Swallowed Fluticasone Propionate Is an Effective Long-Term Maintenance Therapy for Children With Eosinophilic Esophagitis

Abstract

Background and Aims While effective in the treatment of eosinophilic esophagitis (EoE) in children, limited data exists on long-term safety and efficacy of swallowed topical corticosteroids.. We investigated if long-term use of swallowed fluticasone in children with EoE leads to sustained reduction in esophageal eosinophils, and endoscopic and clinical improvement. Methods In an open-label, prospective, single center study, we offered pediatric patients with active EoE fluticasone 2 puffs to swallow twice a day (strengths in μg/puff: 2–4 years: 44, 5–11 years: 110, ≥12 years: 220). Clinical, endoscopic and histological assessments were performed at baseline and shortly after therapy. If histological remission was seen, fluticasone was continued with clinical follow-ups every 4 months, and endoscopic and histological follow-ups yearly. Clinical scores were derived from 8 symptoms (abdominal pain, nausea, vomiting, regurgitation, chest pain, dysphagia, food impaction and early satiety). Endoscopic scores were derived from 6 features (rings, exudates, furrows, edema, stricture and shearing). Scores were expressed as ratio (features present/total). In addition to peak eosinophils/HPF (primary outcome), histological features (eosinophilic microabscesses, degranulation, superficial layering, basal zone hyperplasia, dilated intercellular spaces and lamina propria fibrosis) were assessed. Median clinical and endoscopic scores and individual histologic features were compared over 4 time intervals: <4 months, 4–12 months, 13–24 months and >24 months. Growth and adverse effects were monitored. Results We enrolled 54 patients, 80% male, median age 6.5 years (range 2–17 years), 85% atopic (57% asthma, 68% allergic rhinitis, 31% atopic dermatitis) and 74% with food allergy. Mean follow-up was 20.4 months, the longest being 68 months (5.7 years). Esophageal eosinophils counts significantly decreased (median peak eosinophils/HPF at baseline 72, <4 months: 0.5, 4–12 months: 1.75, 13–24 months: 10, and >24 months: 12, all p<0.01). All histological features significantly decreased from baseline to all follow-up time points (all p<0.01). Lamina propria fibrosis significantly decreased (% patients with fibrosis at baseline 92, <4 months: 41, 4–12 months: 50, 13–24 months: 45, and >24 months: 39, all p<0.01). Endoscopic features improved (score at baseline 0.37, <4 months: 0.17, 4–12 months: 0.17, 13–24 months: 0, and >24 months: 0.1, all p<0.01 except at >24 months: p<0.05). Symptoms improved (score at baseline 0.22, <4 months: 0, 4–12 months: 0.11, 13–24 months: 0.11, and >24 months: 0.11, all p<0.05 except at >24 months: p=0.05). Asymptomatic esophageal candidiasis was seen in 3 children but resolved with anti-fungal therapy. Height and weight Z-scores followed expected growth curves. Conclusion We demonstrate that swallowed fluticasone is effective as a long-term maintenance therapy for children with EoE, without growth impediment or serious side effects.

Influence of Age and Eosinophilic Esophagitis on Esophageal Distensibility in a Pediatric Cohort

“…It may also support a theory of the “burned out” esophagus in adult EoE where there is little or variable ongoing active inflammation but instead a narrowed stiff esophagus due to chronic remodeling [1, 2]. Regardless, it suggests there may be some ability to reverse or halt fibrotic remodeling when inflammation is treated effectively in children, making a strong argument in favor of early and ongoing therapy and tissue healing in patients at risk of fibrostenosis[16]. …”

Systematic review: adrenal insufficiency secondary to swallowed topical corticosteroids in eosinophilic oesophagitis

“…We identified 1610 unique reports, and 17 met inclusion criteria (Tables and ) . There were 7 randomised controlled trials, 6 prospective observational studies, 3 retrospective observational studies, and 1 case report (Figure ).…”

Six-Food Elimination Diet and Topical Steroids are Effective for Eosinophilic Esophagitis: A Meta-Regression

“…Only a few studies examined the effectiveness of maintenance therapy with a mucosal agent [25,72,73]. Very little is known about the longitudinal course of EoE patients under treatment, especially among patients on SFED, and what is known suggests relapse is common if treatments are stopped.…”