As noted in previous blog posts (EoE: Drugs, Diets, Dilatation and PPI-REE | gutsandgrowth, EoE –Journal Club (Part 1) | gutsandgrowth, and EoE –Journal Club (Part 2) | gutsandgrowth), proton pump inhibitors are recommended as 1st line therapy in suspected eosinophilic esophagitis (EoE) for several reasons. Besides the potential for gastroesophageal reflux to cause esophageal eosinophilia, there has been recognition of PPI-responsive eosinophilic esophagitis (PPI-REE). In adults, the response to proton pump inhibitors, both clinically and histologically, is likely higher than in children; nevertheless, in children it is anticipated that 20-40% of patients with suspected EoE will have a histological remission with PPI therapy.
A recent study in adults suggests that PPIs may in fact outperform topical steroids (Am J Gastroenterol 2013; 108: 366-72). Thanks to Ben Gold and Seth Marcus for identifying this reference. This study enrolled 42 patients: 90% male, 81% white, mean age 38 years. It was a prospective single-blinded, randomized controlled trial with newly suspected EoE; half of the patients received esomeprazole 40 mg daily and half fluticasone swallowed aerosol 440 mcg twice a day. After 8 weeks, all patients had repeat endoscopy; a total of eight biopsies were obtained –four at two locations: 15 cm above LES and 3 cm above LES. In addition, at the start of the study, patients also underwent 24-h pH/impedance monitoring. 4 of the 21 patients in each group had abnormal degrees of gastroesophageal reflux/gastroesophageal reflux disease (GERD).
Study characteristics note that 62% of patients had coexisting atopic disorders.
- There was no significant difference in esophageal eosinophilia response with 19% of the fluticasone and 33% of the esomeprazole achieving an eosinophil count < 5/hpf (P=0.484)
- In patients with coexisting GERD, all 4 esomeprazole patients achieved histologic remission compared with none of the fluticasone-treated patients.
- When the GERD patients were excluded, the histological remission was quite similar: 24% with fluticasone and 18% for esomeprazole.
Overall, this study population had a lower rate of response to topical steroids than in multiple previous studies. More typically, response rates of ~50% have been reported; however, studies have shown lower responses in some adult studies. Variability in response could be related to multiple factors included dosage, duration, delivery, and definition of response. In addition, population characteristics included disease duration and frequency of underlying atopic disease and GERD play a role.
Take-home points: Although this is a small study, it reinforces the fact that PPIs induce a histological response and clinical response in some patients suspected of having EoE regardless of whether GERD is present. PPIs are considered 1st line therapy. Topical fluticasone had a lower response rate in this study. However, in clinical pediatric practice, topical steroids are effective in about 50% of patients.
Additional related blog entries:
- CHOOSING TOPICAL THERAPY FOR EOE | GUTSANDGROWTH
- GUIDELINES FOR EOSINOPHILIC ESOPHAGITIS | GUTSANDGROWTH
- EOSINOPHILIC ESOPHAGITIS –SIX FOOD GROUP DIET | GUTSANDGROWTH
- LOOK OF IMPROVEMENT ON AN EOE DIET | GUTSANDGROWTH
- STRING TEST | GUTSANDGROWTH
- LOOKING BETTER OR FEELING BETTER IN EOE? | GUTSANDGROWTH
- THE UNDISCOVERED COUNTRY | GUTSANDGROWTH