**12.2 Topical glucocorticosteroids**

Have become the second line medications for the treatment of EoE. Fluticasone metered dose inhaler 880 microgram puffed directly into the mouth without breathing and then dry swallowed twice a day for 6 to 8 weeks has been found to be effective in reducing symptoms and esophageal eosinophilia in 50 to 80% of cases [38, 39]. Patients are advised not to take any food or drink or rinse their mouth for half an hour to prevent the medication from washing off the esophageal mucosa. The maximal anti-inflammatory effect is found in proximal esophagus. Oral viscous budesonide (OVB) 1 mg twice a day also decreases dysphagia and esophageal eosinophilia. OVB is easy to swallow, more mucoadherent and is made by mixing aqueous solution of budesonide (1 mg/2 mL) with the sugar substitute sucralose (5 g), chocolate syrup or honey [40]. Both forms of topical corticosteroids are more effective in histologic improvement than symptomatic improvement. Only 1% of the topical steroid is absorbed, so systemic side effects are extremely rare although oral and esophageal candidiasis can occur in up to one third of the time and herpes simplex esophagitis have been reported rarely.

Topical steroid is generally given for 8 weeks. If that fails, prolonged or higher doses of topical steroids or systemic steroids or dietary treatment or esophageal dilation should be tried to get symptomatic improvement. The AGA/JTF suggests continuation of topical glucocortisteroids as maintenance therapy in patients with EoE in remission after short-term use of topical glucocoticosteroids.

## **13. Diet**

Dietary therapy is very effective in the management of EoE. It can be used as an initial therapy or when other modalities of treatments fail. Dietary therapy depends on the resources available and can be expensive. As the dietary food allergen is removed, dietary therapy is very effective in inducing and maintaining clinicopathological remission. The three ways of dietary modification include:


#### **14. Systemic steroids**

Oral methylprednisolone induced marked clinical and histological improvement in pediatric EoE patients [46]. Because of systemic side effects, this therapy is reserved when other therapeutic interventions fail. Steroids work by reducing the synthesis of eota xin3, IL5 and GMCSF, and inducing the apoptosis of eosinophils. But recurrence of the EoE occurs after withdrawal of the steroids. The AGA/JTF suggests topical glucocorticosteroids rather than systemic steroids should be used in patients with EoE.

#### **15. Immunomodulators**

Azathiopurine and 6mercaptopurine induced and maintained clinical and histological remission in steroid dependent EoE patients in a case series [47]. They are not currently recommended for routine clinical use in EoE.
