An audit of corticosteroid dosing in children with eosinophilic oesophagitis treated with swallowed corticosteroids

Abstract

Objectives and Study:-Swallowed topical corticosteroids (CS) such as fluticasone and budesonide are effective and commonly used in the treatment of children with Eosinophilic Oesophagitis (EoE). Guidelines for use of topical CS and when to screen for adrenal suppression (AS) have been published in the asthma literature. Recent literature has highlighted the risk of AS with the use of CS in the treatment of EoE in children even though screening for AS is not commonly performed in children. This study aims to assess the rate of excessive CS dosing in children with EoE treated with topical CS. Methods: All children attending the EoE clinic at Queensland Children's Hospital were eligible for inclusion in this study. All treatments including dietary exclusion therapy, proton pump inhibitors or swallowed CS for the treatment of EoE were recorded. Total swallowed CS dose with fluticasone inhaler or budesonide slurry was recorded, and the dose adjusted for body surface area (BSA). BSA was calculated using the Mosteller method. Additional topical CS used to treat other conditions including asthma and allergic rhinitis were added to the total CS dose. Children with doses of budesonide greater than 848mcg/m2 or fluticasone 424mcg/m2 were assessed by low dose adrenocorticotropin stimulation test (LDST) at the time of gastroscopy, or by short synacthen test. Children with low LDST test results (< 500 nmol/L serum cortisol at 20 minutes) were considered to have an inadequate adrenal response and were referred for further assessment of adrenal function by short synacthen test. Results: 133 patients attended the Eosinophilic Oesophagitis clinic between 1st January, 2020 and 1st December2020. 92/133 (69%) were treated with swallowed CS, 35 treated with budesonide, 53 fluticasone, 3 a combination of budesonide and fluticasone and 1 a patient on another steroid. 24/92 patients (26%) were taking doses of corticosteroids above the recommended level. This was most likely in those on budesonide only (16/35), and combination steroids (1/3), although a significant number on fluticasone only (8/53) also exceeded maximum recommended CS dosing. Of the 24 patients with corticosteroid doses above recommended levels for BSA, five have been assessed for AS to date. Three patients have been assessed by LDST and all had cortisol levels < 500 nmol/L at 20 minutes. Two patients have had short synacthen tests with 1 of 2 having cortisol levels < 500 nmol/L at 60 minutes (inadequate cortisol response). Conclusion: Many children with EoE, more than a quarter in this study, are at risk of adrenal suppression because their topical CS treatment exceeds maximal recommended dosing. Screening for AS by LDST at the time of gastroscopy needs to further assessed as a screening method for AS in children.L6351748772021-06-08 <br />