No medication is currently FDA approved for treatment of eosinophilic esophagitis. All medications prescribed for EoE prescribed should be considered as off-label and experimental. Therefore any decision to start treatment and continued monitoring should be discussed carefully with your medical provider.
Summary of Oral Viscous Mometasone
- Retrospective study of 36 patients using swallowed mometasone for EoE
- Overall: 76% response (≤15 eos/hpf), 68% remission (≤5 eos/hpf),
- Unresponsive to other swallowed steroids: 72% response, 56% remission
- No prior steroid therapy: 81% response and remission
- Improvement of behavioral issues that were seen with other swallowed steroid therapy
Swallowed steroid therapy has been used for more than 10 years for management of eosinophilic esophagitis. Studies have looked at various types of steroids including budesonide, fluticasone, beclomethasone, and ciclesonide for treatment of EoE. To date there are no FDA approved swallowed steroids for EoE. Before starting on any therapy for EoE, you should consult with your doctor.
Steroids may be effective but patients and families have concerns about potential side effects of taking steroids. This retrospective EoE study looks to see if mometasone may be more effective, while minimizing side effects.
To understand differences in possible steroid effects, bioavailability is an important concept. According to wikipedia bioavailability is “the fraction of an administered dose of unchanged drug that reaches the systemic circulation.” In other words, how much steroids remains active to have an effect on the body. When steroids are swallowed for EoE, they coat the esophagus to treat the eosinophilic inflammation. It then is asborbed by the gut and is broken down by the liver. The liver has the ability to break down different steroids to varying extents.
The authors quote a study of intranasal steroids that show systemic bioavailability of different steroids
- Mometasone 0.1% bioavailability(i.e 99.9% of the drugs gets broken down into inactive form)
- Fluticasone 1% bioavailability
- Budesonide 34% bioavailability
This study looked at mometasone that was compounded into a viscous suspension of methylcellulose. Three doses were used based on the height of the patient.
- Height <110cm: 750 micrograms (5 ml or 1 teaspoon) once daily
- Height 110-149 cm: 1125 micrograms (7.5 ml or 1 1/2 teaspoons) once daily
- Height 150 cm and higher: 1500 micrograms (10 ml or 2 teaspoons) once daily
In this retrospective study 34 EoE patients were started on mometasone (age range 1.4 years to 28 years). Endoscopies were performed and esophageal biopsies were taken in these patients and were classified as treatment failure, histologic response (peak eosinophils ≤15 eosinophils/high powered field) or histologic remission (peak eosinophils ≤5 eosinophils/high powered field)
Results of oral viscous mometasone on peak eosinophil counts in eosinophilic esophagitis:
- Overall 76% (26 patients) experience histologic response, while 68% (23 patients) experienced histologic remission
- Of those who failed a prior swallowed steroid therapy, e.g budesonide or fluticasone, 72% (13 of 18) had histologic response and 10 of 18 (56%) had histologic remission (FIGURE A)
- Of those who never received any prior steroid therapy, 81% (13 of 16) had histologic response and remission. (FIGURE B)
Safety profile or oral viscous mometasone in eosinophilic esophagitis
- 6 patients while on budesonide reported behavioral issues such as “aggression, mood swings, hyperactivity and disrupted sleep.” After changing to oral viscous mometasone, all these patients had reported improvement of their behaviors, in addition, had histologic remission of their eosinophilic esophagitis.
- None of the 34 patients were noted to have slowing of their growth on mometasone
- 13 patients were evaluated for adrenal issues, one patient was diagnosed with adrenal suppression. This patient was receiving multiple steroids
Based on results, mometasone is shown to be a possible alternative for eosinophilic esophagitis when other swallowed steroid have failed or caused behavioral issues.
This was a small retrospective EoE study therefore additional prospective studies would be needed to confirm these finding.
Methods for compounding of mometasone may vary from pharmacy, so the authors provided the contact information of one of the pharmacies used for this study. (ACC Apothecary, Newton MA 617 527-1563).