Medical Treatment for Pediatric Eosinophilic Esophagitis

Abstract

Medication for EoE generally falls into acid suppression therapy, steroid medications, and additional therapies. The 2007 Consensus Guidelines for EoE define this condition as present only with the exclusion of other conditions such as gastroesophageal reflux disease (GERD). Exclusion of GERD is achieved by persistent clinicopathologic findings consistent with EoE despite negative pH probe testing or 8 weeks of proton pump inhibitor (PPI) therapy. Topical esophageal swallowed corticosteroid treatment using either Fluticasone propionate or oval viscous Budesonide are the current standards of care for pharmacologic treatment of EoE. Fluticasone propionate is sprayed into the pharynx and swallowed to topically coat the esophagus with doses ranging from 220 mcg to 1760 mcg per day depending on patient’s age, degree of clinical symptoms, and the preference of the practitioner. Budesonide is administered in a slurry formulation that is made using Splenda®. The majority of EoE patients will respond histologically and symptomatically to chronic steroid administration, but intermittent dosing will likely lead to disease relapse. The advantage of using topical steroids as maintenance therapy is that their side effects are significantly less than systemic steroids, however long term side effects of either Fluticasone propionate or oval viscous Budesonide in pediatric EoE have not been well characterized. Biologic therapies directed against cytokines such as IL-5 and IL-13 implicated in the pathogenesis of EoE are sources of current active investigation. Future therapies for chronic EoE will seek to effectively induce sustained histologic remission, positively impact patient reported outcomes of symptoms as well as quality of life, and optimize growth with minimal side effects and medication toxicity profiles.