Steroids vs Dietary Therapy to Treat Eosinophilic Esophagitis
Steroids vs Dietary Therapy to Treat Eosinophilic Esophagitis
In the past year, several studies have confirmed the effectiveness of medical therapy for EoE, but also have highlighted some limitations of the current treatment approach. Moawad et al. recently performed a randomized controlled trial of swallowed fluticasone versus esomeprazole for the treatment of esophageal eosinophilia. In this study, 42 patients suspected of having EoE (defined by clinical symptoms of esophageal dysfunction and >15 eos/hpf) underwent esophageal pH testing with 24 h pH/impedance monitoring. Patients were then stratified by the presence of GERD and randomized to receive either fluticasone 440 μg twice daily or esomeprazole 40 mg once daily for 8 weeks. Repeat endoscopy was performed, and the primary outcome was a histologic response of less than 7 eos/hpf. Secondary outcomes included clinical change in symptoms using the Mayo Dysphagia Questionnaire (MDQ) score and interval change in endoscopic features. The investigators showed that there was no difference in the frequency of resolution of esophageal eosinophilia between the fluticasone and esomeprazole groups (19 versus 33%; P = 0.484). They also found that patients with established GERD (based on pH testing) were much more likely to respond to proton pump inhibitor (PPI) than fluticasone. Interestingly, they also found that symptoms improved with PPI treatment, but not with fluticasone. They concluded that the histologic response with both treatment options was similar and significantly less than expected (based on prior studies). This study raises concern about the limited efficacy of some formulations of swallowed aerosolized topical corticosteroids, and highlights the importance of using acid suppression as part of the initial diagnostic and therapeutic strategy for patients with esophageal symptoms and eosinophilia.
Topical Corticosteroids Versus Acid Suppression
In the past year, several studies have confirmed the effectiveness of medical therapy for EoE, but also have highlighted some limitations of the current treatment approach. Moawad et al. recently performed a randomized controlled trial of swallowed fluticasone versus esomeprazole for the treatment of esophageal eosinophilia. In this study, 42 patients suspected of having EoE (defined by clinical symptoms of esophageal dysfunction and >15 eos/hpf) underwent esophageal pH testing with 24 h pH/impedance monitoring. Patients were then stratified by the presence of GERD and randomized to receive either fluticasone 440 μg twice daily or esomeprazole 40 mg once daily for 8 weeks. Repeat endoscopy was performed, and the primary outcome was a histologic response of less than 7 eos/hpf. Secondary outcomes included clinical change in symptoms using the Mayo Dysphagia Questionnaire (MDQ) score and interval change in endoscopic features. The investigators showed that there was no difference in the frequency of resolution of esophageal eosinophilia between the fluticasone and esomeprazole groups (19 versus 33%; P = 0.484). They also found that patients with established GERD (based on pH testing) were much more likely to respond to proton pump inhibitor (PPI) than fluticasone. Interestingly, they also found that symptoms improved with PPI treatment, but not with fluticasone. They concluded that the histologic response with both treatment options was similar and significantly less than expected (based on prior studies). This study raises concern about the limited efficacy of some formulations of swallowed aerosolized topical corticosteroids, and highlights the importance of using acid suppression as part of the initial diagnostic and therapeutic strategy for patients with esophageal symptoms and eosinophilia.