Advertisement

Digestive Diseases and Sciences

, Volume 55, Issue 5, pp 1313–1319 | Cite as

Comparison of Esomeprazole to Aerosolized, Swallowed Fluticasone for Eosinophilic Esophagitis

  • Kathryn A. Peterson
  • Kristen L. Thomas
  • Kristen Hilden
  • Lyska L. Emerson
  • Jason C. Wills
  • John C. FangEmail author
Original Article

Abstract

Background

Both gastroesophageal reflux disease and allergy/atopy have been implicated in the pathogenesis of eosinophilic esophagitis (EoE). There are no prospective studies comparing treatment of EoE with acid suppression versus topical corticosteroids.

Objective

To determine the outcome of adult eosinophilic esophagitis patients treated with esomeprazole versus topical fluticasone.

Design

Prospective randomized controlled trial.

Setting

Academic medical center.

Participants

Adults (18–80) diagnosed with EoE by symptoms of dysphagia and esophageal biopsies with ≥15 eosinophils/hpf.

Interventions

Subjects were randomized to esomeprazole (40 mg by mouth every morning) or aerosolized, swallowed fluticasone (440 mcg by mouth twice a day) for 8 weeks.

Main Outcome Measurements

Improvement in dysphagia (8-point scale), esophageal eosinophil infiltration before and after treatment, prevalence of GERD measured by validated questionnaire and baseline pH study.

Results

About 56% (14/25) had acid reflux by pH study. There was no difference between treatment groups in improvement in dysphagia scores [3/12 (25%) of the esomeprazole group versus 6/12 (50%) in the fluticasone group, P = 0.40]. Eosinophil infiltration decreased with treatment in both groups, and there was no difference in the amount of decrease between groups (P = 0.70).

Limitations

Small sample size, unexpectedly high drop-out rate.

Conclusions

Gastroesophageal reflux disease is common in adult eosinophilic esophagitis patients. Dysphagia improves and esophageal eosinophilic infiltration decreases with either treatment. There was no difference in degree of improvement in dysphagia or eosinophil infiltration in patients treated with either topical fluticasone or oral esomeprazole. GERD may be important in the pathogenesis of adult EoE.

Keywords

Eosinophilic esophagitis Dysphagia Gastroesophageal reflux disease 

References

  1. 1.
    Furuta G, Licouras C, Collins M, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology. 2007;133:1342–1363. doi: 10.1053/j.gastro.2007.08.017.CrossRefPubMedGoogle Scholar
  2. 2.
    Liacouras C. Eosinophilic esophagitis in children and adults. J Pediatr Gastroenterol Nutr. 2003;37(Suppl 1):S23–S28.PubMedGoogle Scholar
  3. 3.
    Orebaugh H, Peterson K, Kuwada S, Fang J. Ringed esophagus is associated with atopy not GERD. Gastroenterology. 2003;124:A235. doi: 10.1016/S0016-5085(03)81181-2.CrossRefGoogle Scholar
  4. 4.
    Fox V, Nurko S, Furuta G. Eosinophilic esophagitis: it’s not just kid’s stuff. Gastrointest Endosc. 2002;56:260–270. doi: 10.1016/S0016-5107(02)70188-0.CrossRefPubMedGoogle Scholar
  5. 5.
    Straumann A, Spichtin H, Grize L, Bucher K, Beglinger C, Simon H. Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years. Gastroenterology. 2003;125:1660–1669.CrossRefPubMedGoogle Scholar
  6. 6.
    Spergel J, Andrews T, Brown-Whitehorn T, Beausoleil J, Liacouras CA. Treatment of eosinophilic esophagitis with specific food elimination diet directed by a combination of skin prick and patch tests. Ann Allergy Asthma Immunol. 2005;95:336–343.CrossRefPubMedGoogle Scholar
  7. 7.
    Sant’Anna A, Rolland S, Fournet J, Yazbeck S, Drouin E. Eosinophilic esophagitis in children: symptoms, histology and pH probe results. J Pediatr Gastroenterol Nutr. 2004;39:373–377. doi: 10.1097/00005176-200410000-00013.CrossRefPubMedGoogle Scholar
  8. 8.
    Orenstein S, Shalaby T, Lorenzo C, Putnam P, Sigurdsson L, Kocochis S. The spectrum of pediatric eosinophilic esophagitis beyond infancy: a clinical series of 30 patients. Am J Gastroenterol. 2000;95(6):1422–1430.CrossRefPubMedGoogle Scholar
  9. 9.
    Teitelbaum J, Fox V, Twarog F, et al. Eosinophilic esophagitis in children: immunopathological analysis and response to fluticasone proprionate. Gastroenterology. 2002;122:1216–1225. doi: 10.1053/gast.2002.32998.CrossRefPubMedGoogle Scholar
  10. 10.
    Attwood S, Lewis C, Bronder C, Morris C, Armstrong G, Whittam J. Eosinophilic oesophagitis: a novel treatment using montelukast. Gut. 2003;52(8):1228–1229.CrossRefGoogle Scholar
  11. 11.
    Remedios M, Campbell C, Jones D, Kerlin P. Eosinophilic esophagitis in adults: clinical, endoscopic, histologic findings, and response to treatment with fluticasone propionate. Gastrointest Endosc. 2006;63:3–12. doi: 10.1016/j.gie.2005.07.049.CrossRefPubMedGoogle Scholar
  12. 12.
    Lucendo A, Pascual Turrion JM, Navarro M, et al. Endoscopic, bioptic, and manometric findings in eosinophilic esophagitis before and after steroid therapy: a case series. Endoscopy. 2007;39:765–771. doi: 10.1055/s-2007-966738.CrossRefPubMedGoogle Scholar
  13. 13.
    Langdon D. Fluticasone in eosinophilic corrugated ringed esophagus. Am J Gastroenterol. 2001;96(3):926–927.CrossRefPubMedGoogle Scholar
  14. 14.
    Konikoff M, Noel R, Blanchard C, et al. A randomized, double-blind, placebo-controlled trial of fluticasone propionate for pediatric eosinophilic esophagitis. Gastroenterology. 2006;131:1381–1391. doi: 10.1053/j.gastro.2006.08.033.CrossRefPubMedGoogle Scholar
  15. 15.
    Arora A, Perrault J, Smyrk T. Topical corticosteroid treatment of dysphagia due to eosinophilic esophagitis in adults. Mayo Clin Proc. 2003;78:830–835. doi: 10.4065/78.7.830.CrossRefPubMedGoogle Scholar
  16. 16.
    Faubion W, Perrault J, Burgart L, Zein N, Clawson M, Freese D. Treatment of eosinophilic esophagitis with inhaled corticosteroids. J Pediatr Gastroenterol Nutr. 1998;27(1):118–119.CrossRefGoogle Scholar
  17. 17.
    Morrow J, Vargo J, Goldblum J, Richter J. The ringed esophagus: histological features of GERD. Am J Gastroenterol. 2001;96:984–989. doi: 10.1111/j.1572-0241.2001.03682.x.CrossRefPubMedGoogle Scholar
  18. 18.
    Ngo P, Furuta G, Antonioli D, Fox V. Eosinophils in the esophagus—Peptic or allergic eosinophilic esophagitis? Case series of three patients with esophageal eosinophilia. Am J Gastroenterol. 2006;101:1666–1670. doi: 10.1111/j.1572-0241.2006.00562.x.CrossRefPubMedGoogle Scholar
  19. 19.
    DiSario J, Pedersen P, Bichis-Canoutas C, Alder S, Fang J. Incision of recurrent distal esophageal (Schatzki) ring after dilation. Gastrointest Endosc. 2002;56:244–248. doi: 10.1016/S0016-5107(02)70185-5.CrossRefPubMedGoogle Scholar
  20. 20.
    Aanen M, Numens M, Wusten B, Smout A. Diagnostic value of the reflux disease questionnaire in general practice. Digestion. 2006;74:162–168.PubMedGoogle Scholar
  21. 21.
    Emerson L, Tripp S, Baird B, Layfield L, Rohr L. A comparison of immunohistochemical stain quality in conventional and rapid microwave processed tissues. Am J Clin Pathol. 2006;125:176–183.PubMedGoogle Scholar
  22. 22.
    Wills J, Hilden K, DiSario J, Fang J. A randomized, prospective trial of electrosurgical incision followed by rabeprazole versus bougie dilation followed by rabeprazole of symptomatic esophageal (Schatzki’s) rings. Gastrointest Endosc. 2008;67:808–813. doi: 10.1016/j.gie.2007.10.062.CrossRefPubMedGoogle Scholar
  23. 23.
    Brown L, Goldman H, Antonioli D. Intraepithelial eosinophils in endoscopic biopsies of adults with reflux esophagitis. Am J Surg Pathol. 1984;8:899–905. doi: 10.1097/00000478-198412000-00002.CrossRefPubMedGoogle Scholar
  24. 24.
    Tummala V, Barwick K, Sontag S, Vlahsevic R, McCallum R. The significance of intraepithelial eosinophils in the histologic diagnosis of gastroesophageal reflux. Am J Clin Pathol. 1987;87:43–48.PubMedGoogle Scholar
  25. 25.
    Gupta S, Fitzgerald J, Kondratyuk T, HogenEsch H. Cytokine expression in normal and inflamed esophageal mucosa: a study into the pathogenesis of allergic eosinophilic esophagitis. J Pediatr Gastroenterol Nutr. 2006;42:22–26. doi: 10.1097/01.mpg.0000188740.38757.d2.CrossRefPubMedGoogle Scholar
  26. 26.
    Steiner S, Gupta S, Croffie J, Fitzgerald J. Correlation between number of eosinophils and reflux index on same day esophageal biopsy and 24 hour esophageal pH monitoring. Am J Gastroenterol. 2004;99:801–805. doi: 10.1111/j.1572-0241.2004.04170.x.CrossRefPubMedGoogle Scholar
  27. 27.
    Steiner S, Kernek K, Fitzgerald J. Severity of basal cell hyperplasia differs in reflux versus eosinophilic esophagitis. J Pediatr Gastroenterol Nutr. 2006;42:506–509. doi: 10.1097/01.mpg.0000221906.06899.1b.CrossRefPubMedGoogle Scholar
  28. 28.
    Gonsalves N, Policarpio-Nicolas M, Zhang Q, Rao M, Hirano I. Histopathologic variability and endoscopic correlates in adults with eosinophilic esophagitis. Gastrointest Endosc. 2006;64:313–319. doi: 10.1016/j.gie.2006.04.037.CrossRefPubMedGoogle Scholar
  29. 29.
    Coen A, Petersen K, Clark H, Moore E, Hilden K, Fang J. Prevalence of GERD and allergy in eosinophilic esophagitis. Gastroenterology. 2004;126:A447.Google Scholar
  30. 30.
    Spechler S, Genta R, Souza R. Thoughts on the complex relationship between gastroesophageal reflux disease and eosinophilic esophagitis. Am J Gastroenterol. 2007;102:1301–1306. doi: 10.1111/j.1572-0241.2007.01179.x.CrossRefPubMedGoogle Scholar
  31. 31.
    Calabrese C, Bortolotti M, Fabbri A, et al. Reversibility of GERD ultrastructual alterations and relief of symptoms after omeprazole treatment. Am J Gastroenterol. 2005;100:537–542. doi: 10.1111/j.1572-0241.2005.40476.x.CrossRefPubMedGoogle Scholar
  32. 32.
    Caviglia R, Ribolsi M, Gentile M, et al. Dilated intercellular spaces and acid reflux at the distal and proximal oesophagus in patients with non-erosive gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2007;25:629–636.PubMedCrossRefGoogle Scholar
  33. 33.
    Mishra A, Hogan S, Brandt E, Rothenberg M. An etiological role for aeroallergens and eosinophils in experimental esophagitis. J Clin Invest. 2001;107:83–90. doi: 10.1172/JCI10224.CrossRefPubMedGoogle Scholar
  34. 34.
    Aceves S, Bastian J, Newbury R, Dohil R. Oral viscous budesonide: a potential new therapy for eosinophilic esophagitis in children. Am J Gastroenterol. 2007;102:2271–2279. doi: 10.1111/j.1572-0241.2007.01379.x.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Kathryn A. Peterson
    • 1
  • Kristen L. Thomas
    • 1
  • Kristen Hilden
    • 1
  • Lyska L. Emerson
    • 1
  • Jason C. Wills
    • 1
  • John C. Fang
    • 1
    Email author
  1. 1.University of Utah Health Sciences CenterSalt Lake CityUSA

Personalised recommendations