Eosinophilic Esophagitis treatment options can be defined into 3 treatment categories.
2. Pharmacotherapy (medications)
In a previous blog post, we discussed Eosinophilic Esophagitis in depth.
Here we will discuss specific treatment options for eosinophilic esophagitis.
Swallowed, Topical Steroids
Fluticasone- Also known as Flovent, has been examined in multiple studies. Patients should administer the medication directly into their mouth without a spacer and without any inhalation. One should not eat or drink for 30 minutes after dosing, this allows for contact time of the medicine on the esophagus. Studies showed 220, 2 puffs twice daily, led to complete resolution in half the patients. Some studies have shown that doubling the dose led to more resolution in 65% of the patients. All of the studies used the MDI (metered dose inhaler) form of Flovent. These studies were done in adult patients, other studies with pediatric patients showed even higher efficacy, although higher doses were used.
Budesonide– The trade name for this is Pulmicort. This medication has the advantage that it already comes in an oral viscous solution in 0.25mg, 0.5 mg and 1 mg vials. A pediatric study showed close to 90% of patients showed a significant reduction in the eosinophil count (mean 67% to 5%) after treatment. The dosing was either 1 mg daily or 2 mg daily based on the height of the patient (5 feet). Thickening agents may be needed in this form of eosinophilic esophagitis treatment, vehicles used have been powdered sugar, corn starch, agave nectar and honey.
The big question though is how long do patients need to be treated. Unfortunately there are no well designed studies to properly answer this question. Symptom recurrence was common after treatment was stopped and it occurred an average of 5.5 weeks after cessation of the medications. Another study showed that it took 8 months to come back. Current guideline recommendations now state “… after induction of clinicopathologic remission, topical corticosteroid therapy might need to be maintained; however, long-term therapy must be individualized for each patient.” So there are no good answers on how long this eosinophilic esophagitis treatment must be maintained.
Adverse effects of topical steroids for EoE have not shown any serious events to date. Although the studies have been very limited and most patients do not continue these mediations for extended periods of time.
Conclusion- Based on available data, topical steroids work for most patients with few adverse effects other than oral or esophageal candidiasis. However the drawback is that they do not lead to a cure and it usually comes back when treatment is stopped. And for pediatric patients, many parents are hesitant to administer steroids. To date there are no effective non-steroidal treatment options, however new treatments are emerging including Nucala an anti-IL -5 treatment option that was approved for asthma.
Or Cinquil another anti IL-5 treatment option, it is possible that one or both may get an indication for eosinophilic esophagitis.
Your allergy doctor or allergist would be the best person to speak to regarding what options are right for you. He or she will work with your Gastroenterologist to figure out if you are the right candidate for drug treatment, elimination diets or mechanical intervention such as esophageal dilation.