A recent study published by the BSPGHAN Eosinophilic Oesophagitis Working Group provides new evidence-based guidelines for using swallowed topical steroids (STS) in treating paediatric Eosinophilic Oesophagitis (EoE) in the UK.

This disease has seen a rise in prevalence, highlighting the need for effective treatment protocols to manage symptoms and improve histological outcomes in affected children. 

Swallowed Topical Steroids in EoE Treatment

STS have become a common practice in recent years for both the induction and maintenance treatment of EoE.

However, paediatric patients still face practical challenges, such as difficulties in preparing and administering STS, variations in local dispensing policies, and the need for age-appropriate formulations.

The study provides practical guidance for induction and maintenance therapy, developed with consensus from the EoE Working Group, including EOS Network and Guts UK patient representatives and education and research representatives of BSPGHAN.

Key Findings:

• High Remission Rates: STS achieve high rates of symptom (71%) and histological (59%) remission in children with EoE who do not respond to proton pump inhibitors (PPIs).
• Age-Based Dosing Recommendations: The study suggests dosing steroids by age, with 0.5 mg twice daily for children under ten years and 1 mg twice daily for those aged ten years and older, for an induction period of at least three months.
• Maintenance Therapy: Once histological remission is achieved, maintenance dosing of steroids reduces the frequency and severity of relapse. A weaning regimen is proposed for ongoing maintenance therapy.
• Guidance Development: The study resulted in a practical, evidence-based flow chart and detailed guidance recommendations for use in the UK.

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What is Eosinophilic Oesophagitis

EoE is a chronic, immune-mediated oesophageal disease characterised by symptoms of oesophageal dysfunction and significant eosinophil-predominant inflammation. 

These symptoms can significantly impair the quality of life, especially in children, so giving the proper treatment early in life is essential. 

Symptoms in Children vs. Adults with EoE

Children of different ages have different symptoms:

• Infants and toddlers often present with feeding difficulties: vomiting, regurgitating, and feeding refusal, which leads to failure to thrive.
• Older children present abdominal pain but can manage to eat. 

Adolescents, on the other hand, have reflux symptoms, heartburn and severe swallowing problems. Often food impaction, motility problems when food gets stuck in the gullet.

Dr Marcus Auth, consultant Alder Hey Children Hospital, Chair of the EoE Working Group.

Current Treatment Options

The treatment options for children with EoE are limited. There is no licensed formulation of STS specifically for paediatric EoE, unlike in adults. This leads to reliance on various local dispensing policies for prescribing these therapies.

The recent study by the BSPGHAN EoE Working Group is vital as it provides evidence-based guidelines to standardise and improve the treatment of paediatric EoE. This study aims to ensure better health outcomes and consistent care practices.

Study Methodology

The study systematically reviewed the literature using Cochrane methodology to investigate the preparation, dosage, and duration of STS therapy for paediatric EoE. Seven key themes were explored, including indications for STS, best preparations, age-appropriate dosing, and the duration of both induction and maintenance therapies.

The study found that STS effectively achieved remission in children who did not respond to PPIs. It also highlighted the successful use of oral viscous budesonide (OVB) and orodispersible budesonide tablets.

Recommendations

The study provided specific dosing recommendations: 0.5 mg twice daily for children under ten years old and 1 mg twice daily for those ten years old and older. It also included a practical appendix on how to prepare and use OVB.

Additionally, the study established maintenance therapy guidelines, addressing the management of side effects such as candidiasis and adrenal suppression. A practical flow chart was developed for treating paediatric EoE with swallowed topical budesonide, including diagnosis, dosing, and maintenance therapy.

Swallowed topical budesonide flow chart (quick clinical reference guide).

BD, two times per day; PPI, proton pump inhibitor. Source: bmjpaedsopen.bmj.com

Implications for the Eosinophilic Community

The findings of the BSPGHAN study offer significant benefits to the eosinophilic community, particularly children with EoE and their families. The high remission rates with STS mean that more children can achieve symptom relief and improved oesophageal health, reducing the burden of this chronic condition.

The clear dosing guidelines and practical recommendations ensure that treatment is both effective and manageable, promoting better adherence and outcomes.

The practical flow chart included in the study serves as a valuable tool for clinicians, facilitating standardised and efficient treatment practices across various healthcare settings.

Read the full study

Previous EoE Guidelines 

• British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults (May 2022)
• AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis (2020)
• Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference (2018)
• EoE INTERNATIONAL GUIDELINE(2011)