Pharmacist Counseling for Pediatric Eosinophilic Esophagitis Treatment with Fluticasone
Few people are aware that pathologists believed children were physically the same as adults up until the 1950s. Of course, experts now know children are different and should be medically treated as such—until something like pediatric eosinophilic esophagitis comes along. The more researchers learn, the more they find similarities between adults and children when it comes to the disease’s clinical features and treatment. This helps explain why parents recognize the symptoms and figure their child has heartburn, only to discover they were wrong. Pharmacists who reach out to teach parents about pediatric eosinophilic esophagitis can help these children find relief sooner rather than later.
Key Facts About Pediatric Eosinophilic Esophagitis
Primary eosinophilic esophagitis (EoE) is such a new disease that the experts are still fine-tuning its definition and treatment. The first consensus guidelines were published in 2007, then updated in 2011 when a multidisciplinary committee of 33 physicians developed this definition: “EoE is a chronic immune/antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation.”1
While prevalence isn’t known, its incidence is increasing, which isn’t only due to better recognition and diagnosis. “When performing endoscopy in the 1980s and 1990s, we biopsied every patient and rarely saw patients with eosinophilic esophagitis, so the disease is actually occurring more frequently as well,” said one of the leading experts, Chris A. Liacouras, MD, Co-Director of the Center for Pediatric Eosinophilic Disorders at the Children’s Hospital of Philadelphia.2 He estimates that one out of every 10 children who go to a gastroenterologist for treatment of reflux actually has EoE.
The confounding factor for parents and pediatricians is that children usually seem to have gastroesophageal reflux disease. Their symptoms fall into four categories:
- GERD symptoms such as heartburn, chest pain, and hoarseness
- Dysphagia – may present as impacted food, feeding intolerance, or failure to thrive
- Abdominal pain
- Nausea and vomiting
EoE is associated with food allergies, but the key piece of information—one that underscores the importance of pharmacist outreach—is that eosinophilic esophagitis is a lifelong condition. Fewer than five percent of children and adults diagnosed with EoE have outgrown the disease. The experts are concerned that over time, these young patients may develop subepithelial fibrosis, smooth muscle hypertrophy, and epithelial basal cell hyperplasia.
Fluticasone Currently a Primary Treatment
Proton pump inhibitors are the first treatment used when children have symptoms of reflux. If symptoms don’t improve, or if they return when the proton pump inhibitor is stopped, then it’s time for an endoscopy with a biopsy to differentiate EoE from reflux. Researchers are beginning to uncover EoE’s genetic basis, which will lead to new diagnostic markers and specific biological treatments. For now, a biopsy to identify eosinophils is the only way to make an accurate diagnosis.
After a diagnosis is made, treatment takes a two-pronged approach—dietary therapy and swallowed or topical corticosteroids. Oral steroids are only recommended for short-term emergency treatment of food impaction or debilitating symptoms, such as failure to thrive or protracted vomiting.
Swallowed steroids: Swallowed steroids effectively treat 50 to 80 percent of all patients, including the youngest ones, and may reverse EoE-related esophageal fibrosis in children.
- Fluticasone 110 to 220 mcg daily is the first-line therapy for initial treatment and maintenance of EoE.3 It’s administered as a spray with a metered dose inhaler twice daily. A recent study indicates that swallowed fluticasone is safe for at least two years. When researchers tested children on fluticasone at four, 12, and 24 months, they found improved symptoms and endoscopic features without growth impediment or side effects, reported the American Journal of Gastroenterology in June 2016.4
- Budesonide 0.5 to 2 mg is an alternative regimen. It’s used as an oral viscous slurry once or twice daily.
Dietary intervention: Most kids with EoE are allergic to food or environmental allergens. Three dietary elimination approaches are considered:
- Strict elemental diet – All protein is eliminated and patients receive nutrients from a formula of amino acids, simple sugars, and oils.
- Antigen avoidance – Used when allergy testing targets specific foods.
- Empiric elimination – Removes the major food allergens before allergy testing, which eliminates dairy, egg, wheat, soy, peanuts, tree nuts, and fish.
Some researchers report that milk is the most common trigger and suggest that epicutaneous immunotherapy may improve tolerance. While elimination diets are successful—close to 100 percent with elemental diets and up to 80 percent for those on empiric elimination—they’re hard to follow. After symptoms improve, foods may be added back one at a time, with endoscopies to monitor eosinophilic activity.
Pharmacist Outreach Promotes Early Diagnosis and Treatment [93 words]
Targeting outreach can be challenging at first because these parents first enter pharmacies seeking OTC products for their child’s reflux. You could put up a poster saying, “If your child has unrelieved reflux, talk with the pharmacist,” or ask the question during checkout. Of course, once they have a prescription for steroids, medication review provides the opportunity to keep up with their progress. Whichever way you reach out, keep in mind that the effort you put into it makes a difference because early diagnosis and treatment improves outcomes and can help stop a child’s suffering.
Pharmaceutica North America provides prescription drug products, OTC supplements and high quality bulk APIs such as fluticasone. Contact us today to talk about how we can support the needs of your patients and pharmacy.
- “Eosinophilic Esophagitis: Updated Consensus Recommendations for Children and Adults,” July 2011, http://www.ncbi.nlm.nih.gov/pubmed/21477849 ↩
- “Clinical Presentation and Treatment of Pediatric Patients with Eosinophilic Esophagitis,” April 2011, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127030/ ↩
- “From Genetics to Treatment of Eosinophilic Esophagitis, October 2015, http://www.medscape.com/viewarticle/850403_1 ↩
- “Swallowed Fluticasone Propionate is an Effective Long-Term Maintenance Therapy for Children with Eosinophilic Esophagitis,” June 2016, http://www.ncbi.nlm.nih.gov/pubmed/27325220 ↩