Keywords: Eosinophilic Esophagitis; EOE; Eosinophils; Reflux; Epidemiology; Steroid; Diet; Dilation
In 1998, Faubion et al, was the first to use topical steroids by swallowing, rather than inhaling, an inhaled fluticasone or beclomethasone in 4 pediatric patients with EoE. Improvement was shown to occur about 1 week after using this regimen [52]. Since then several observational studies and randomized controlled trials have shown improved symptoms and / or histologic response using topical steroids (Table 1). Teitelbaum et al in 2002 treated 9 EoE pediatric patients with fluticasone who did not respond to dietary restriction. These patients showed improved symptoms and also significant change in follow-up esophageal eosinophilia count [53]. In a 2006 RCT of 21 EoE pediatric patients that were treated with fluticasone, 50% achieved histologic remission defined as a peak eosinophil count of < 1 eosinophil / HPF, versus only 9% of patients receiving placebo (P=0 .047) [54]. Similar findings of symptomatic improvement were seen in adult patients receiving fluticasone [55]. A study by Remedios et al treated EoE patients with fluticasone, including a subset of patients with concomitant GERD. Patients overall responded both clinically and histologically to fluticasone [31]. A study by Lucendo et al in 2007 treated EoE patients with findings of abnormal esophageal caliber and abnormal mucosa. After treatment with fluticasone, the esophagus showed a normal caliber in 97% of patients, and 63% of patients had normal mucosa [56]. In a double blind RCT by Alexander et al evaluated 30 patients with EoE treated with fluticasone versus placebo. Histologic response was seen in the topical steroid group, however dysphagia was not significantly reduced in the treatment group (63% fluticasone group and 47% placebo group; (P = 0.49) [57]. In a study by Butz et al in 2014, recommended that patients being treated with high dose fluticasone (1760 mcg) should be followed up in 3 months for response and can either have dose reduction to 880 mcg or continue with high dose for another 3 months [58]. Due to the difficulty aerosolized corticosteroids may be for young children to ingest, Aceves et al used viscous budesonide to treat pediatric patients with EoE with significant reduction in symptoms and histology [59,60]. Further studies including RCTs by Straumann et al in 2010 and Dohil et al in 2010, both showed clinical and histologic improvement after nebulized to liquid budesonide or viscous budesonide was given [61,62]. A study by Dellon et al, in 2012, compared viscous budesonide to nebulized steroid therapy for EoE. Histologic improvement was significantly better in the viscous budesonide group, favoring this therapy [63]. We use 3 mg tablet or preferentially liquid budesonide before bedtime for 6-8 weeks. Advanced cases may need to be treated for a longer period of time with maintenance therapy and a GI hypoallergenic diet. Although, an indefinite GI hypoallergenic diet is recommended in patients with EoE, no definitive studies are available for a possible maintenance therapy in this chronic and usually progressive disease.
Author/Year of Study |
Type of study / Study Duration |
Age group |
N = cohort (Male) |
# Treated |
Therapy |
Duration |
Symptoms improved |
Pre Therapy Eos/HPF |
Post Therapy Eos/HPF |
P-value |
||
|
|
|
|
|
|
|
|
Esophagus (location) |
Eos / HPF |
|
||
Teitelbaum53 |
Prospective |
Peds |
19 (14) |
9 |
FP |
8 weeks |
Yes |
Proximal |
22.5 ± 4.9 |
2.8 ± 2.4 |
p= 0.001 |
|
2002 |
1998-2001 |
|
|
|
|
|
|
Distal |
23.0 ± 2.7 |
2.7 ± 1.4 |
p=0.001 |
|
Arora55 |
Prospective |
Adults |
21 (17) |
21 |
FP |
6 weeks |
Yes |
Proximal |
N/A |
N/A |
N/A |
|
2003 |
1999-2001 |
|
|
|
|
|
|
Distal |
> 50 |
N/A |
N/A |
|
Konikoff54 |
RCT |
Peds |
36 (17) |
21 |
FP |
3 months |
Yes |
Proximal |
69.4±14.5 |
35.2±12.6 |
p=0.05 |
|
2006 |
2003-2005 |
|
|
|
|
|
|
Distal |
82.2±11.7 |
45.7±13.6 |
p=0.07 |
|
Remedios31 |
Prospective |
Adult |
26 (18) |
19 |
FP |
4 weeks |
Yes |
Proximal |
24.98 |
4.46 |
p < 0.0004 |
|
2006 |
2002-2003 |
|
|
|
|
|
|
Distal |
39.34 |
3.81 |
p < 0.0001 |
|
Lucendo56 |
Prospective |
Adult |
30 (27) |
27 |
FP |
3 months |
Yes |
|
N/A |
N/A |
|
|
2007 |
2002-2005 |
|
|
|
|
|
|
|
|
|
|
|
Aceves60 |
Retrospective |
Peds |
20 (16) |
20 |
VB |
3 months |
Yes |
Proximal |
43 |
2 |
p < 0.0001 |
|
2007 |
2007 |
|
|
|
|
|
|
Distal |
80 |
9 |
|
|
Straumann61 |
RCT |
Adolescent/ Adult |
36 (31) |
18 |
SIB |
15 days |
Yes |
Overall |
68.2 |
5.5 |
p < 0.0001 |
|
2010 |
2006-2007 |
|
|
|
|
|
|
|
|
|
||
Dohil62 |
RCT |
Peds |
24 (20) |
15 |
VB |
3 months |
Yes |
Overall |
66.7 |
4.8 |
p < 0.0001 |
|
2010 |
2008-2009 |
|
|
|
|
|
|
|
|
|
|
|
Dellon63 |
RCT |
Adults |
25 (15) |
11 |
VB vs SIB |
8 weeks |
Yes (VB) |
Overall |
89 |
11 |
p = 0.02 |
|
2012 |
N/A |
|
|
|
|
Yes (SIB) |
Overall |
101 |
89 |
|
||
Alexander57 |
RCT |
Adult |
42 (30) |
21 |
FP |
6 weeks |
No |
Peak (Eos) |
40 |
2 |
p < 0.001 |
|
2012 |
2005-2009 |
|
|
|
|
|
|
|
|
|
|
|
Butz58 |
RCT |
Adult / Peds |
42 (35) |
28 |
FP |
6 months |
Yes |
Proximal |
53.5 |
> 90% decrease |
p = 0.0001 |
|
2014 |
2006 |
|
|
|
|
|
Yes |
Distal |
56.3 |
> 90% decrease |
p = 0.0001 |
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