Topical inhaled ciclesonide for treatment of eosinophilic esophagitis

Reply

To the Editor:

We were encouraged to read of the experience of Lee et al¹ with ciclesonide and would address their concerns as follows. In our series of 4 patients, all 4 had taken topical fluticasone before successful use of ciclesonide, making steroid resistance alone unlikely. We wonder whether some of the differences in response could be from the younger age (mean, 7.75 vs 13.5 years) of our patients. Younger patients could have a shorter esophagus, making for better coverage by the swallowed preparation. In addition, there would be a higher probability that parents, as opposed to the patient himself or herself, would administer the medication, leading to higher compliance. With respect to serum IgE levels, patients reported in our letter had increased IgE levels (172–441 IU/mL) but did not have the same degree of increased serum IgE levels as the 2 nonresponders in the Rubenstein series.¹ Finally, our patients were treated for an average of 3 months, whereas the exact duration of treatment in their group was not noted. Longer duration might be necessary to achieve histologic remission because one of their nonresponders had somewhat of a diminished eosinophilia. As with any disease, there might be genetically defined differences with respect to therapeutic responsiveness, and these could be addressed with future biomarker studies, as suggested previously.^2,3