Topical steroids for eosinophilic esophagitis are administered by swallowing the medication (not inhaling) from a metered-dose inhaler or as a viscous preparation mixed with a carrier substance, ensuring the drug coats the esophageal mucosa rather than being delivered to the airways. 1, 2

Standard Administration Methods

Metered-Dose Inhaler (MDI) Technique

• Patients should actuate the inhaler directly into their mouth and swallow the puffs without inhaling, allowing the medication to coat the esophagus rather than enter the lungs 1, 2
• The most commonly used agents are fluticasone propionate and budesonide, delivered via asthma inhalers used "off-label" for esophageal delivery 1, 3
• After swallowing the medication, patients must not eat, drink, or rinse their mouth for 30-45 minutes to maximize esophageal contact time and topical anti-inflammatory effect 2, 3

Dosing Regimens

• For adults: Fluticasone propionate 440-880 μg twice daily or budesonide 2 mg/day in divided doses 1, 2, 3
• For children: Fluticasone 110-440 μg twice daily (110 μg/puff for age <10 years, 220 μg/puff for age 11-18 years, given as 2 puffs 4 times daily) 1, 2
• Treatment duration for initial remission induction is typically 4-8 weeks 1, 3

Viscous Preparations for Enhanced Delivery

Rationale and Preparation

• Mixing topical steroids with viscous carriers such as honey, sucralose solutions, or other proprietary solvents significantly improves esophageal contact time and medication delivery compared to standard MDI administration 2, 4, 5
• Oral viscous budesonide (OVB) achieves better histological results than aerosolized swallowed routes due to prolonged mucosal contact 4
• To prepare: Empty the MDI puffs into a small amount of honey or viscous carrier and swallow the mixture without chewing 2

Administration Protocol for Viscous Formulations

• Administer the viscous preparation twice daily 5
• Patients must avoid eating, drinking, or rinsing for 30-45 minutes after administration 2, 3
• Viscous formulations have shown effectiveness rates of 65-90% for histological remission 5

Novel Esophageal-Targeted Formulations

• Newer formulations specifically designed for esophageal delivery include budesonide orodispersible tablets and oral fluticasone powder, which have shown superior efficacy with response rates up to 85-100% 4, 6
• A budesonide tablet formulation was approved by the European Medicines Agency in 2018 as the first "in-label" medication for EoE 1, 6
• Oral fluticasone powder (500-1000 mcg twice daily) has demonstrated 75% of patients achieving <15 eosinophils/hpf 7

Important Clinical Considerations

Monitoring and Side Effects

• The most common side effect is oral or esophageal candidiasis, occurring in approximately 15% of patients treated with topical steroids 1
• Monitor for fungal infections and treat with nystatin oral suspension or miconazole oral gel if necessary 8
• In children, growth should be carefully monitored during chronic topical steroid use 1
• Short-term studies (≤3 months) show no increased risk of adverse events compared to placebo, though long-term safety data regarding adrenal suppression remain limited 1

Maintenance Therapy

• Disease relapse is extremely common (approximately 45%) after discontinuation of topical steroids, so maintenance therapy is often necessary 1
• Maintenance dosing and duration must be individualized, but ongoing treatment is recommended to prevent recurrence and esophageal fibrotic remodeling 1, 4

Comparison to Systemic Steroids

• Topical steroids are strongly preferred over systemic corticosteroids due to similar efficacy (72% vs 65% symptomatic response) but significantly fewer systemic side effects (15% oral candidiasis vs 40% systemic complications including weight gain and cushingoid appearance) 1
• Systemic steroids (prednisone 1-2 mg/kg/day, maximum 60 mg) should be reserved only for emergency situations requiring urgent symptom relief, such as severe dysphagia, dehydration, significant weight loss, or high-risk strictures 1

Common Pitfalls to Avoid

• Do not allow patients to inhale the medication into their lungs—this is the most critical error, as the drug must coat the esophagus 1, 2
• Ensure patients understand the 30-45 minute nothing-by-mouth period after administration, as premature eating or drinking washes away the medication 2, 3
• Do not assume clinical symptom improvement equals histological remission—repeat endoscopy with biopsies is necessary to confirm response 2
• Be aware that approximately 25-40% of patients demonstrate steroid resistance and may require alternative therapies 4