OC16 Induction and maintenance therapy using topical steroid preparations in eosinophilic oesophagitis in children: a practical guideline

Abstract

Topical steroid use in Eosinophilic Oesophagitis (EoE) has become common practise in recent years for induction and maintenance treatment. Several different steroids have been proposed and newer delivery methods are becoming more readily available for children, with several guidelines published over the past 10 years. As a result of this and exponential increases in wider research into EoE, UK practise is not standardised and varies widely. The EoE working group and research leads of BSPGHAN together carried out a systematic literature review to determine evidence based guidance for preparation, dosing and duration of use of swallowed topical steroid (STS) formulations in EoE in children.

A systematic literature review (no date limits) was carried out using Cochrane guidance and this technical review has informed an evidenced based, best practice guideline, with easy access flow chart for use by healthcare professionals involved in the management of paediatric EoE. It is hoped that this BSPGHAN guideline will be adopted and shared with other professional societies.

2638 citations were identified and 18 Randomised controlled trials pertaining to steroid use were included. Evidence exists for the use of STS for induction and for maintenance therapy in EoE, especially with regards to histological improvement. Using AGREE criteria, dosing of steroids by age (0.5 mg BD <10 years and 1 mg BD ≥ 10 years) for induction of at least 3 months was suggested based on evidence and practical consideration. Once histological remission has been accomplished, use of maintenance dosing of steroids appears to reduce the frequency and severity of relapse. A maintenance weaning regime was proposed with half dosage (evaluated by repeat endoscopy) and an option to further reduce to a quarter of the dosage. We provide an overview of the practical considerations including; once or twice daily dosing and treatment concordance. Oral viscous budesonide (OVB) and, if agreed by local regulatory committees as current license ≥18 years old, oro-dispersible budesonide (Budesonide 1 mg tablets) were selected as the easiest to use preparations with most improvement in histology. A practical ‘how to prepare and use’ appendix is included. Side effects were identified including candidiasis and adrenal gland suppression, mainly restricted to those receiving other topical steroids for atopic conditions e.g. asthma. The use of oral systemic steroids in strictures may have a role and this was discussed briefly. Dual therapies and when to change therapy were not included as part of this protocol.

In summary, a practical, evidence-based guideline and flow chart with consensus from the EoE Working Group, education and research representatives of BSPGHAN was developed with detailed practical considerations for use in the UK. We plan to demonstrate the algorithm at the annual conference for wider society member review using a QR coded survey system for feedback to ensure stakeholder input before wider dissemination.