Routine reduction of maintenance steroid doses leads to inferior outcomes in EoE
Among adult eosinophilic esophagitis (EoE) patients with initial response to steroid therapy and receiving maintenance treatment, loss of treatment response is associated with dose reduction and results in worsening of endoscopic findings, according to a study.
“Results from this study suggest that maintaining the initial dose of topical fluticasone or budesonide may result in sustained endoscopic and histologic remission,” the investigators said.
The investigators examined 55 patients with proton pump inhibitor-nonresponsive EoE who showed an initial histologic response (<15 eosinophils [eos]/high-power field [hpf]) after an 8-week course of topical corticosteroids (fluticasone or budesonide), and who were subsequently maintained on steroid therapy for ≥75 percent of the follow-up time. The mean age of the group was 39.9 years, with males comprising the majority (67 percent). [Clin Transl Gastroenterol 2017;doi:10.1038/ctg.2017.27]
A total of 33 patients had at least two follow-up esophagogastroduodenoscopy (EGD), among whom more than half (61 percent) had histologic loss of response to treatment and the remaining 39 percent maintained histologic response over a median follow-up time of 11.7 months.
While baseline steroid dose did not differ between the two groups, patients who maintained their initial treatment dose (daily >1,000 mcg of budesonide or >880 mcg of fluticasone) were less likely to lose response than those who had subsequent dose reduction (daily ≤1,000 budesonide or ≤880 mcg of fluticasone; odds ratio [OR], 0.10; 95 percent CI, 0.01 to 0.90). Histologic loss of response to treatment was associated with worsening of endoscopic findings.
As expected, compared with the group who showed ongoing response, the group with loss of response had a higher endoscopic severity score (ESS) score (median, 3 vs 1; p=0.02) and higher peak eosinophil count (63 vs 1 eos/hpf; p<0.01) at recurrence or end of follow-up, the investigators noted.
“On survival analysis, 50 percent had loss of response to steroids by 18.5 months and 75 percent by 29.6 months,” they added.
The investigators pointed out that the present data counter the hypothesis that once histologic remission is achieved with topical steroids, the medications can be sustained long-term without a detriment in efficacy.
“Additionally, our finding that recurrence appears to be dose dependent, and that reincreasing the dose may not lead to histologic improvement is also an important observation, potentially challenging whether decreasing the dose is appropriate clinically,” they said.
Despite the presence of limitations including the retrospective design, a study population derived from a single tertiary care referral centre, and the inability to fully measure patient adherence to treatment, the study is said to contribute to the existing literature and shows that the rates of loss of response to steroid therapy are comparable to that reported in the paediatric population. [Am J Gastroenterol 2016; 111: 1187–1197]
In light of the little guidance regarding the duration and management of dose changes in adult EoE patients, the investigators said, “[T]he practice of dose reduction, which is primarily done in an attempt to minimize steroid exposure and side effects, may not be the optimal strategy for best long-term outcomes.”