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Amil-Dias J, Oliva S, Papadopoulou A, Thomson M, Gutiérrez-Junquera C, Kalach N, Orel R, Auth MKH, Nijenhuis-Hendriks D, Strisciuglio C, Bauraind O, Chong S, Ortega GD, Férnandez SF, Furman M, Garcia-Puig R, Gottrand F, Homan M, Huysentruyt K, Kostovski A, Otte S, Rea F, Roma E, Romano C, Tzivinikos C, Urbonas V, Velde SV, Zangen T, Zevit N. Diagnosis and management of eosinophilic esophagitis in children: An update from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2024; 79:394-437. [PMID: 38923067 DOI: 10.1002/jpn3.12188] [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: 05/22/2023] [Revised: 08/17/2023] [Accepted: 09/04/2023] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus characterized by symptoms of esophageal dysfunction and histologically by predominantly eosinophilic infiltration of the squamous epithelium. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published a guideline in 2014; however, the rapid evolution of knowledge about pathophysiology, diagnostic criteria, and therapeutic options have made an update necessary. METHODS A consensus group of pediatric gastroenterologists from the ESPGHAN Working Group on Eosinophilic Gastrointestinal Diseases (ESPGHAN EGID WG) reviewed the recent literature and proposed statements and recommendations on 28 relevant questions about EoE. A comprehensive electronic literature search was performed in MEDLINE, EMBASE, and Cochrane databases from 2014 to 2022. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess the quality of evidence and formulate recommendations. RESULTS A total of 52 statements based on the available evidence and 44 consensus-based recommendations are available. A revision of the diagnostic protocol, options for initial drug treatment, and the new concept of simplified empiric elimination diets are now available. Biologics are becoming a part of the potential armamentarium for refractory EoE, and systemic steroids may be considered as the initial treatment for esophageal strictures before esophageal dilation. The importance and assessment of quality of life and a planned transition to adult medical care are new areas addressed in this guideline. CONCLUSION Research in recent years has led to a better understanding of childhood EoE. This guideline incorporates the new findings and provides a practical guide for clinicians treating children diagnosed with EoE.
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Affiliation(s)
- Jorge Amil-Dias
- Pediatric Gastroenterology, Hospital Lusíadas, Porto, Portugal
| | - Salvatore Oliva
- Maternal and Child Health Department, University Hospital - Umberto I, Sapienza - University of Rome, Rome, Italy
| | - Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, Children's hospital Agia Sofia, University of Athens, Athens, Greece
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, International Academy for Paediatric Endoscopy Training, Sheffield Children's Hospital, UK
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, Hospital Universitario Puerta de Hierro Majadahonda, Universidad Autónoma de Madrid, Spain
| | - Nicolas Kalach
- Department of Pediatrics, Saint Vincent de Paul Hospital, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Catholic University, Lille, France
| | - Rok Orel
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | | | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialized Surgery of the University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Sonny Chong
- Epsom and St Helier University Hospitals NHS Trust, UK
| | - Gloria Dominguez Ortega
- Pediatric Gastroenterology and Nutrition Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Sonia Férnandez Férnandez
- Pediatric Gastroenterology Unit, Department of Pediatrics, Severo Ochoa University Hospital, Madrid, Spain
| | - Mark Furman
- Royal Free London NHS Foundation Trust, London, UK
| | - Roger Garcia-Puig
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Pediatrics Department, Hospital Universitari MútuaTerrassa, Universitat de Barcelona, Barcelona, Spain
| | | | - Matjaz Homan
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Koen Huysentruyt
- Kindergastro-enterologie, hepatologie en nutritie, Brussels Centre for Intestinal Rehabilitation in Children (BCIRC), Belgium
| | - Aco Kostovski
- University Children's Hospital Skopje, Faculty of Medicine, University Ss Cyril and Methodius, Skopje, Republic of North Macedonia
| | - Sebastian Otte
- Childrens' Hospital, Helios Mariahilf Hospital, Hamburg, Germany
| | - Francesca Rea
- Endoscopy and Surgey Unit, Bambino Gesu Children's Hospital, Rome, Italy
| | - Eleftheria Roma
- First Department of Pediatrics, University of Athens and Pediatric Gastroenterology Unit Mitera Children's Hospital, Athens, Greece
| | - Claudio Romano
- Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Christos Tzivinikos
- Paediatric Gastroenterology Department, Al Jalila Children's Specialty Hospital, Dubai, UAE
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Vaidotas Urbonas
- Vilnius University Medical Faculty Clinic of Children's Diseases, Vilnius, Lithuania
| | | | - Tsili Zangen
- Pediatric Gastroenterology Unit, Wolfson Medical Center, Holon, Israel
| | - Noam Zevit
- Eosinophilic Gastrointestinal Disease Clinic, Institute of Gastroenterology, Hepatology, and Nutrition, Schneider Children's Medical Center of Israel, Israel
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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.
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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
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Laserna‐Mendieta EJ, Navarro P, Casabona‐Francés S, Savarino EV, Amorena E, Pérez‐Martínez I, Guagnozzi D, Blas‐Jhon L, Betoré E, Guardiola‐Arévalo A, Pellegatta G, Krarup AL, Perello A, Barrio J, Gutiérrez‐Junquera C, Teruel Sánchez‐Vegazo C, Fernández‐Fernández S, Naves JE, Oliva S, Rodríguez‐Oballe JA, Carrión S, Espina S, Llorente Barrio M, Masiques‐Mas ML, Dainese R, Feo‐Ortega S, Martín‐Dominguez V, Fernández‐Pacheco J, Pérez‐Fernández MT, Ghisa M, Maniero D, Nantes‐Castillejo Ó, Nicolay‐Maneru J, Suárez A, Maray I, Llerena‐Castro R, Ortega‐Larrodé A, Alcedo J, Granja Navacerrada A, Racca F, Santander C, Arias Á, Lucendo AJ. Swallowed topical corticosteroids for eosinophilic esophagitis: Utilization and real-world efficacy from the EoE CONNECT registry. United European Gastroenterol J 2024; 12:585-595. [PMID: 38284792 PMCID: PMC11176909 DOI: 10.1002/ueg2.12533] [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: 08/30/2023] [Accepted: 11/25/2023] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Swallowed topical corticosteroids (tC) are common therapy for patients with eosinophilic esophagitis (EoE). Widely heterogeneous results have occurred due to their active ingredients, formulations and doses. OBJECTIVE To assess the effectiveness of topical corticosteroid therapy for EoE in real-world practice. METHODS Cross-sectional study analysis of the multicentre EoE CONNECT registry. Clinical remission was defined as a decrease of ≥50% in dysphagia symptom scores; histological remission was defined as a peak eosinophil count below 15 per high-power field. The effectiveness in achieving clinico-histological remission (CHR) was compared for the main tC formulations. RESULTS Overall, data on 1456 prescriptions of tC in monotherapy used in 866 individual patients were assessed. Of those, 904 prescriptions with data on formulation were employed for the induction of remission; 234 reduced a previously effective dose for maintenance. Fluticasone propionate formulations dominated the first-line treatment, while budesonide was more common in later therapies. A swallowed nasal drop suspension was the most common formulation of fluticasone propionate. Doses ≥0.8 mg/day provided a 65% CHR rate and were superior to lower doses. Oral viscous solution prepared by a pharmacist was the most common prescription of budesonide; 4 mg/day provided no benefit over 2 mg/day (CHR rated being 72% and 80%, respectively). A multivariate analysis revealed budesonide orodispersible tablets as the most effective therapy (OR 18.9, p < 0.001); use of higher doses (OR 4.3, p = 0.03) and lower symptom scores (OR 0.9, p = 0.01) were also determinants of effectiveness. CONCLUSION Reduced symptom severity, use of high doses, and use of budesonide orodispersible tablets particularly were all independent predictors of tC effectiveness.
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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.
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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
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Schupack DA, Johnson K, Akambase JA, Geno D, Lavey C, Lennon RJ, Ravi K, Snyder DL, Katzka DA, Alexander JA. Histologic response to steroids in eosinophilic esophagitis is dependent on delivery compound. Dis Esophagus 2022; 36:6627605. [PMID: 35780320 DOI: 10.1093/dote/doac040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/04/2022] [Accepted: 05/30/2022] [Indexed: 01/11/2023]
Abstract
Topical steroids are commonly used in treatment of eosinophilic esophagitis (EoE), but currently there is lack of data to clarify most effective regimen. We aimed to study the achievement of histologic remission using the same dose of budesonide in two different delivery formulations. Patients with established EoE treated with pharmacy compounded budesonide capsule or budesonide Rincinol gel (both 3 mg twice daily) were studied retrospectively. Those with pre-treatment and post-treatment histologic assessment were included with main endpoint being histologic remission. 103 patients (62 gel, 41 capsule) were included, with higher rate of histologic remission with gel (84 vs. 59%, P=0.004). A subset of patients in both groups had lack of steroid response (<50% drop in eosinophils) (15% for gel, 32% for capsule). Formulation/delivery vehicle of steroid treatments to esophageal mucosa in EoE appears important for treatment efficacy, with budesonide gel having higher likelihood of histologic remission compared to budesonide capsules in our population. A truly steroid refractory group appears likely in our population. Larger, prospective studies may help clarify best regimen of topical steroids in EoE and may work to identify patients likely to benefit from alternative therapies.
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Affiliation(s)
- Daniel A Schupack
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Joseph A Akambase
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Debra Geno
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Crystal Lavey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ryan J Lennon
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Karthik Ravi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Diana L Snyder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey A Alexander
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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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.
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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.
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Affiliation(s)
- Adam Główczewski
- Department of Pediatrics, Allergology and Gastroenterology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland;
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Krause J, Brokmann F, Rosenbaum C, Weitschies W. The challenges of drug delivery to the esophagus and how to overcome them. Expert Opin Drug Deliv 2022; 19:119-131. [DOI: 10.1080/17425247.2022.2033206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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, 17489 Greifswald, Germany
| | - Friederike Brokmann
- University of Greifswald, Institute of Pharmacy, Department of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, Felix-Hausdorff-Str. 3, 17489 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, 17489 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, 17489 Greifswald, Germany
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Hao LX, Lu Y, Li T, Gong B. A meta-analysis of efficacy of topical steroids in eosinophilic esophagitis: From the perspective of histologic, clinical, and endoscopic outcome. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 44:251-260. [PMID: 33162187 DOI: 10.1016/j.gastrohep.2020.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Swallowed topical steroids are a mainstay drug therapy for eosinophilic esophagitis (EoE), studies have demonstrated good histologic response, but with enormous discrepancy in clinical and endoscopic improvement. We conducted this meta-analysis to investigate the efficacy of topical steroids in EoE in histological, clinical and endoscopic improvement. METHODS Several databases were searched from inception to August 1, 2019 for randomized controlled trials (RCTs) comparing topical steroids with placebo for EoE in the short-term. The outcomes of interest mainly included basic characteristics of the studies, histologic, clinical, endoscopic response rate and adverse events. The results were pooled together using Reviewer Manager 5.3.5 software, and inconsistency was quantified using I2 statistics. RESULTS Nine studies were eventually selected. The results showed that topical steroids were effective in inducing histologic response compared with placebo for both complete (OR 35.82, 95% CI 14.98-85.64, P<0.0001; I2=0, P=0.72) and partial response (OR 28.44, 95% CI 8.56-94.47, P<0.0001; I2=70%, P=0.0009). Moreover, topical steroids were useful in gaining clinical response (OR 2.53, 95% CI 1.14-5.60, P=0.02; I2=60%, P=0.02) and endoscopic response (OR 3.51, 95% CI 1.47-8.36, P=0.005; I2=0, P=0.57). Generally, topical steroids are well tolerated. The most common adverse events are infections and infestations (59 cases). CONCLUSION Topical steroids were effective in inducing histological, clinical and endoscopic response in the short-term, and the adverse events were almost tolerable; however, we should interpret the result of clinical and endoscopic response with caution.
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Affiliation(s)
- Li-Xiao Hao
- Department of Digestive Endoscopy, Shanghai Shuguang Hospital, Shanghai University of Chinese Medicine, Shanghai 201203, People's Republic of China
| | - Yi Lu
- Department of Gastrointestinal Endoscopy, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, People's Republic of China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, People's Republic of China
| | - Tao Li
- Department of Digestive Endoscopy, Shanghai Shuguang Hospital, Shanghai University of Chinese Medicine, Shanghai 201203, People's Republic of China
| | - Biao Gong
- Department of Digestive Endoscopy, Shanghai Shuguang Hospital, Shanghai University of Chinese Medicine, Shanghai 201203, People's Republic of China.
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Reddy A, Ashat D, Murali AR. Recent insights on the use of topical steroids in eosinophilic esophagitis. Expert Rev Gastroenterol Hepatol 2020; 14:953-963. [PMID: 32567417 DOI: 10.1080/17474124.2020.1785869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Eosinophilic Esophagitis (EoE) is an immune-mediated, chronic inflammatory disorder of the esophagus. Topical steroids have been used in the management of EoE for over 15 years. However, there are no Food and Drug Administration (FDA) approved drug therapies for EoE. AREAS COVERED This review discusses the current understanding of EoE and the role of topical steroids in the induction and maintenance of remission in patients with EoE. We performed a comprehensive review of the literature, summarized randomized control trials from 2006 to 2020, and provided a simplified management algorithm for EoE. EXPERT OPINION In patients with EoE, topical steroids are effective in inducing clinical and histologic remission. Formulations of topical steroids that maximize the exposure to esophageal mucosa have the highest efficacy. A majority of patients who achieve remission with topical steroids develop clinical and histologic relapse off therapy within a year. Current evidence suggests that maintenance therapy with long-term topical steroids decreases the risk of relapse and progression to fibrostenotic disease. While uncertainty over the dose and duration of maintenance topical steroids and their potential side effects exists, long-term maintenance therapy with topical steroids appears to be the way forward to improve long-term outcomes in patients with EoE.
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Affiliation(s)
- Aditi Reddy
- Department of Internal Medicine, University of Iowa Hospitals and Clinics , Iowa City, IA, USA
| | - Divya Ashat
- Department of Internal Medicine, University of Iowa Hospitals and Clinics , Iowa City, IA, USA.,Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics , Iowa City, IA, USA
| | - Arvind R Murali
- Department of Internal Medicine, University of Iowa Hospitals and Clinics , Iowa City, IA, USA.,Division of Gastroenterology & Hepatology, University of Iowa Hospitals and Clinics , Iowa City, IA, USA
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Wong J, Goodine S, Samela K, Vance KS, Chatfield B, Wang Z, Sayej WN. Efficacy of Dairy Free Diet and 6-Food Elimination Diet as Initial Therapy for Pediatric Eosinophilic Esophagitis: A Retrospective Single-Center Study. Pediatr Gastroenterol Hepatol Nutr 2020; 23:79-88. [PMID: 31988878 PMCID: PMC6966220 DOI: 10.5223/pghn.2020.23.1.79] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/14/2019] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Management of eosinophilic esophagitis (EoE) varies from center to center. In this study, we evaluated the effectiveness of a dairy-free diet (DFD) and the 6-Food Elimination Diet (SFED) as initial therapies for the treatment of EoE in our practice. METHODS This was a retrospective study of children who had been treated for EoE at Connecticut Children's Medical Center, Hartford, CT, USA. Pre- and post-treatment endoscopy findings and histology results of patients treated with DFD or SFED were examined. RESULTS One hundred fifty-two patients (age 9.2±5.2 years, 76.3% male, 69.7% caucasian) met the inclusion criteria for initial treatment with DFD (n=102) or SFED (n=50). Response for DFD was 56.9% and for SFED was 52.0%. Response based on treatment duration (<10, 10-12, and >12 weeks) were 81.8%, 50.0%, and 55.1% for DFD, and 68.8%, 50.0%, and 40.0% for SFED. Response based on age (<6, 6-12, and >12 years) were 59.3%, 42.9%, and 67.5% for DFD, and 36.4%, 58.8%, and 72.7% for SFED. In patients treated with DFD, concomitant proton pump inhibitor (PPI) administration resulted in improved outcomes (p=0.0177). Bivariate regression analysis showed that PPI with diet is the only predictor of response (p=0.0491), however, there were no significant predictors on multiple regression analysis. CONCLUSION DFD and SFED are effective first line therapies for EoE. DFD should be tried first before extensive elimination diets. Concomitant therapy with PPI's may be helpful.
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Affiliation(s)
- Jonathan Wong
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Sue Goodine
- Department of Pediatrics, Division of Digestive Diseases, Hepatology and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Kate Samela
- Department of Pediatrics, Division of Digestive Diseases, Hepatology and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Katherine S Vance
- Department of Pediatrics, Division of Digestive Diseases, Hepatology and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Beth Chatfield
- Department of Pediatrics, Division of Digestive Diseases, Hepatology and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Zhu Wang
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA.,Department of Pediatric Research, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Wael N Sayej
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA.,Department of Pediatrics, Division of Digestive Diseases, Hepatology and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
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12
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Kinoshita Y, Oouchi S, Fujisawa T. Eosinophilic gastrointestinal diseases - Pathogenesis, diagnosis, and treatment. Allergol Int 2019; 68:420-429. [PMID: 31000445 DOI: 10.1016/j.alit.2019.03.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/03/2019] [Accepted: 03/05/2019] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic gastrointestinal diseases (EGIDs) are divided into eosinophilic esophagitis (EoE) and eosinophilic gastroenteritis (EGE), depending on the involved gastrointestinal tract, though both are considered to be chronic Th2-type allergic diseases caused by food or environmental allergens. In development of EoE, refluxed gastric acid may also have an important role. For diagnosis of EGIDs, the presence of symptoms possibly originating from the involved gastrointestinal tract and dense eosinophil infiltration are important factors. Imaging studies, including endoscopy and computed tomography, along with histopathological examinations of biopsy specimens are useful for diagnosis, whereas laboratory testing of blood, urine, and stool samples has limited value. Three useful options for treating EoE patients are acid inhibitors, swallowed topical corticosteroids, and an elimination diet, while systemic administration of glucocorticoids is the standard treatment of EGE, though information is limited. Since the prevalence of EGIDs is increasing in Western countries as well as Japan, development of effective treatments based on sufficient evidence is becoming an urgent need.
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13
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Zheng P, Tan HY. New developments in diagnosis and treatment of eosinophilic esophagitis. Shijie Huaren Xiaohua Zazhi 2019; 27:828-834. [DOI: 10.11569/wcjd.v27.i13.828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic, allergen-driven, immune mediated disease of the esophagus that progresses to esophageal fibrostenosis if not well treated. The aim of this review is to provide an update on recent clinical advances in the development of diagnostic and therapeutic approaches for EoE. At present, the diagnosis and disease monitoring for EoE rely on repetitive endoscopic evaluations and esophageal tissue acquisition for histopathologic analysis. Recent advancements in EoE diagnosis include transnasal endoscopy, endoscopic functional lumen imaging probe, and the emergence of non-invasive diagnostic tools including cytosponge, esophageal string test, and mucosal impedance probe. Biomarkers for EoE have not yet proven their clinical utility. The current treatment modalities for EoE are topical corticosteroid, proton-pump inhibitors, elimination diet, and dilation. Promising results from clinical trials are emerging for biologic agents that target the interleukin (IL)-13 and the IL-4/IL-13 receptor, specifically, RPC4046 and dupilumab. Especially, dupilumab is promising to become the orphan drug of EoE.
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Affiliation(s)
- Pu Zheng
- Department of Emergency Medicine, Beijing Hospital, Beijing 100005, China
| | - Huang-Ying Tan
- Department of Integrative Oncology, China-Japan Friendship Hospital, Beijing 100029, China
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14
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Dellon ES, Woosley JT, Arrington A, McGee SJ, Covington J, Moist SE, Gebhart JH, Tylicki AE, Shoyoye SO, Martin CF, Galanko JA, Baron JA, Shaheen NJ. Efficacy of Budesonide vs Fluticasone for Initial Treatment of Eosinophilic Esophagitis in a Randomized Controlled Trial. Gastroenterology 2019; 157:65-73.e5. [PMID: 30872104 PMCID: PMC6581596 DOI: 10.1053/j.gastro.2019.03.014] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/01/2019] [Accepted: 03/05/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Topical steroid treatments for eosinophilic esophagitis (EoE) include swallowed fluticasone from a multi-dose inhaler (MDI) or oral viscous budesonide (OVB) slurry, but the 2 have never been compared. We assessed whether OVB was more effective than MDI for initial treatment of patients with EoE. METHODS In a double-blind, double-dummy trial, patients with a new diagnosis of EoE were randomly assigned to groups given 8 weeks of either OVB (1 mg/4 mL) twice daily plus a placebo inhaler (n = 56) or fluticasone MDI (880 μg) twice daily plus a placebo slurry (n = 55). Primary outcomes were post-treatment maximum eosinophil counts per high-power field (eos/hpf) and a validated dysphagia score (dysphagia symptom questionnaire [DSQ]) at week 8. Secondary outcomes included endoscopic severity (validated EoE endoscopic reference score), histologic response (<15 eos/hpf), and safety. RESULTS In a modified intention-to-treat analysis, the subjects had baseline peak eosinophil counts of 73 and 77 eos/hpf in the OVB and MDI groups, respectively, and DSQ scores of 11 and 8. Post-treatment eosinophil counts were 15 and 21 in the OVB and MDI groups, respectively (P = .31), with 71% and 64% achieving histologic response (P = .38). DSQ scores were 5 and 4 in the OVB and MDI groups (P = .70). Similar trends were noted for post-treatment total EoE endoscopic reference scores (2 vs 3; P = .06). Esophageal candidiasis developed in 12% of patients receiving OVB and 16% receiving MDI; oral thrush was observed in 3% and 2%, respectively. CONCLUSIONS In a randomized clinical trial, initial treatment of EoE with either OVB or fluticasone MDI produced a significant decrease in esophageal eosinophil counts and improved dysphagia and endoscopic features. However, OVB was not superior to MDI, so either is an acceptable treatment for EoE. ClinicalTrials.gov ID NCT02019758.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - John T Woosley
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ashley Arrington
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sarah J McGee
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jacquelyn Covington
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Susan E Moist
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jessica H Gebhart
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Alexandra E Tylicki
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Shiyan O Shoyoye
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Christopher F Martin
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Joseph A Galanko
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - John A Baron
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Nhu QM, Moawad FJ. New Developments in the Diagnosis and Treatment of Eosinophilic Esophagitis. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:48-62. [PMID: 30707411 PMCID: PMC6519728 DOI: 10.1007/s11938-019-00216-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Eosinophilic esophagitis (EoE) is a chronic, allergen-driven, immune-mediated disease of the esophagus that progresses to esophageal fibrostenosis if left untreated. The aim of this review is to provide a concise update on recent clinically relevant advances in the development of diagnostic and therapeutic approaches for EoE. RECENT FINDINGS Current diagnostic and disease monitoring protocols for EoE rely on repetitive endoscopic evaluations and esophageal tissue acquisition for histopathologic analysis. Recent advancements in EoE diagnosis include endoscopic functional lumen imaging probe (FLIP), transnasal endoscopy (TNE), and the emergence of non-invasive diagnostic tools including cytosponge, esophageal string test, and mucosal impedance probe. Biomarkers for EoE have not yet proven their clinical utility. No Food and Drug Administration (FDA)-approved drugs currently exist for the treatment of EoE. Topical corticosteroid, proton-pump inhibitors (PPI), elimination diet, and dilation are the current treatment modalities for confirmed EoE. Promising results from clinical trials are emerging for biologic agents that target the interleukin (IL)-13 and the IL-4/IL-13 receptor, specifically, RPC4046 and dupilumab, respectively. New diagnostic algorithms, non-invasive diagnostic strategies, and treatment modalities for EoE are emerging. Patients with EoE continue to require a multimodal and multi-disciplinary management approach.
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Affiliation(s)
- Quan M Nhu
- Division of Gastroenterology & Hepatology, Scripps Clinic, 10666 N. Torrey Pines Road, Suite 203N, La Jolla, CA, 92037, USA.
- Scripps Research Translational Institute, The Scripps Research Institute, La Jolla, CA, USA.
| | - Fouad J Moawad
- Division of Gastroenterology & Hepatology, Scripps Clinic, 10666 N. Torrey Pines Road, Suite 203N, La Jolla, CA, 92037, USA.
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16
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Rawla P, Sunkara T, Thandra KC, Gaduputi V. Efficacy and Safety of Budesonide in the Treatment of Eosinophilic Esophagitis: Updated Systematic Review and Meta-Analysis of Randomized and Non-Randomized Studies. Drugs R D 2019; 18:259-269. [PMID: 30387081 PMCID: PMC6277325 DOI: 10.1007/s40268-018-0253-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and Objective Eosinophilic esophagitis (EE) is an immune/antigen-driven inflammation that causes esophageal dysfunction. Budesonide has shown promising effect in the management of EE in multiple studies, and we therefore conducted this systematic review/meta-analysis to assess budesonide efficacy and safety in order to provide more updated and robust evidence. Methods In April 2018, we conducted a systematic electronic search through four databases: PubMed, Scopus, Web of Science (ISI), and Cochrane Central. All original studies reporting the efficacy of budesonide in the treatment of EE were included in our meta-analysis. The Cochrane Collaboration tool was employed to assess the risk of bias among included randomized controlled trials, while the Newcastle–Ottawa Scale was used for non-randomized studies. Results A total of 12 studies including 555 participants were included in our review. Budesonide showed marked efficacy at the level of histological response compared to placebo [risk ratio (RR) (95% confidence interval (CI)) 11.93 (4.82–29.50); p > 0.001]. Analysis of randomized and non-randomized studies revealed considerable reduction in eosinophil count, with a mean difference (MD) (95% CI) of − 69.41 (− 105.31 to − 33.51; p < 0.001) and 46.85 (33.93–59.77; p < 0.001), respectively. Similarly, there was a marked improvement in the clinical symptoms via the analysis of randomized and non-randomized studies, with an RR (95% CI) of 1.72 (1.22–2.41; p = 0.002) and MD (95% CI) of 2.45 (0.76–4.15; p = 0.005), respectively. Conclusion Budesonide showed significant effect at all treatment endpoints. However, since budesonide carries a risk of candidiasis and our inferences are based only on a small number of included studies, more research is warranted to clarify these results. Electronic supplementary material The online version of this article (10.1007/s40268-018-0253-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Prashanth Rawla
- Department of Internal Medicine, SOVAH Health, 320 Hospital Dr, Martinsville, VA 24112 USA
| | - Tagore Sunkara
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, 121 Dekalb Ave, Brooklyn, NY 11201 USA
| | | | - Vinaya Gaduputi
- Division of Gastroenterology, SBH Health System, 4422 Third Ave, Bronx, NY 19457 USA
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17
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Abstract
PURPOSE OF REVIEW Eosinophilic esophagitis (EoE) is a relatively new disease but its understanding is evolving over a period of time. This review highlights recent advances in the understanding of pathophysiology, diagnostic modalities, short and long-term goals of therapy and novel therapeutic agents. RECENT FINDINGS The prevalence of EoE is increasing. Upper endoscopy and biopsy remains the gold standard for diagnosing EoE but less invasive and more cost-effective testing has been under investigation. Scoring systems to assess symptoms, histology and endoscopic findings can distinguish between active and inactive disease. Step up therapy with 2-4-6 food elimination can result in early identification of triggering foods and reduce frequency of endoscopies. The term proton pump inhibitor (PPI) responsive eosinophilia should be avoided and PPI should be considered a therapeutic modality. Oral viscous budesonide has been more effective than fluticasone in achieving remission. Adrenal suppression should be looked for patients on swallowed steroids. IL-13 antagonists can be a promising therapy for EoE and dilation is a safe and effective treatment modality in patients with EoE but as is expected, does not decrease inflammation. SUMMARY EoE has been increasingly recognized as a cause of food impactions and dysphagia. Less invasive methods for diagnosis and to monitor treatment response have been studied but need validation in children. Short-term treatment goals include symptomatic and histological improvement, with prevention of fibrostenotic disease the primary long-term goal. Elemental diet and empiric elimination diet appear to be successful in inducing remission. PPI and swallowed steroids cause symptomatic improvement and histological remission but relapse is common after discontinuation of therapy.
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18
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Nhu QM, Aceves SS. Medical and dietary management of eosinophilic esophagitis. Ann Allergy Asthma Immunol 2018; 121:156-161. [PMID: 29753831 DOI: 10.1016/j.anai.2018.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Eosinophilic esophagitis (EoE) is a disease of chronic, allergen-driven, T-helper 2 (Th2) immune-mediated inflammation that progresses to fibrostenosis of the esophagus if left untreated. There are currently no Food and Drug Administration (FDA)-approved drugs for the treatment of EoE. This review focuses on the medical and dietary management of EoE. DATA SOURCES Manuscripts on EoE treatments were identified on PubMed. STUDY SELECTIONS Original research, randomized control trials, retrospective studies, meta-analyses, case series, and on occasions, case reports of high relevance, were selected and reviewed. RESULTS Current treatment strategies available to EoE patients center on monotherapy or combination therapy with dietary modification to exclude antigenic stimulation and topical corticosteroids to control Th2-mediated tissue inflammation and pathologic remodeling. Dilation as a rescue therapy for the narrowed, fibrostenotic, symptomatic esophagus can potentially be avoided with optimal medical and elimination diet therapies. The molecular mechanisms underlying EoE pathogenesis are being unraveled, from which targeted therapies can be developed and evaluated in preclinical and clinical studies. Current clinical research efforts focus on optimization of topical corticosteroid delivery, dosing, frequency, and duration of treatment, either alone or in combination with tailored elimination diet. Preliminary clinical trials with biologics targeting interleukin (IL)-5 and IL-13/IL-4 have been completed. CONCLUSION Topical corticosteroid, elimination diet, and dilation are the current treatment modalities for confirmed EoE. The use of proton-pump inhibitors (PPI) is being suggested as a potential regimen to treat EoE, based on evolving understanding of PPI-responsive esophageal eosinophilia (PPI-REE). The complexity of EoE treatment regimens and frequent follow-ups require a multimodal, multi-disciplinary management approach to optimize patient care.
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Affiliation(s)
- Quan M Nhu
- Scripps Translational Science Institute, The Scripps Research Institute, La Jolla, California; Division of Gastroenterology & Hepatology, Department of Medicine, Scripps Clinic-Scripps Green Hospital, La Jolla, California; Division of Allergy & Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, California; Division of Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Seema S Aceves
- Division of Allergy & Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, California; Division of Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, California; Rady Children's Hospital, San Diego, San Diego, California.
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19
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Bonnet M, Dermu M, Roessle C, Bellaiche M, Abarou T, Vasseur V, Benakouche S, Storme T. Formulation of a 3-months Stability Oral Viscous Budesonide Gel and Development of an Indicating Stability HPLC Method. PHARMACEUTICAL TECHNOLOGY IN HOSPITAL PHARMACY 2018. [DOI: 10.1515/pthp-2018-0005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Abstract
Background
Eosinophilic Esophagitis is an increasing pathology which can cause stomach symptom like dysphagia, vomiting, food blockage. The treatment consists in dietary therapy and topical corticosteroid therapy to avoid the important number of side effects of the oral corticosteroids. There is presently no available topical form adapted for treating esophageal pathology.
Methods
The aim of this work was to develop an oral viscous budesonide gel (OVBG). A focus on palatability was made in order to use OVBG in children. A stability indicating HLPC method able to quantify budesonide contained in our OVBG has been developed.
Results
Previous work of Hefner and Al. showed that xanthan gum had a longer esophageal mucosal contact time than sucralose. This encouraged the development of a xanthan gum-based formulation. This OVBG has also the advantage to facilitate compliance thanks to its taste and pleasant texture. The stability length of the preparation can be extended over a 3-months period, stored in a refrigerator at 2–8 °C.
Conclusions
An adapted pediatric formulation with a 3-months stability was developed. Furthermore, the formulation can be easily reproduced in community pharmacy. Regarding the increasing number of patients concerned OVBG is a good answer to a real clinical need.
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Affiliation(s)
- Mathilde Bonnet
- Pharmacy , Hopital Universitaire Robert-Debre , 48 boulevard Sérurier , Paris 75019 , France
| | - Marine Dermu
- Pharmacy , Hopital Universitaire Robert-Debre , 48 boulevard Sérurier , Paris 75019 , France
| | - Clara Roessle
- Pharmacy, Hopital Universitaire Robert-Debre , 48 boulevard Sérurier , Paris 75019 , France
| | - Marc Bellaiche
- Gastroenterology , Hopital Universitaire Robert-Debre , Paris , Île-de-France , France
| | - Tarik Abarou
- Pharmacy , Hopital Universitaire Robert-Debre , 48 boulevard Sérurier , Paris 75019 , France
| | - Véronique Vasseur
- Pharmacy , Hopital Universitaire Robert-Debre , 48 boulevard Sérurier , Paris 75019 , France
| | - Samira Benakouche
- Pharmacy , Hopital Universitaire Robert-Debre , 48 boulevard Sérurier , Paris 75019 , France
| | - Thomas Storme
- Pharmacy , Hopital Universitaire Robert-Debre , 48 boulevard Sérurier , Paris 75019 , France
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Bolton SM, Kagalwalla AF, Wechsler JB. Eosinophilic Esophagitis in Children: Endoscopic Findings at Diagnosis and Post-intervention. Curr Gastroenterol Rep 2018; 20:4. [PMID: 29492720 DOI: 10.1007/s11894-018-0607-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to present and summarize studies on endoscopic findings in eosinophilic esophagitis (EoE), at diagnosis and in response to treatment, utilizing rigorous peer-reviewed literature in children wherever possible and to introduce a recently proposed standardized endoscopic evaluation system. RECENT FINDINGS Gold standard of diagnosis and assessment of response to therapy in EoE requires multiple endoscopies with biopsies for histology, which allows for observation of the esophageal mucosa. Typical endoscopic findings in patients with EoE include edema, exudate, furrowing, concentric rings, and strictures. Endoscopic findings have been broadly characterized into inflammatory features (edema, exudate, furrowing) and fibro-stenotic features (rings, stricture), in order to better reflect their underlying pathophysiology. Recent studies suggest strong correlations between endoscopic findings, through composite scoring systems, and histology, and therefore may be helpful as part of disease surveillance. The EoE Endoscopic Reference Score (EREFS) classification system was proposed in 2013 as an outcome metric for standardization in reporting endoscopic signs of EoE. Subsequent studies support utility of composite scoring, which utility has similarly been seen in pediatric treatment trials. Endoscopy in children provides insight into the natural history of EoE, with progressively more fibro-stenotic features occurring over time, giving an additional perspective into esophageal remodeling and response to treatment. Recognition of typical endoscopic findings at diagnosis and upon repeat endoscopy has allowed a clinician to monitor visual changes in esophageal mucosal health. Further studies to assess the role of composite scoring in disease management are needed.
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Affiliation(s)
- S M Bolton
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - A F Kagalwalla
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
- John H. Stroger Hospital of Cook County, Chicago, IL, USA
| | - J B Wechsler
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA.
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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.
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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.
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