1
|
Lendner N, Minich NM, Malay S, Sferra TJ, Young DD. Comparison of budesonide vehicles in inducing histologic remission in pediatric eosinophilic esophagitis. J Pediatr Gastroenterol Nutr 2024; 79:92-99. [PMID: 38803200 DOI: 10.1002/jpn3.12273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/27/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVES Oral viscous budesonide (OVB) is a common medication used to treat eosinophilic esophagitis (EoE). It is typically mixed with Splenda to produce a slurry, but other delivery vehicles have been used in clinical practice. We aimed to evaluate outcomes of pediatric EoE patients treated with OVB using different drug delivery vehicles. METHODS We performed a retrospective chart review of pediatric EoE patients treated with OVB. The primary aim was to evaluate rates of histologic remission (defined by <15 eosinophils per high power field in both mid and distal esophagus) after 6-12 weeks of OVB treatment for each delivery vehicle. Secondary aims were to evaluate histologic response and endoscopic response and remission of different delivery vehicles, and to compare the efficacy of different treatment regimens. RESULTS A total of 111 patients were included in the study. Median treatment duration was 3.4 months. Overall rate of histologic remission with OVB was 52.6%. There was no difference in rates of histologic remission (p = 0.313) or response (p = 0.195 and p = 0.681 in mid and distal esophagus, respectively) among the different vehicle types or treatment regimens. Similarly, there was no difference in endoscopic remission and response among the different vehicle types (p = 0.853 and p = 0.727) or treatment regimens (p = 0.244 and p = 0.157). Patients who achieve histologic remission were more likely to be non-Hispanic Caucasian. CONCLUSION Our findings suggest there is no difference in histologic and endoscopic outcomes with various delivery vehicles or combination therapy with OVB in the treatment of EoE. More palatable and cost-effective vehicles can be used to treat EoE.
Collapse
Affiliation(s)
- Nuphar Lendner
- Pediatrix Gastroenterology of the Rocky Mountains, Denver, Colorado, USA
| | - Nori Mercuri Minich
- Biostastics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sindhoosha Malay
- Biostastics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Thomas J Sferra
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Denise D Young
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| |
Collapse
|
2
|
Syverson EP, Tobin M, Patton T, Franciosi JP, Gupta SK, Venkatesh RD. Variability in Swallowed Topical Corticosteroid Practice Patterns for Treatment of Pediatric Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2023; 77:256-259. [PMID: 37204839 DOI: 10.1097/mpg.0000000000003834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Given the variety of preparations and lack of standardization of swallowed topical corticosteroids (STC) for treatment of eosinophilic esophagitis (EoE), we sought to better understand STC prescribing practices of pediatric gastroenterologists. A 12-question survey was distributed to members of North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Eosinophilic Gastrointestinal Disease Special Interest Group and responses were analyzed. Forty-two of 68 physicians responded. Oral viscous budesonide (OVB) was overall first choice STC in 31 (74%) survey respondents, with OVB most frequently utilized in patients under 5 years old and fluticasone propionate in patients 13-18 years old. Nineteen types of mixing vehicles were used for OVB preparation, the 3 most frequent being sucralose, honey, and artificial maple syrup. Insurance coverage, cost, and patient compliance were most frequently cited barriers to STC use. Highly variable STC prescribing practices reported by this group highlights the need for standardization of STC treatment in EoE.
Collapse
Affiliation(s)
| | | | | | - James P Franciosi
- Nemours Children's Hospital, Orlando, FL
- University of Central Florida College of Medicine, Orlando, FL
| | - Sandeep K Gupta
- Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, IN
| | - Rajitha D Venkatesh
- Nationwide Children's Hospital, Columbus, OH
- The Ohio State University, Columbus, OH
| |
Collapse
|
3
|
Cases of drug repositioning in children's orphan drugs: Licenced drugs versus unlicenced magistral preparations. J Drug Deliv Sci Technol 2023. [DOI: 10.1016/j.jddst.2023.104349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
|
4
|
A New Viscous Budesonide Formulation for the Treatment of Eosinophilic Esophagitis in Children: A Preliminary Experience and Review of the Literature. J Clin Med 2022; 11:jcm11226730. [PMID: 36431208 PMCID: PMC9694526 DOI: 10.3390/jcm11226730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic disease, characterized clinically by esophageal disfunction. Topical corticosteroids (tCS), predominantly fluticasone and budesonide, are considered the effective first line treatment, as well as an option of maintenance therapy in EoE. The way that tCS are administered significantly affects their effectiveness. There is still no ready-to-use steroid drug to be applied topically to the esophagus in children-a few experimental viscous slurries (mainly of budesonide) have been shown in trials to be more effective than steroids administered via metered dose inhalers (MDIs) and swallowed. The best examined steroid solvent of all is sucralose, a high-intensity artificial sweetener. Although it has been shown in a critical review that it is non-toxic and safe for all consumers, there are still some concerns among patients about its potential adverse effect on humans. Due to that fact, we developed a new viscous formulation and evaluated its effectiveness in the treatment of children with EoE. In an open, prospective, single-center study, we administered our new formulation of viscous budesonide twice daily for 8 weeks in patients with an active EoE. After treatment, we performed a control gastroscopy with the collection and evaluation of histopathological samples. We have proven our formulation effectiveness at 64%, as far as histological remission is concerned. We have also shown a reduction in the mean endoscopic reference score (EREFS) from 3.1 points at the beginning of the study to 1.6 points at the end of the study. Bearing in mind how important the acceptance of the solvent is for long-time compliance, especially among children, we also decided to assess the taste of the formulation. Therefore, we asked 46 adults and 10 children to swallow a sample of the solvent and fill in a short anonymous questionnaire about its taste, smell, consistency and easiness of swallowing. General acceptance for the proprietary solvent was high, reaching 7.5/10 among adults and 6.5/10 in children. To be able to compare the results of our preliminary experience, we reviewed the studies which evaluated substances that have been used so far as steroid solvents for the treatment of EoE. The overall effectiveness of the oral viscous budesonide (OVB) ranged from 65% to 90%, which is consistent with the results obtained in our study. Unfortunately, the high heterogeneity of the studies did not allow us to draw reliable conclusions.
Collapse
|
5
|
Lucendo AJ, Molina-Infante J. Current treatment options and long-term outcomes in patients with eosinophilic esophagitis. Expert Rev Clin Immunol 2022; 18:859-872. [PMID: 35770955 DOI: 10.1080/1744666x.2022.2096591] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Dietary and pharmacological (proton pump inhibitors, swallowed topical corticosteroids) therapies are effective for induction of clinical and histological remission of eosinophilic esophagitis. However, data evaluating their long-term efficacy and safety is limited. AREAS COVERED Since eosinophilic esophagitis is chronic, clinical, endoscopic, and histological features usually recur when successful treatments are stopped. In untreated patients, persistent esophageal eosinophilic inflammation may progress to fibrostenosis over time, giving place to strictures and narrow-caliber esophagi. This article comprehensively reviews available data on long-term maintenance of eosinophilic esophagitis with pharmacological and dietary treatment. It also discusses limitations re: available literature and outlines data gaps on adherence to therapy and monitoring disease activity in the long-term. EXPERT OPINION Evidence indicates that long-term maintenance therapy may decrease the risk of esophageal stricture, food bolus impaction, and need for dilation in patients with eosinophilic esophagitis. Further knowledge on eosinophilic esophagitis phenotypes is needed to ascertain who will benefit best from sustained therapy. Unanswered questions include an adequate definition for sustained remission, best strategies for maintenance drugs and diets, enhancement of treatment adherence, and proper monitoring for long-term surveillance.
Collapse
Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Spain.,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Javier Molina-Infante
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de Caceres, Caceres, Spain
| |
Collapse
|
6
|
Lucendo AJ. Drug treatment strategies for eosinophilic esophagitis in adults. Expert Opin Pharmacother 2022; 23:827-840. [PMID: 35379069 DOI: 10.1080/14656566.2022.2060077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a clinical and pathological disorder, characterized by symptoms of esophageal dysfunction, and eosinophil-predominant inflammation restricted to the esophagus. Treatment outcomes include symptomatic remission, histological and endoscopic normalization and improving quality of life. Besides dietary modifications and endoscopic dilation, drugs available are swallowed topical corticosteroids (STCs) with reduced bioavailability and proton pump inhibitors (PPI). AREAS COVERED Herein, the authors review the current treatment strategies for EoE in adults, providing the reader with their expert perspectives. The authors give discussion to the value of PPIs as a first-line therapy for EoE, in addition to the use of STCs. The current development of new formulations of STCs targeting the esophagus and novel therapies aimed at blocking molecular pathways are also discussed. Finally, the authors briefly look at the value of monoclonal antibodies targeting IL-5RA, IL-13, IL-4 or Siglec8, and oral S1PR agonists to the treatment of EoE. EXPERT OPINION Viscose formulations of STC designed to coat the esophagus and new effervescent orodispersible tablets provide increased effectiveness at low doses. Investigational therapies that target several Th2-associated diseases seem useful in EoE. Comparative effectiveness and cost-utility analyses will help to position them in a complex therapeutic scenario.
Collapse
Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology. Hospital General de Tomelloso, Tomelloso, Spain.,Instituto de Investigación Sanitaria La Princesa, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM).,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| |
Collapse
|
7
|
Główczewski A, Krogulska A. Formulations of Topical Steroids in Eosinophilic Esophagitis-Current Treatment and Emerging Possibilities. J Clin Med 2022; 11:1454. [PMID: 35268544 PMCID: PMC8910832 DOI: 10.3390/jcm11051454] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 12/17/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated disorder characterised by eosinophilic inflammation and esophageal dysfunction symptoms. The recommended first-line treatment options are proton pump inhibitors and swallowed topical steroids (STS). However, current recommendations regarding STS are based on relatively few studies employing various doses and formulations. Our aim was to review the STS formulations currently used in the treatment of eosinophilic esophagitis, to demonstrate in a practical way the variety of exiting application methods, and to present emerging options for STS delivery to the esophagus. After the literature review, we established that the three most commonly used STS formulations include mist from an inhaler, viscous suspensions compounded with vehicles for oral use, and a recently introduced proprietary medication in the form of orodispersible tablets. Several drug delivery technologies with potential use in EoE are under investigation. To ensure optimal adherence, the choice of formulation should be based on efficacy, patient preferences and experience of the clinician, as well as current recommendations. Further studies are needed to compare the efficacy and acceptability of existing STS types, and to develop new, well-tolerated and effective drug formulations.
Collapse
Affiliation(s)
- Adam Główczewski
- Department of Pediatrics, Allergology and Gastroenterology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland;
| | | |
Collapse
|
8
|
Ruffner MA, Juste L, Muir AB. Medical Management of Eosinophilic Esophagitis in Pediatric Patients. Pediatr Clin North Am 2021; 68:1191-1204. [PMID: 34736584 DOI: 10.1016/j.pcl.2021.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Eosinophilic esophagitis is an immune-mediated allergic disease of the esophagus that affects pediatric patients of all ages. The diagnosis is made by esophagogastroduodenoscopy demonstrating eosinophilic infiltrate of the esophagus. Approaches to treatment involve proton pump inhibitors (PPIs), swallowed topical steroid preparations, as well as dietary elimination. In this review we discuss the evidence and efficacy of each of these approaches.
Collapse
Affiliation(s)
- Melanie A Ruffner
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34th and Civic Center Boulevard, Wood Building 3rd Floor, Philadelphia, PA 19104, USA
| | - Linola Juste
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Abramson Research Center 902E, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Abramson Research Center 902E, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| |
Collapse
|
9
|
Variability in Practices of Compounding Budesonide for Eosinophilic Esophagitis. Am J Gastroenterol 2021; 116:1336-1338. [PMID: 33538420 PMCID: PMC9161310 DOI: 10.14309/ajg.0000000000001170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/30/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Little is known about the use of compounded steroids for eosinophilic esophagitis (EoE). METHODS We conducted a telephone survey of all compounding pharmacies in Michigan and queried about practices and costs of compounded budesonide for EoE. RESULTS Of 68 Michigan pharmacies, 93% responded, and 20 (29%) offer compounded budesonide suspension for EoE. Formulations, dose, and instructions for use varied across pharmacies. The mean cost for a 30-day supply was $74.50. DISCUSSION Although few compounding pharmacies offer budesonide suspension and there are substantial variations in formulations, this may be a significantly more affordable treatment option for many.
Collapse
|
10
|
Red Between the Lines: Evolution of Eosinophilic Esophagitis as a Distinct Clinicopathologic Syndrome. Dig Dis Sci 2020; 65:3434-3447. [PMID: 33052498 PMCID: PMC7669680 DOI: 10.1007/s10620-020-06642-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/09/2022]
Abstract
Eosinophilic esophagitis (EoE) is characterized by eosinophilic infiltration of the esophageal mucosa and symptoms of esophageal dysfunction, including dysphagia. While EoE is still considered a rare disease, in practice it seems that more and more cases are diagnosed every week, research in the field is exploding, and the pipeline for treatments contains multiple agents, some of which are quite far along the development pathway. After only scattered cases and small series were published in the late 1970s and 1980, Stephen Attwood, Thomas Smyrk, Tom DeMeester, and James Jones, published in Digestive Diseases and Sciences in 1993 a seminal report that described a clinicopathologic syndrome of esophageal eosinophilia with dysphagia. This review details the origins of this paper and compares and contrast what was observed then and what is known now about multiple aspects of EoE, including the clinical presentation, diagnosis, epidemiology, natural history, and treatments and outcomes. Moreover, it will highlight how the paper presaged a number of controversies in the field that have yet to be resolved, as well as foreshadowed the collaborative, multidisciplinary approach that has led to rapid advances.
Collapse
|
11
|
Brown-Whitehorn T, Spergel JM. Food allergy and eosinophilic gastrointestinal disorders. JOURNAL OF FOOD ALLERGY 2020; 2:39-43. [PMID: 39022152 PMCID: PMC11250641 DOI: 10.2500/jfa.2020.2.200010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Eosinophilic esophagitis (EoE) is a non-immunoglobulin E mediated disorder that has been seen with increasing frequency over the past 25 years. Although the presentation varies per age group from vomiting and refusal to eat in infants and toddlers to abdominal pain and dysphagia in school-aged children, and food impaction and indigestion in adolescents and adults. Treatment options include proton-pump inhibitors, dietary avoidance, swallowed steroids, or a combination of these. Newer therapies with biologics show promise in early studies. Cow's milk is the most common food trigger of EoE across all age groups, followed by wheat and eggs. Different dietary avoidance strategies have been used, and help from a knowledgeable nutritionist is often key to success. Patients with EoE commonly have other baseline atopic disease. Clinicians who take care of patients who are atopic, therefore, should have a higher index of suspicion for EoE in patients with dysphagia. The goals of treatment are both a decrease in symptoms and normalization of esophageal histology. Eosinophilic gastrointestinal diseases are less common and less likely to respond to dietary therapies and/or avoidance. Pathogenesis seems to be different and may be more autoimmune mediated. Trialing dietary restrictions is certainly an option in this cohort of patients. For persistent symptoms and abnormalities, systemic medications have been used, although biologics may be used in the future. Additional studies are needed to determine which patients will respond to which therapies.
Collapse
Affiliation(s)
- Terri Brown-Whitehorn
- From the Division of Allergy and Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan M Spergel
- From the Division of Allergy and Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
12
|
Krause J, Rosenbaum C, Grimm M, Rump A, Keßler R, Hosten N, Weitschies W. The EsoCap-system - An innovative platform to drug targeting in the esophagus. J Control Release 2020; 327:1-7. [PMID: 32781172 DOI: 10.1016/j.jconrel.2020.08.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023]
Abstract
For the therapy of esophageal diseases such as eosinophilic esophagitis, there are no possibilities of local targeted therapy. This publication describes a novel, innovative drug delivery concept, that enables a targeted, long-lasting administration of drug substances to the esophageal mucosa. In addition to a comprehensive in-vitro characterization of the dosage form, this work includes a proof-of-concept study with healthy volunteers, which shows the functionality and acceptance of this novel drug delivery concept. This novel drug delivery technology enables for the first time a targeted, local and long-lasting therapy of the esophagus.
Collapse
Affiliation(s)
- Julius Krause
- University of Greifswald, Institute of Pharmacy, Department of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, Felix-Hausdorff-Str. 3, 17487 Greifswald, Germany
| | - Christoph Rosenbaum
- University of Greifswald, Institute of Pharmacy, Department of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, Felix-Hausdorff-Str. 3, 17487 Greifswald, Germany
| | - Michael Grimm
- University of Greifswald, Institute of Pharmacy, Department of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, Felix-Hausdorff-Str. 3, 17487 Greifswald, Germany
| | - Adrian Rump
- University of Greifswald, Institute of Pharmacy, Department of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, Felix-Hausdorff-Str. 3, 17487 Greifswald, Germany
| | - Rebecca Keßler
- Department of Diagnostic Radiology and Neuroradiology, University Hospital Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
| | - Norbert Hosten
- Department of Diagnostic Radiology and Neuroradiology, University Hospital Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
| | - Werner Weitschies
- University of Greifswald, Institute of Pharmacy, Department of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, Felix-Hausdorff-Str. 3, 17487 Greifswald, Germany.
| |
Collapse
|
13
|
Casiraghi A, Gennari CG, Musazzi UM, Ortenzi MA, Bordignon S, Minghetti P. Mucoadhesive Budesonide Formulation for the Treatment of Eosinophilic Esophagitis. Pharmaceutics 2020; 12:pharmaceutics12030211. [PMID: 32121553 PMCID: PMC7150804 DOI: 10.3390/pharmaceutics12030211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/21/2020] [Accepted: 02/23/2020] [Indexed: 01/07/2023] Open
Abstract
Eosinophilic esophagitis (EE) is a chronic immune/antigen-mediated esophageal inflammatory disease for which off-label topical corticosteroids (e.g., budesonide) are widely used in clinic. In general, thickening excipients are mixed with industrial products to improve the residence time of the drug on the esophageal mucosa. The compounding procedures are empirical and the composition is not supported by real physicochemical and technological characterization. The current study aimed to propose a standardized budesonide oral formulation intended to improve the resistance time of the drug on the esophageal mucosa for EE treatment. Different placebo and drug-loaded (0.025% w/w) formulations were prepared by changing the percentage of xanthan gum alone or in ratio 1:1 with guar gum. Both excipients were added in the composition for their mucoadhesive properties. The formulative space was rationalized based on the drug physicochemical stability and the main critical quality attributes of the formulation, e.g., rheological properties, syringeability, mucoadhesiveness and in vitro penetration of budesonide in porcine esophageal tissue. The obtained results demonstrated that gums allowed a prolonged residence time. However, the concentration of the mucoadhesive polymer has to be rationalized appropriately to permit the syringeability of the formulation and, therefore, easy dosing by the patient/caregiver.
Collapse
Affiliation(s)
- Antonella Casiraghi
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo 71-20133 Milan, Italy; (C.G.G.); (U.M.M.); (P.M.)
- Correspondence:
| | - Chiara Grazia Gennari
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo 71-20133 Milan, Italy; (C.G.G.); (U.M.M.); (P.M.)
| | - Umberto Maria Musazzi
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo 71-20133 Milan, Italy; (C.G.G.); (U.M.M.); (P.M.)
| | - Marco Aldo Ortenzi
- CRC Materiali Polimerici (LaMPo), Department of Chemistry, Università degli Studi di Milano, Via Golgi 19-20133 Milan, Italy;
- Department of Chemistry, Università degli Studi di Milano, Via Golgi 19-20133 Milan, Italy
| | - Susanna Bordignon
- Student of Specialization School in Pharmacy, Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo 71-20133 Milan, Italy;
| | - Paola Minghetti
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo 71-20133 Milan, Italy; (C.G.G.); (U.M.M.); (P.M.)
| |
Collapse
|
14
|
Carr S, Chan ES, Watson W. Correction to: Eosinophilic esophagitis. Allergy Asthma Clin Immunol 2019; 15:22. [PMID: 31007687 PMCID: PMC6456987 DOI: 10.1186/s13223-019-0336-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is an atopic condition of the esophagus that has become increasingly recognized over the last 15 years. Diagnosis of the disorder is dependent on the patient’s clinical manifestations, and must be confirmed by histologic findings on esophageal mucosal biopsies. Patients with EoE should be referred to an allergist for optimal management, which may include dietary modifications and pharmacologic agents such as proton pump inhibitors (PPI) and corticosteroids, and for the diagnosis and management of comorbid atopic conditions. Mechanical dilation of the esophagus may also be necessary. The epidemiology, pathophysiology, diagnosis, treatment, and prognosis of EoE are discussed in this review.
Collapse
Affiliation(s)
- Stuart Carr
- 1Department of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - Edmond S Chan
- 2Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC Canada.,3EoE Clinic, BC Children's Hospital, Vancouver, BC Canada
| | - Wade Watson
- 4Division of Allergy, Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, NS Canada
| |
Collapse
|
15
|
Abstract
PURPOSE OF REVIEW Eosinophilic esophagitis (EoE) is a multifactorial, non-IgE-mediated inflammatory disorder of the esophagus and is the most common cause of food impaction in the pediatric population. The purpose of this review is to describe the current recommendations for diagnosis and management of EoE. RECENT FINDINGS New data has associated EoE with other allergic disorders of the atopic march as well as several risk factors, which predispose to allergic conditions. A subset of patients with esophageal eosinophilia respond to proton pump inhibitor (PPI) therapy with a partial or complete resolution of esophageal eosinophilia. Therefore, some patients can be treated with PPI alone. If this is unsuccessful, dietary elimination and swallowed steroid therapy are recommended for long-term management. There is a growing appreciation that untreated esophageal inflammation can lead to complications of fibrosis and stricture formation. SUMMARY The current review will focus on the diagnosis and management of EoE in the pediatric population. Identification and diagnosis of pediatric patients with EoE is critical to prevent long-term esophageal complications.
Collapse
|
16
|
Abstract
Eosinophilic esophagitis (EoE) is an atopic condition of the esophagus that has become increasingly recognized over the last 15 years. Diagnosis of the disorder is dependent on the patient’s clinical manifestations, and must be confirmed by histologic findings on esophageal mucosal biopsies. Patients with EoE should be referred to an allergist for optimal management, which may include dietary modifications and pharmacologic agents such as corticosteroids, and for the diagnosis and management of comorbid atopic conditions. Mechanical dilation of the esophagus may also be necessary. The epidemiology, pathophysiology, diagnosis, treatment, and prognosis of EoE are discussed in this review.
Collapse
|
17
|
Steinbach EC, Hernandez M, Dellon ES. Eosinophilic Esophagitis and the Eosinophilic Gastrointestinal Diseases: Approach to Diagnosis and Management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:1483-1495. [PMID: 30201096 PMCID: PMC6134874 DOI: 10.1016/j.jaip.2018.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/06/2018] [Accepted: 06/21/2018] [Indexed: 12/12/2022]
Abstract
The eosinophilic gastrointestinal diseases (EGIDs) represent disorders of the gastrointestinal (GI) tract that result from the local infiltration and aberrant activity of eosinophils and other immune cells. Eosinophilic esophagitis (EoE) is the most well-characterized EGID and is defined by the presence of intraepithelial eosinophils in the esophagus (≥15 eosinophils per high-powered field) and clinical symptoms associated with esophageal dysfunction. The other EGIDs are rare and lack strong data regarding pathogenesis and management. The incidence and prevalence of EoE are increasing, and EoE is now a major cause of upper GI morbidity. Management is multidisciplinary, with collaboration between gastroenterologists, allergists, pathologists, and dieticians, and is aimed at amelioration of symptoms and prevention of long-term complications such as esophageal stricture. Treatment options for EoE include proton pump inhibitors, swallowed topical corticosteroids, and elimination diets. Esophageal dilation is used when esophageal strictures or fibrostenotic changes are present. Additional therapies targeting eosinophils and other mediators of Th2 inflammation are under development and are promising. Treatment options for other EGIDs typically involve corticosteroids or dietary elimination.
Collapse
Affiliation(s)
- Erin C Steinbach
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Michelle Hernandez
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC.
| |
Collapse
|
18
|
Abstract
PURPOSE OF REVIEW EoE is a significant cause of gastrointestinal morbidity affecting 1:2000. Patients with EoE typically have multiple atopic comorbidities, and additionally, many patients with EoE can be controlled well with elimination diets. The purpose of this review is to summarize the care of pediatric eosinophilic esophagitis patients. RECENT FINDINGS EoE represents a distinct clinical syndrome which is characterized by esophageal dysfunction and eosinophil-predominant inflammation of the esophageal mucosa. Patients with EoE can present with varying symptoms depending on their age; in this review, we review the presenting features of eosinophilic esophagitis in children as well as a diagnostic algorithm for EoE. The mucosal inflammation in EoE is driven by exposure to food antigens in many patients with EoE. Therefore, for the majority of patients, the mainstays of treatment remain food elimination diets or swallowed steroids. This review summarizes the diagnostic approach to eosinophilic esophagitis (EoE) in pediatric patients, focusing on the importance of accurate diagnosis and selection of appropriate therapy.
Collapse
|
19
|
Wilson JM, McGowan EC. Diagnosis and Management of Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2017; 38:125-139. [PMID: 29132668 DOI: 10.1016/j.iac.2017.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Unlike traditional food allergies, immunoglobulin E (IgE) is not a key mediator of eosinophilic esophagitis (EoE). Nonetheless, foods antigens are important triggers of EoE, and allergists play an important role in management of this chronic disease. This review addresses insights into the diagnosis and management as it relates to our evolving understanding about the pathogenesis of EoE.
Collapse
Affiliation(s)
- Jeffrey M Wilson
- Division of Allergy and Immunology, Department of Medicine, University of Virginia, PO Box 801355, Charlottesville, VA 22908, USA
| | - Emily C McGowan
- Division of Allergy and Immunology, Department of Medicine, University of Virginia, PO Box 801355, Charlottesville, VA 22908, USA; Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, 501 Hopkins Bayview Circle, Baltimore, MD 21224, USA.
| |
Collapse
|
20
|
Abstract
The goal of this Review is to discuss the clinical approach to patients who do not respond to treatment for eosinophilic oesophagitis (EoE). Refractory EoE is challenging to manage as there are limited data to guide decision-making. In this Review, refractory EoE is defined as persistent eosinophilia in the setting of incomplete resolution of the primary presenting symptoms and incomplete resolution of endoscopic findings following a PPI trial, and after treatment with either topical steroids or dietary elimination. However, this definition is controversial. This Review will examine these controversies, explore how frequently non-response is observed, and highlight potential explanations and predictors of non-response. Non-response is common and affects a large proportion of patients with EoE. It is important to systematically assess multiple possible causes of non-response, as well as consider treatment complications and an incorrect diagnosis of EoE. If non-response is confirmed, second-line treatments are required. Although the overall response rate for second-line therapy is disappointing, with only half of patients eventually responding, there are several promising agents that are currently under investigation, and the future is bright for new treatment modalities for refractory EoE.
Collapse
Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, CB# 7080, Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, North Carolina 27599-7080, USA
- Center for Gastrointestinal Biology and Diseases, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, CB# 7080, Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, North Carolina 27599-7080, USA
| |
Collapse
|
21
|
Hirano I, Spechler S, Furuta G, Dellon ES. White Paper AGA: Drug Development for Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2017; 15:1173-1183. [PMID: 28342955 PMCID: PMC5522639 DOI: 10.1016/j.cgh.2017.03.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/13/2017] [Accepted: 03/15/2017] [Indexed: 02/07/2023]
Abstract
Since first characterized in 2 small case series in the early 1990s, eosinophilic esophagitis (EoE) has emerged as a commonly identified cause of esophageal symptoms in children and adults.1,2 Although several highly effectively dietary, pharmacologic, and endoscopic therapies have been reported, none is currently approved by either the US Food and Drug Administration (FDA) or European regulatory authorities. Evolving diagnostic criteria have challenged drug development, in particular the recognition of complex interactions with the most prevalent esophageal disorder, gastroesophageal reflux disease (GERD). Heterogeneity in the clinical presentations of affected children and adults has created difficulties with uniform inclusion criteria and the development of disease-specific, patient-reported outcome (PRO) instruments. Furthermore, controversies regarding the appropriate therapeutic endpoints of EoE have impeded the design of clinical trials. Despite these obstacles, collaborative efforts by investigators, industry, the FDA, and patient advocacy groups have resulted in substantial progress in drug development in EoE over the past 2 decades.3 The purpose of this article is to summarize discussions on EoE based on the 2016 Drug Development Conference sponsored by the Center for Diagnostics and Therapeutics of the American Gastroenterological Association.
Collapse
Affiliation(s)
- Ikuo Hirano
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Stuart Spechler
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Glenn Furuta
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center at Dallas and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas
| | - Evan S Dellon
- Division of Gastroenterology, University of Colorado School of Medicine, Denver, Colorado
| |
Collapse
|
22
|
|
23
|
Schatz M, Sicherer SH, Zeiger RS. The Journal of Allergy and Clinical Immunology: In Practice - 2016 Year in Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:218-236. [PMID: 28143692 DOI: 10.1016/j.jaip.2016.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 01/19/2023]
Abstract
As editors, we concluded that it would be helpful to our readers to write a Year in Review article that highlights the Review, Original, and Clinical Communication articles published in 2016 in The Journal of Allergy and Clinical Immunology: In Practice. We summarized articles on the topics of asthma, rhinitis/rhinosinusitis, food allergy, anaphylaxis, drug allergy, urticarial/angioedema, eosinophilic disorders, and immunodeficiency. Within each topic, epidemiologic findings are presented, relevant aspects of prevention are described, and diagnostic and therapeutic advances are enumerated. Diagnostic tools described include history, skin tests, and in vitro tests. Treatments discussed include behavioral therapy, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We hope this review will help you, our readers, consolidate and use this extensive and practical knowledge for the benefit of your patients.
Collapse
Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif.
| | - Scott H Sicherer
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif
| |
Collapse
|