24 HOW TO TREAT : EOSINOPHILIC OESOPHAGITIS
24 HOW TO TREAT : EOSINOPHILIC OESOPHAGITIS
14 JUNE 2024 ausdoc . com . au
PAGE 21 approximately 50 % of patients responding to diet beyond 1-2 years . 45
Recent studies demonstrated that a single-food elimination diet ( excluding all cow ’ s milk protein ) may also be effective for treating EoE , with histological remission occurring in 50 % of children with EoE . 45A In addition , a recent randomised trial remarkably demonstrated histological remission in 34 % of patients in the 1-FED group compared with 40 % in the 6-FED group , highlighting that 1-FED is a valid initial dietary treatment for EoE . 45B
Dietary therapy for patients with EoE involves careful consideration , patient selection and choice of dietary approach as it requires motivation , access to allied health resources and repeated endoscopic procedures . Patients need support during this process , with clear information before and throughout the evaluation .
Dietary therapy for EoE is empirical , and it is important to note that allergy testing in patients with EoE is of no benefit . This is because EoE is not an IgE-mediated condition , and non-IgE-based allergy tests , such as atopic patch testing , do not provide significant benefit . 2
In the authors ’ opinion , in most patients where dietary therapy is appropriate , it is most pragmatic to start with a single or 2-FED elimination , understanding that a step-up approach may be required .
Swallowed topical corticosteroids
STC are the most extensively studied drug class in EoE ( see table 1 ). They include swallowed fluticasone ( via metered-dose inhaler ), budesonide slurry and BOT . More recently , available preparations include budesonide oral suspension and fluticasone orally disintegrating tablet . 46 Both swallowed budesonide and fluticasone propionate are significantly superior to placebo in reducing EoE to 15 or fewer eosinophils / hpf ( odds
46 , 47 ratio = 24.5 , 95 % CI = 7-86.8 ).
Optimisation of delivery of STC onto the oesophageal mucosa is key . Historically , asthma medication was adapted and used off label for the indication . The use of compounded or homemade budesonide viscous slurry was developed to try to improve distribution of the drug into the oesophagus . When budesonide ( oral viscous or nebulised ) is administered at the same doses for the same period , oral viscous budesonide provides longer contact time between mucosa , and the medication and results in a reduction in eosinophil count and improved endoscopic features . 48 Individuals with a BMI in the obese range had a decreased treatment response to topical steroids compared with those who were non-obese . 49
The preparation of a viscous solution can be burdensome for patients . In the authors ’ experience , even the most diligent patients describe difficulty with adherence on a long-term basis . To overcome this , commercially prepared BOT has been developed . BOT therapy has been pivotal in managing EoE as it not only provides outstanding remission rates ( 93 % histological remission after six weeks ) but also maintains long-term remission ( 75 % continued remission on 1mg BOT bd ). 46 , 50 There is
Figure 6 . Peptic stricture associated with gastro-oesophageal reflux disease .
Figure 7 . Micrograph showing features of gastro-oesophageal reflux disease .
Table 1 . Swallowed topical corticosteroids utilised in eosinophilic oesophagitis Medication
currently only one PBS-listed BOT 1mg bd formulation , which uses saliva to transport and adhere the drug to the oesophageal mucosa .
Following initiation of treatment , confirmation of histological remission ( five eosinophils or fewer / hpf ) is necessary to meet the PBS criteria for a subsequent maintenance dose of 0.5 or 1mg bd . To ensure preservation of medication release onto the oesophageal mucosa , patients should not eat or drink for 30 minutes after administration . As such ,
Target population
Induction dosing
it is best taken after breakfast and before bed .
BOT therapy is well tolerated with minimal side effects : the most frequent being histologically confirmed candidiasis that did not affect treatment duration . 2 Of note , mean morning cortisol levels at baseline did not change at the end of treatment . Randomised controlled trials have reported no clinical evidence of adrenal suppression or growth impairment ; however , more research is required regarding
Maintenance dosing
Fluticasone proprionate MDI a Adults 1760 µ g / day ( divided dose ) 440-880 µ g / day divided dose Budesonide viscous solution Adults 2-4mg / day 1mg / day Budesonide orodispersible tablet Adults 1mg bd 1mg bd preferred ( can be decreased to 0.5mg bd )
a
If a metered-dose inhaler ( MDI ) is used , instruct the patient to hold their breath and puff the medication into their mouth ; they should then wash their mouth out ( but not swallow ) to avoid candidiasis . Instruct patients not to eat for 30-60 minutes after administering medication .
the monitoring and long-term effects of these medications . 46
Nephron / CC BY : bit . ly / 3G76w2z
Oesophageal dilation
EoE is a chronic inflammatory condition that if left untreated may result in the development of strictures and other fibrostenotic complications . Oesophageal dilation has no effect on oesophageal inflammation but may improve symptoms in those with fibrostenotic disease . Oesophageal dilation has been used as a technique for managing
EoE since early documented cases . Dilation is performed using either pneumatic balloons or Savary bougies , with no differences in the response to the dilation devices noted . 46 These procedures are associated with a perforation rate of fewer than 1 %. 51 An oesophageal calibre of at least 16mm has been shown to relieve dysphagia and avoid food impaction , and this may be achieved with one or sequential endoscopies . 46
As endoscopic therapy does not address inflammation , adding an effective drug- or dietary-based EoE therapy has reduces the need for repeated procedures . 51 Oesophageal dilation can be considered in patients with fibrostenotic EoE at the time of diagnosis , in patients who have symptoms of EoE and persistent oesophageal strictures despite medical or dietary therapy and in persistent dysphagia in the presence of endoscopic and histological remission with medical or dietary therapy . 46
Monitoring
Long-term maintenance of a treatment strategy at the lowest effective dose / dietary food group elimination is advocated in order to minimise progression of EoE as evidenced by luminal narrowing , stricturing disease or complications such as food bolus obstruction or perforation . 52 Given that symptoms do not correlate accurately with histology , consensus is that the goal of maintenance therapy is to improve or normalise histology ; however , given the paucity of studies demonstrating decreased complications associated with histological remission , this concept is inferred . 52
There are no strict guidelines for review or assessment . Routine clinical evaluation to determine symptoms ( using a structured symptom score , such as the Dysphagia Symptom Questionnaire , see figure 10 ), compliance with therapy and to ensure there are no features of malnutrition is prudent . 52 A nutritional screen for those on dietary therapy may be appropriate . In addition , endoscopic assessment may be warranted for patients with known stricturing disease who may require dilation or for patients who report ongoing symptoms .
FUTURE DIRECTIONS
FLUTICASONE , also available as an orally disintegrating formulation , has been reported to improve histological , endoscopic and symptom criteria compared with placebo ( 63-75 % of participants achieving a reduction in inflammation to fewer than 15 eosinophils / hpf compared with 13 % of participants treated with placebo ). 53 This small proof-ofconcept study was followed by the larger FLUTE trial , which demonstrated that 3mg once daily at bedtime conferred the most favourable risk – benefit profile . 54
Novel therapies , such as preformulated budesonide oral suspension demonstrated that 2mg ( 10mL ) bd was superior to placebo in improving histological , endoscopic and symptomatic outcomes over 12 weeks . 55 However , it did not perform as well as BOT therapy , with 30 % achieving full response defined as stringent histological response