Q:

9/4/2013
Recently saw a 30 year old woman for the first time who was diagnosed with eosinophilic esophagitis 2 year back. At the time of diagnosis she had a food impaction. Subsequent to diagnosis, she was treated with a PPI and swallowed topical corticosteroids. She improved and was not adherent to therapy or recommended follow-up with GI. Symptoms recently worsened (increased dysphagia) and she was referred to our office. Concurrently, she recently became pregnant.

I am hesitant to do food or other skin testing due to her pregnancy, especially because I would be very hesitant to initiate any type of dietary elimination during pregnancy (due to risk of nutritional harm). I have recommended she follow up with GI and would like to treat with pharmacotherapy, including topical Fluticasone and possibly a PPI (although I would want GI input as well). The fluticasone would seem reasonable to use in this way, since it can be used for treatment of pregnant asthmatics. I was not able to find any guidance on treatment of pregnant EoE patients and was curious if I could be offered any guidance. Thank you for any advice.

A:

Thank you for your inquiry.

Should you choose to treat your patient with a swallowed topical steroid, my choice would be budesonide. Fluticasone is classified as a Class C drug in pregnancy whereas budesonide is a Class B drug. Also, budesonide slurries have been shown to be effective (see abstract below). Finally, budesonide has an extensive first pass metabolism when administered orally (85 to 95%), making it comparable to fluticasone in this regard.

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

Viscous Topical Is More Effective Than Nebulized Steroid Therapy for Patients With Eosinophilic Esophagitis
Gastroenterology
Volume 143, Issue 2, August 2012, Pages 321–324.e1
We performed a randomized trial to compare nebulized and viscous topical corticosteroid treatments for eosinophilic esophagitis (EoE). Subjects with incident EoE (n = 25) received budesonide 1 mg twice daily, either nebulized and then swallowed (NEB) or as an oral viscous slurry (OVB), for 8 weeks. Baseline eosinophil counts for the NEB and OVB groups were 101 and 83 (P = .62). Posttreatment counts were 89 and 11 (P = .02). The mucosal medication contact time, measured by scintigraphy, was higher for the OVB group than the NEB group (P < .005) and was inversely correlated with eosinophil count (R = −0.67; P = .001). OVB was more effective than NEB in reducing numbers of esophageal eosinophils in patients with EoE. OVB provided a significantly higher level of esophageal exposure to the therapeutic agent, which correlated with lower eosinophil counts.

Sincerely,
Phil Lieberman, M.D.


AAAAI - American Academy of Allergy Asthma & Immunology