From the Guidelines
Eosinophilic esophagitis (EoE) is not directly associated with adrenal insufficiency, but the treatment of EoE with topical corticosteroids can potentially lead to secondary adrenal insufficiency due to hypothalamic-pituitary-adrenal (HPA) axis suppression. These are two distinct medical conditions with different pathophysiological mechanisms. EoE is an allergic/immune-mediated inflammatory condition of the esophagus characterized by eosinophilic infiltration, while adrenal insufficiency is an endocrine disorder resulting from inadequate production of adrenal hormones, particularly cortisol. According to the British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of EoE in children and adults 1, the treatment of EoE often involves topical corticosteroids.
Some key points to consider in the management of EoE and potential adrenal insufficiency include:
- The use of topical corticosteroids such as fluticasone or budesonide for EoE treatment
- Monitoring for symptoms of adrenal insufficiency such as fatigue, weakness, hypotension, and electrolyte abnormalities in patients on long-term topical steroid therapy
- Periodic assessment of morning cortisol levels in patients requiring long-term steroid therapy for EoE management, especially if systemic symptoms develop, as recommended by recent guidelines 1
- The risk of clinically significant adrenal suppression from topical esophageal steroids is generally low when used at recommended doses, but increases with higher doses and longer duration of treatment.
It is essential to weigh the benefits of topical corticosteroid therapy in managing EoE against the potential risks, including the development of secondary adrenal insufficiency, and to closely monitor patients for any signs of adrenal suppression 1.
From the Research
Eosinophilic Esophagitis and Adrenal Insufficiency
- Eosinophilic esophagitis (EoE) has been associated with adrenal insufficiency (AI) in some studies 2, 3.
- A study published in 2016 found that 10% of children treated with swallowed glucocorticoids for ≥ 6 months had AI, and all cases were found in those treated with fluticasone propionate (FP) at a dose >440 μg/d 2.
- Another study published in 2020 found that 5% of children with EoE treated with topical corticosteroids had AI, and that serum dehydroepiandrosterone sulfate (DHEA-S) levels had a moderate correlation with morning serum cortisol (MSC) levels 3.
- A case series published in 2021 described three patients with EoE and primary adrenal insufficiency, suggesting a possible association between the two conditions, although the underlying mechanisms are unclear 4.
- Other studies have focused on the treatment and management of EoE, including the use of proton pump inhibitors, topical steroids, dietary therapy, and endoscopic dilation 5, 6.
- While there is evidence to suggest a link between EoE and adrenal insufficiency, further research is needed to fully understand the relationship between the two conditions.