Introduction

Eosinophilic esophagitis (EoE) is a chronic and progressive disease characterized by eosinophil-predominant inflammation of the esophagus. First-line therapy is represented by topical corticosteroids with anti-inflammatory effects, in particular budesonide orodispersible tablets (BOT). Their efficacy and safety are nowadays well established, but very low number of patients develop oral and esophageal candidiasis.

Aims & Methods

The aim of the study is to evaluate risk factors for the development of oral and esophageal candidiasis during budesonide therapy in eosinophilic esophagitis patients. To date, these data have not still been studied. A retrospective study was conducted to include all EoE patients in therapy with BOT referred to Fondazione Policlinico Universitario A. Gemelli IRCCS between March 2022 and November 2023. Prevalence, localization, and time of presentation of candidiasis were evaluated. Histological findings, in particular eosinophilic count in gastroscopy before BOT therapy were analyzed. Concomitant treatment with proton-pump inhibitors (PPI) and its dosage were reviewed. In addition, each case of discontinuation of BOT for disabling candidiasis was studied.

Results

A total of 52 EoE patients in BOT therapy, 44 males and 8 females, were included in the study. 7 patients (13%) developed oral and/or esophageal candidiasis, in particular 6 patients (85%) during induction phase (1 mg bid) and 1 patient (15%) during early maintenance phase (0.5 mg bid). All these 7 patients presented peak eosinophil count >35/HPF before corticosteroid treatment, with mean count of 46 eos/HPF. 4 patients (57%) of this group were in concomitant PPI therapy at 40 mg per day or more dosage. 3 patients (42%) presented recurrent and severe oral candidiasis inducing discontinuation of treatment.

Conclusion

Oral and esophageal candidiasis is a well-known side effect of budesonide orodispersible tablets in eosinophilic esophagitis. Our results suggest that consistent eosinophilic count (> 35/HPF) and concomitant PPI therapy could represent risk factors in developing mycosis in EoE patients. According to literature, major esophageal inflammation, PPI-induced elimination of the gastric acid barrier and corticosteroid immunosuppression are the main mechanisms leading to oral and esophageal candida colonization. Concomitant use of PPI during BOT treatment in eosinophilic esophagitis should be carefully evaluated, especially in patients with elevated eosinophilic count.

References

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