Efficacy of Budesonide vs Fluticasone for Initial Treatment of Eosinophilic Esophagitis in a Randomized Controlled Trial

Abstract

See editorial on page 14. See Covering the Cover synopsis on 1.BACKGROUND AND AIMS: Topical steroid treatments for eosinophilic esophagitis (EoE) include swallowed fluticasone from a multi-dose inhaler (MDI) or oral viscous budesonide (OVB) slurry, but the 2 have never been compared. We assessed whether OVB was more effective than MDI for initial treatment of patients with EoE. METHODS: In a double-blind, doubledummy trial, patients with a new diagnosis of EoE were randomly assigned to groups given 8 weeks of either OVB (1 mg/4 mL) twice daily plus a placebo inhaler (n ¼ 56) or fluticasone MDI (880 mg) twice daily plus a placebo slurry (n ¼ 55). Primary outcomes were post-treatment maximum eosinophil counts per high-power field (eos/hpf) and a validated dysphagia score (dysphagia symptom questionnaire [DSQ]) at week 8. Secondary outcomes included endoscopic severity (validated EoE endoscopic reference score), histologic response (<15 eos/ hpf), and safety. RESULTS: In a modified intention-to-treat analysis, the subjects had baseline peak eosinophil counts of 73 and 77 eos/hpf in the OVB and MDI groups, respectively, and DSQ scores of 11 and 8. Post-treatment eosinophil counts were 15 and 21 in the OVB and MDI groups, respectively (P ¼ .31), with 71% and 64% achieving histologic response (P ¼ .38). DSQ scores were 5 and 4 in the OVB and MDI groups (P ¼ .70). Similar trends were noted for post-treatment total EoE endoscopic reference scores (2 vs 3; P ¼ .06). Esophageal candidiasis developed in 12% of patients receiving OVB and 16% receiving MDI; oral thrush was observed in 3% and 2%, respectively. CONCLUSIONS: In a randomized clinical trial, initial treatment of EoE with either OVB or fluticasone MDI produced a significant decrease in esophageal eosinophil counts and improved dysphagia and endoscopic features. However, OVB was not superior to MDI, so either is an acceptable treatment for EoE. ClinicalTrials.gov ID NCT02019758.Abbreviations used in this paper: DSQ, dysphagia symptom questionnaire; EoE, eosinophilic esophagitis; eos/hpf, eosinophil counts per high-power field; EREFS, EoE Endoscopic Reference Score; MDI, multi-dose inhaler; OVB, oral viscous budesonide; PPI, proton pump inhibitor. Most current article

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