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PPIs Better Than Topical Steroids for Eosinophilic Esophagitis

Summary and Comment |
May 10, 2013

PPIs Better Than Topical Steroids for Eosinophilic Esophagitis

  1. David A. Johnson, MD

Although histological response was similar with both treatments, dysphagia symptoms improved only with a proton-pump inhibitor.

  1. David A. Johnson, MD

Despite the increasing prevalence of eosinophilic esophagitis (EoE), an optimal medical therapy has not been identified (JW Gastroenterol Sep 3 2010). Prior studies have described the efficacy of topical steroids (e.g., fluticasone and budesonide) as well as proton-pump inhibitors (PPIs), even for those without demonstrable gastroesophageal reflux disease (GERD; JW Gastroenterol Jan 28 2011 and JW Gastroenterol Aug 12 2011).

Now, investigators have conducted a prospective, single-institution, single-blinded, randomized, controlled trial to compare the efficacy of a topical steroid (nebulized, swallowed fluticasone) versus a PPI (esomeprazole) in 42 patients (90% male, 81% white) with newly diagnosed EoE. Patients had ≥1 esophageal dysfunction symptom (e.g., dysphagia, food impaction, heartburn) with ≥15 eosinophils per high power field (eos/hpf) at index endoscopy. Patients were stratified by presence of GERD (established by 24-hour impedance pH testing) and randomized to receive fluticasone (440 µg twice daily) or esomeprazole (40 mg daily) for 8 weeks followed by repeat endoscopy with biopsies.

Resolution of esophageal eosinophilia (<7 eos/hpf; the primary endpoint) was similar in both groups. However, among the 8 patients with GERD, resolution was achieved in 4 of 4 who received esomeprazole and 0 of 4 who received fluticasone. Dysphagia symptoms improved with esomeprazole (P<0.001) but not with fluticasone.

Comment

These results suggest that short-term therapy with nebulized fluticasone improves histologic, but not symptomatic parameters, as seen in prior studies (JW Gastroenterol Sep 21 2012). Moreover, fluticasone or another topical steroid might be more effective if delivered in a more viscous preparation. In a recent EoE study, administration of an oral viscous slurry of budesonide versus a nebulized preparation significantly prolonged mucosal contact with the agent and reduced eosinophilic count (Gastroenterol 2012 Aug; 143:321). For now, based on the current evidence, I will continue to recommend a PPI, allergy testing, and a dysphagia diet (i.e., cutting up food and avoiding tough meats, doughy breads, pasta, and hard and raw vegetables and fruits, especially with skins) before embarking on a steroid-treatment approach.

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