Daniel A. Schupack, MD, Kimberly Johnson, MD, Joseph A. Akambase, MBChB, Debra Geno, CCRP, Crystal Lavey, CCRC, Karthik Ravi, MD, David A. Katzka, MD, Jeffrey A. Alexander, MD
Mayo Clinic, Rochester, MN
Introduction: Histologic response rates to steroids for eosinophilic esophagitis (EoE) vary from < 50% to >90% in controlled trials. We have used varied steroid preparations and higher doses than typically used and aimed to study if steroid dose and delivery vehicle might explain the wide variation in response.
Methods: A database of patients with EoE created in our esophageal clinic was reviewed and patients treated with at least an 8 week course of topical steroid therapy and undergoing pre and post-steroid histologic evaluation were included. Histologic remission was defined as eosinophil count < 15/hpf. Symptomatic remission was defined as complete resolution of symptoms and eating an unlimited diet. Endoscopy reports were reviewed.
Results: 94 patients were included, 45 on 3 mg budesonide-Rincinol gel twice daily (HBRG), 29 on 3 mg budesonide capsules BID (BC), and 20 on lower doses of BRG (1.5mg daily to 2 mg BID) (LBRG). 88.5% had dysphagia at time of steroid initiation. Mean eosinophil count before steroids was 58.6/hpf. 38.3% had esophageal dilation just prior to steroids. Average EFERS prior to steroid treatment was 1.8. There were not significant differences between the groups in terms of demographics, initial eosinophil counts, symptoms, visual EoE assessment (EREFS) or dilation rates. Histologic remission rate for HBRG was 82.2% vs 55.1% for all others combined (p< 0.001), 51.7% for BC (p=0.005 vs 3 mg BRG BID), and 60.0% for LBRG (p=0.06 vs 3 mg BRG BID). Symptomatic remission was similar between groups, as was change in EREFS and change in eosinophil counts. Non-responders to HBRG had mean decrease in eosinophil count of only 0.3/hpf (vs 53.2/hpf for responders, p< 0.003) and mean change in EREFS of +1.6 (vs -1.1 for responders, p< 0.001). 62.5% of non-responders to HBRG actually had increase in eosinophil count after steroids. Response rate to HBRG at < 5 eos/hpf was 77.8% overall and 94.6% in those achieving remission.
Discussion: A higher remission rate achieved with a more viscous steroid preparation compared to other formulations suggests the importance of both dose and esophageal delivery in treatment of EoE. Further, with adequate mucosal delivery and dosing of topical steroids, steroid refractory EoE appears to be uncommon. On the other hand, these results suggest the existence of a small truly steroid refractory group of EoE patients with negligible histologic, symptomatic and endoscopic response to high dose steroids that warrant further investigation.
Citation: Daniel A. Schupack, MD, Kimberly Johnson, MD, Joseph A. Akambase, MBChB, Debra Geno, CCRP, Crystal Lavey, CCRC, Karthik Ravi, MD, David A. Katzka, MD, Jeffrey A. Alexander, MD. P0275 - HISTOLOGIC RESPONSE TO STEROIDS IN EOSINOPHILIC ESOPHAGITIS IS DEPENDENT ON DOSE AND DELIVERY COMPOUND. Program No. P0275. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.