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Topical budesonide effective for eosinophilic esophagitis in pivotal trial

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New hope for EoE treatment

This is an exciting abstract from Hirano et al. highlighting the results of the first phase 3 trial for an eosinophilic esophagitis (EoE) treatment. Furthermore, the trial design, which included histologic and symptom-based endpoints, may be critical to attaining Food and Drug Administration approval. Given the lack of any FDA-approved therapies for EoE, the results of this trial are welcome news for clinicians who treat patients with EoE.

This study of a topical muco-adherent steroid formulation (budesonide oral suspension) specifically designed to treat EoE significantly improved histologic, symptom, and endoscopic endpoints, compared with placebo. Of note, 62% of patients on the drug achieved a histologic response of less than 15 eosinophils per high-power field (53% achieved less than 6), compared with 1% in the placebo group. This study supplements the existing data supporting the use of swallowed topical steroids in EoE.

It is important to note that the subjects in this study had fairly severe disease, with more than 40% having previously undergone esophageal dilation and all patients experiencing dysphagia, on average, multiple times per week. Given the disease severity in the subject population, there can be even greater enthusiasm regarding the response rates for the budesonide group. Also notable is the relatively high dose of budesonide used in this study (2 mg twice daily), which may have contributed to the 3.8% incidence of esophageal candidiasis. Importantly, adrenal function was assessed during the study and will be monitored during the ongoing maintenance portion of the study.

These last points do highlight the challenges of treating more severe EoE given 38% of patients did not achieve histologic remission (less than 15 eosinophils per high-power field) despite the doses of budesonide used in this study. This emphasizes the need for other treatment options for steroid nonresponders.

Taken together, these results are very exciting and will lead to an FDA-approved EoE treatment in short order.

Paul Menard-Katcher, MD, is associate professor of medicine in the division of gastroenterology and hepatology at the University of Colorado at Denver, Aurora. He has no conflicts of interest.


 

REPORTING FROM ACG 2019

– An investigational muco-adherent swallowed formulation of budesonide developed specifically for treatment of eosinophilic esophagitis aced all primary and secondary endpoints in a pivotal, phase 3, double-blind, placebo-controlled randomized trial, Ikuo Hirano, MD, reported at the annual scientific meeting of the American College of Gastroenterology.

Dr. Ikuo Hirano, gastroenterologist and professor of medicine at Northwestern University, Chicago.

Dr. Ikuo Hirano

This is welcome news for patients with this chronic immune-mediated disease, for which no Food and Drug Administration–approved drug therapy exists yet.

“This is the first phase 3 trial to demonstrate efficacy using the validated Dysphagia Symptom Questionnaire, the first completed phase 3 trial of any medical therapeutic for eosinophilic esophagitis, and the largest clinical trial for eosinophilic esophagitis conducted to date,” declared Dr. Hirano, professor of medicine at Northwestern University in Chicago.

This was a 12-week induction therapy study including 318 adolescents and adults randomized 2:1 to 2 mg of budesonide oral suspension (BOS) or placebo twice daily. Patients were instructed not to eat or drink anything for 30 minutes afterward to avoid washing away the medication.

This was a severely affected patient population with high-level inflammatory activity: their mean baseline peak eosinophil count was 75 cells per high-power field, well above the diagnostic threshold of 50 eosinophils per high-power field. In keeping with a requirement for study participation, all patients had failed to respond to at least 6 weeks of high-dose proton pump inhibitor therapy. They also had to experience solid food dysphagia on at least 4 days per 2 weeks. More than 40% of subjects had previously undergone esophageal dilation.

One coprimary endpoint addressed histologic response, defined as 6 or fewer eosinophils per high-power field after 12 weeks of double-blind treatment. The histologic response rate was 53% in the BOS group and 1% in placebo-treated controls.

The other coprimary endpoint was symptom response as defined by at least a 30% reduction from baseline in the Dysphagia Symptom Questionnaire score. This was achieved in 53% of patients on BOS and 39% of controls.

The prespecified key secondary endpoint was the absolute reduction in Dysphagia Symptom Questionnaire score through week 12. From a mean baseline score of 30 out of a possible 84, the swallowed steroid recipients experienced a mean 13-point improvement, compared with a 9.1-improvement for those on placebo.

The topical budesonide group also did significantly better than placebo in terms of all other secondary endpoints. Endoscopic improvement as reflected in the mean Eosinophilic Esophagitis Reference Score was greater in the BOS group by a margin of 4 versus 2.2 points. A high-bar histologic response rate of no more than a single eosinophil per high-power field at week 12 was achieved in one-third of the BOS group and zero controls. The overall peak eosinophil count from baseline to week 12 dropped by an average of 55.2 cells per high-power field in the budesonide group, compared to a 7.6-eosinophil decrease in controls. And the proportion of patients with no more than 15 eosinophils per high-power field at week 12 was 62% with BOS, compared with 1% with placebo.

Treatment-emergent adverse events were similar in the two study arms and were mild to moderate in severity. Of note, however, the 3.8% incidence of esophageal candidiasis rate in the topical corticosteroid group was twice that seen in the placebo arm. Adrenal function as assessed by ACTH stimulation testing at baseline and 12 weeks was normal in 88% of the BOS group and 94% of controls.

Dr. Hirano noted that adrenal function will continue to be carefully monitored during an ongoing, phase 3, double-blind, placebo-controlled BOS maintenance study.

He reported receiving research funding from and serving as a consultant to Takeda, the study sponsor, as well as a handful of other pharmaceutical companies.

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