Q:

10/11/2012
In patients with eosinophilic eosophagitis treated with flovent or budesonide by the swallow method what is the incidence of thrush and/or esophageaal candidiasis using the high dose treatment?

A:

Thank you for your inquiry.

Of course, we do not have as much data on the incidence of candidiasis due to the use of swallowed corticosteroids to treat eosinophilic esophagitis as we do due to the use of inhaled corticosteroids to treat asthma. There simply are not as many patients treated for eosinophilic esophagitis evaluated in large trials for us to have collected an equal amount of information. What we do have indicates that the incidence can vary considerably, ranging from perhaps a low of approximately 1% to a high of 26%. The references copied below are studies which have reported incidences within this range.

Thank you again for your inquiry and we hope this response is helpful to you.

Gastroenterol Hepatol (N Y). 2011 January; 7(1): 59-61.
PMCID: PMC3038320
Therapeutic Options for Eosinophilic Esophagitis
Jeffrey A. Alexander, MD and David A. Katzka, MD

Clin Gastroenterol Hepatol. 2012 Jul;10(7):742-749.e1. Epub 2012 Apr 1.
Swallowed fluticasone improves histologic but not symptomatic response of adults with eosinophilic esophagitis.
Alexander JA, Jung KW, Arora AS, Enders F, Katzka DA, Kephardt GM, Kita H, Kryzer LA, Romero Y, Smyrk TC, Talley NJ.
Source
Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
Abstract
Background and Aims: We evaluated the effect of aerosolized fluticasone therapy on symptomatic dysphagia and histologic eosinophilia in adults with eosinophilic esophagitis (EoE).
Methods: We performed a double-blind, randomized, placebo-controlled trial of fluticasone in 42 adult patients with a new diagnosis of EoE (30 men; mean age, 37.5 y). Participants were assigned randomly to groups that swallowed 880 ìg of aerosolized fluticasone twice daily (n = 21), or took a placebo inhaler twice daily (n = 15) for 6 weeks. End points of the study were symptomatic and histologic response.
Results: A complete histologic response (>90% decrease in mean eosinophil count) was observed in 11 of 15 subjects who received 6 weeks of fluticasone (62%), compared with none of the 15 subjects who received placebo (P < .001), based on intention-to-treat analysis; histologic responses were observed in 68% of subjects who received fluticasone (13 of 19) compared with none of those who received placebo (0 of 15) by per-protocol analysis (P < .001). Intracellular staining for eosinophil-derived neurotoxin was reduced in 81% of subjects who received fluticasone (13 of 16) compared with 8% who received placebo (1 of 13) (P < .001). Dysphagia was reduced in 57% of subjects who received fluticasone (12 of 21) compared with 33% who received placebo (7 of 21) (P = .22) by intention-to-treat analysis; dysphagia was reduced in 63% of patients who received fluticasone (12 of 19) and 47% of those who received placebo (7 of 15) (P = .49) based on per-protocol analysis. Esophageal candidiasis developed in 26% of subjects who received fluticasone (5 of 19), but in none of the subjects in the placebo group (P = .05).
Conclusions: Aerosolized, swallowed fluticasone leads to a histologic but not a symptomatic response in adults with EoE

Otolaryngol Head Neck Surg. 2011 Oct;145(4):551-6. Epub 2011 May 18.
Dysphagia and quality of life may improve with mometasone treatment in patients with eosinophilic esophagitis: a pilot study.
Bergquist H, Larsson H, Johansson L, Bove M.
Source
Department of Otorhinolaryngology, Head and Neck Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
Abstract
Objective: The treatment of adult patients with eosinophilic esophagitis remains challenging. The aim was to assess dysphagia and health-related quality of life (HRQL) using validated scales and questionnaires before and after treatment with mometasone furoate.
Study Design: Case series with planned data collection.
Setting: University hospital and secondary referral hospital.
Subjects and Methods: Newly diagnosed patients with eosinophilic esophagitis were included and given 200 ?g of orally administered topical mometasone furoate 4 times daily. Questionnaires incorporating the Watson Dysphagia Scale (WDS), the European Organization for Research and Treatment of Cancer Quality of Life-Oesophageal Module 18 (EORTC QLQ-OES18), and the Short Form-36 (SF-36) were completed before the initiation of treatment and after 2 months of treatment.
Results: Thirty-one consecutive patients (23 men; mean age, 45 years; range, 18-89 years) completed the trial. At inclusion, the mean scores of the WDS, the EORTC QLQ-OES18 dysphagia scale, the eating scale and choking item, and the global health and social functioning dimensions of the SF-36 were 21.3, 20.4, 35.0, 38.6, 71.1, and 82.3, respectively. Posttreatment, these scores improved to 8.9 (P < .0001), 4.6 (P < .00001), 17.8 (P < .001), 16.0 (P < .01), 76.1 (P < .05), and 91.9 (P = .0001), respectively. Except for 1 case of oral candidiasis, no significant side effects were reported.
Conclusion: The dysphagia and impaired HRQL found in untreated patients with eosinophilic esophagitis improved significantly after 2 months of mometasone furoate treatment. A randomized placebo-controlled trial is warranted to assess causality. The scales and questionnaires used are sensitive instruments appropriate for symptom surveillance in individuals with eosinophilic esophagitis.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology