Treatment of eosinophlic esophagitis with swallowed topical corticosteroids

Abstract

Eosinophilic esophagitis (EoE) is an emerging chronic local immune-mediated disease of the esophagus. Beside proton pump inhibitors and food-restriction-diets swallowed topical corticosteroids (STC) can be offered as a first line therapy according to current guidelines. This review describes the background and practical management of STCs in EoE. So far, mainly asthma inhalers containing either budesonide or fluticasone have been administered to the esophagus by swallowing these medications “off label”. Recently esophagus-targeted formulations of topical steroids have been developed showing clinicopathological response rates up to 85% - an orodispersible tablet of budesonide has been approved as the first “in label” medication for EoE in Europe in June 2018. Whereas it was shown that disease remission induction of EoE by STCs is highly effective, there is still a lack of data regarding long-term and maintenance therapy. However, current studies on STC maintenance therapy add some movement into the game.

Eosinophilic esophagitis-associated epithelial remodeling may limit esophageal carcinogenesis

“…Whereas genes associated with proliferation were linked to ESCC-enriched clusters, EoE-enriched clusters were associated with the senescence pathway ( Figure 7B; Table 1 ). Genes associated with glucocorticoid receptor signaling, which is a target for corticosteroid-based therapy in EoE patients (41), and aryl hydrocarbon receptor pathway, which has been linked to proton pump inhibitor-mediated inhibition of epithelial proliferation and IL-13 signaling (42), were also identified in EoE-enriched clusters ( Figure 7B; Table 1 ). Furthermore, genes associated with granulocyte macrophage colony-stimulating factor were found in EoE-enriched clusters, consistent with the presence of eosinophils and other granulocytes in EoE patients.…”

Eosinophilic esophagitis: Immune mechanisms and therapeutic targets

“…133,189 Some of these oesophagus-targeted formulations of topical steroids have demonstrated excellent response rates inducing clinical and histologic remission and improvement of QoL in patients with EoE. 133,189,190 However, several patients do not respond to these standard therapies, histologic relapse in EoE is not uncommon and long-term efficacy remains unclear. 191 Recently, there has been increasing focus on the utilization of biologic agents focussed on targeting specific aspects of eosinophil biology (IL-4, IL-5, IL-5Rα, IL-13 and siglec-8) for the treatment of EoE 188 (Figure 1).…”

“…Dietary and pharmacologic therapies are effective in inducing and maintaining disease remission, reducing the risk of esophageal food impactions, and improving quality of life 48,185–188 . Recently, several corticosteroid formulations including fluticasone orodispersible tablet, budesonide oral solution and budesonide orodispersible tablet have been developed to specifically treat EoE 133,189 . Some of these oesophagus‐targeted formulations of topical steroids have demonstrated excellent response rates inducing clinical and histologic remission and improvement of QoL in patients with EoE 133,189,190 .…”

Therapie der eosinophilen Ösophagitis – Fortschritte und Perspektiven

“…Zur remissionsinduzierenden Therapie der EoE mit TCS (Budesonid, Fluticason) liegen mittlerweile zahlreiche plazebo-kontrollierte Doppelblindstudien vor [17,18]. Während in früheren Studien vor allem geschluckte Asthma-Präparate verwendet wurden, sind in neueren Studien EoE-spezifische Formulierungen (Budesonid-Suspensionen, orodispersible Budesonid-Tablette, Fluticason-Schmelztablette) plazebo-kontrolliert in der Remissionsinduktion untersucht worden [19][20][21][22][23][24]28] (▶ Tab.…”