S2700 Eosinophilic Esophagitis: Histologic Remission Induced with Swallowed Nasal Fluticasone

Introduction: Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus caused by an immune-mediated response1. Current therapies include proton pump inhibitors, swallowed topical steroids, food elimination diet, and dupilumab. Treatment choice involves the consideration of response to previous therapy, patient preference, and cost. We present a case of a patient with EoE achieving histological remission by using over-the-counter swallowed fluticasone nasal spray. Case Description/Methods: A 50-year-old man with a history of environmental allergies, asthma, and EoE presented to clinic for EoE management after a decade of intermittent swallowed fluticasone inhaler use. Daily omeprazole 40 mg was initiated with fluticasone discontinuation. Subsequent EGD showed a peak eosinophil count of 10 eos/hpf in the mid esophagus and 5 eos/hpf distally. The omeprazole frequency was increased to twice daily to target deeper histologic remission based on joint-decision making. Three months later, EGD showed 0 eos/hpf distally, but 31 eos/hpf proximally. Omeprazole was discontinued and a twice daily swallowed fluticasone inhaler 440mcg was initiated. After 5 months, EGD showed proximal improvement with 0 eos/hpf, but continued to have elevated eosinophils distally with 45 eos/hpf. Facing decision points after multiple regimen failures, the patient elected to retry daily omeprazole 40mg with excellent adherence. After 3 months, EGD showed 80 eos/hpf at mid-biopsy and 35 eos/hpf distally. It was recommended to retry fluticasone. Based on the patient’s own cost analysis, he began using off-label fluticasone nasal spray mixed with honey—calculated to be 450mcg twice daily. EGD after 2 months showed marked improvement, with 0 eos/hpf at mid-biopsy and 7 eos/hpf distally. Discussion: To our knowledge, this is the first case reported of a patient achieving histologic remission with swallowed fluticasone propionate nasal spray. Currently, oral viscous budesonide and swallowed fluticasone propionate from an inhaler are both acceptable treatments for EoE1. This case highlights that fluticasone propionate nasal spray may be a cost effective and alternative formulation in the treatment of EoE. Reference 1. Dellon ES, Woosley JT, Arrington A, et al. Efficacy of budesonide vs fluticasone for initial treatment of eosinophilic esophagitis in a randomized controlled trial. Gastroenterology 2019;157(1) 65-73 e5.