A Tough Pill to Swallow: Eosinophilic Esophagitis
A Tough Pill to Swallow: Eosinophilic Esophagitis
July 13, 2021
Pharm.D. Candidate 2022
APPE Cycle 2: Community
What is Eosinophilic Esophagitis?
Eosinophilic Esophagitis (EoE) is a chronic allergic condition that causes inflammation in the esophagus. The esophagus is the part of your throat that carries food to the stomach. Eosinophils are a type of white blood cell. They are useful for fighting infection, but they are also responsible for much of the immune/allergic response against our own body. EoE is most common in patients who have other allergic conditions, like environmental allergies and asthma, but the main culprit is food allergies. However, it is not easy to discover the exact cause with traditional allergy testing, because unlike classic allergic reactions that are IgE-mediated, the inflammation in EoE is a delayed reaction. This suggests it is mediated by other types of immune mechanisms.
What are the symptoms?EoE may present in all demographics, but it is most common in males aged 20-40. Symptoms are different depending on the age of the patient. The main trait in infants and toddlers is failure to grow properly due to refusal to eat. Children may have abdominal pain, trouble swallowing, and decreased appetite. In teens and adults, it can cause acid reflux and upper abdominal pain, but the most significant symptom is difficulty swallowing dense foods. This happens because the inflammation in the esophagus causes the space to narrow, making it difficult for food to pass through. As a result, food can get stuck in the esophagus and cause choking.
How do you treat it?
Since food allergies are the most common cause of EoE, the first strategy for managing it is avoiding foods that may be causing the reaction. The most common food triggers are dairy, wheat, soy, and egg products. Once the responsible trigger is removed from the diet, inflammation decreases and symptoms improve within a few weeks. If the food avoidance strategy does not improve symptoms, the EoE likely has a different cause. There is no medication approved by the FDA to treat EoE, but topical steroids are often used.
How are topical steroids used in EoE?
We use corticosteroids to reduce inflammation in many areas of the body. A relevant mechanism is using inhaled corticosteroids to manage swelling in the bronchial tubes in asthma patients. We use the same idea to treat EoE, but the medicine goes down the esophagus instead of the windpipe. Fluticasone is one drug that is still used in its inhaler form, but patients are instructed to swallow the inhaler mist instead of breathing it in. Budesonide is another inhaled steroid that we use to target the esophagus, but this one is compounded into an oral topical form to coat the walls of the esophagus. By swallowing a viscous oral form instead of a mist, we can increase topical contact and directly treat the inflammation there. There are several ways budesonide can be made into an oral drug. First, the inhalation solution can be combined with Splenda to create a thick liquid suspension, or slurry. Effervescent budesonide tablets have also been studied to create a viscous liquid. Lastly, there is an oral suspension in development by Takeda Pharmaceutical.
Dosing of oral budesonide is specific to each patient. It is unsure how long a patient should be on oral budesonide, but it is usually studied for 12 weeks of initial therapy. Then once symptoms are gone, the dose is lowered for maintenance therapy. The viscous suspension should be swallowed slowly over 5 to 10 minutes. Do not eat or drink anything else after taking the slurry for at least 30 minutes. However, it is important to rinse your mouth with water after taking oral budesonide to avoid developing thrush on the tongue or throat.
Where can I get oral budesonide?
Swallowed budesonide for EoE is considered an off-label use, which means it has not been officially approved, but is sometimes used in practice. Budesonide in oral suspension or slurry form is not available commercially, but it can be specially compounded at CareFirst Specialty Pharmacy in Cinnaminson, NJ. It still requires a prescription, so ask your doctor about compounded budesonide.
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