Eosinophilic Esophagitis (cont.)
Bhupinder Anand, MD
In this Article
How is eosinophilic esophagitis treated?
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The treatment of eosinophilic esophagitis is with gentle esophageal dilatation, and medications. The goal of treatment is to relieve symptoms of dysphagia.
For decades, gastroenterologists have been treating patients with dysphagia from eosinophilic esophagitis in the same manner as patients with dysphagia due to esophageal strictures and Schatzki rings, i.e., esophageal dilatation. Esophageal dilatation involves physically stretching the strictures or fracturing of the strictures or fracturing the rings, thus allowing freer passage of solid food. Stretching or fracturing of the strictures or rings can be performed with endoscopes, long and flexible dilators of different diameters inserted through the mouth, or with balloons inserted into the esophagus through a channel in the endoscope. The balloons are positioned at the level of the stricture or ring and then inflated to break the stricture or ring.
While esophageal dilatation has been an effective and usually safe treatment, doctors have observed that some patients with eosinophilic esophagitis develop tears in the esophageal lining that can lead to severe chest pain after dilation. Rare cases of esophageal perforations (tears through the entire esophageal wall) also have been reported. Esophageal perforations are a serious complication that can lead to infections in the chest. Thus, although doctors may still use dilatation to treat dysphagia from eosinophilic esophagitis, they now are more likely to use smaller dilators and less force than they would when treating esophageal strictures and rings. Moreover, doctors also are more commonly using medications to treat dysphagia from eosinophilic esophagitis and using dilation only when medications fail.
The medications primarily used in treating eosinophilic esophagitis are fluticasone propionate (Flovent) and proton pump inhibitors (Protonix, Nexium, Aciphex, Prevacid, Prilosec, and Zegarid).
Fluticasone propionate (Flovent)
Although oral steroids are effective in treating eosinophilic esophagitis, the side effects of orally-administered steroids limit their use. One new oral steroid that is being tested is budesonide, an orally-administered steroid that is absorbed into the body but is rapidly destroyed, resulting in fewer serious side effects. The current treatment of eosinophilic esophagitis is with swallowed (not inhaled) fluticasone propionate. Fluticasone propionate is a synthetic (man-made) steroid that is related to the naturally occurring steroid hormone, cortisol or hydrocortisone, produced by the adrenal glands. These steroids have potent anti-inflammatory actions. When used as an inhaler, fluticasone propionate reduces inflammation in the airways of patients with asthma, thus relieving wheezing and breathing difficulties. When fluticasone propionate is swallowed, it has been shown to reduce the eosinophils in the esophagus and relieve dysphagia in patients with eosinophilic esophagitis.
In treating eosinophilic esophagitis, fluticasone propionate is administered with the same inhaler as for asthma but without the usual spacer in the inhaler. The removal of the spacer causes the fluticasone propionate to deposit in the mouth rather than enter the lungs. The fluticasone propionate that deposits in the mouth is then swallowed with a small amount of water, usually twice daily for several weeks. Patients are instructed not to eat or drink for two hours after each treatment. Improvement in dysphagia usually is prompt, within days or weeks. Most patients develop recurrent symptoms after stopping treatment require treatment and/or continuous retreatment.
When used in low doses, little of the fluticasone propionate is absorbed into the body and therefore side effects are minimal. One possible side effect is thrush (infection of the mouth and throat by a fungus, candida), which is relatively easy to treat. When higher doses are used for a prolonged period, enough fluticasone propionate may be absorbed to cause side effects throughout the body. Side effects of high doses of fluticasone propionate are similar to the side effects of oral steroids such as prednisone and cortisone.
Proton pump inhibitors (PPIs)
Proton pump inhibitors, pantoprazole (Protonix), esomeprazole (Nexium), rabeprazole (Aciphex), lansoprazole (Prevacid), and omeprazole (for example, Prilosec, Zegarid) reduce production of acid by the stomach. They are very safe and effective treatment for the symptoms of acid reflux and esophagitis. Since acid reflux may aggravate esophagitis in some patients with eosinophilic esophagitis, doctors frequently use proton pump inhibitors for treating eosinophilic esophagitis. Proton pump inhibitors do not treat the underlying eosinophilic esophagitis; however, and treatment with fluticasone or another steroid usually is required as well.
Medically Reviewed by a Doctor on 12/2/2013
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