Expecting Change in Eosinophilic Esophagitis Treatment

A recent study (EJ Laserna-Mendieta et al. Clin Gastroenterol Hepatol 2020; 18: 2903-2911. Full text: Efficacy of Therapy for Eosinophilic Esophagitis in Real-World Practice) highlights the disconnect between clinical practice and outcomes.

  • Methods: This study relied on the multicenter EoE CONNECT database—with 589 patients.
    • Clinical remission was < 50% in Dysphagia Symptom Score; any improvement in symptoms = clinical response.
    • Histologic remission was eosinophil count below 5 eosinophils/hpf; 5-14/hpf = histologic response.

Key findings:

  • Topical steroids were most effective in inducing histologic remission: 54.8% compared to 36.1% for PPIs and 18.5% for empiric elimination diet; histologic remission and response was 67.7%, 49.7%, and 48.1% respectively.
  • Topical steroids were most effective in inducing clinical and histologic remission or response (in 67.7% of patients), followed by empiric elimination diets (in 52.0%), and PPIs (in 50.2%).
  • However, PPIs were the first-line treatment for 76.4% of patients, followed by topical steroids (for 10.5%) and elimination diets (for 7.8%).

My take: This data (and others) indicate that topical steroids are most effective pharmacologic therapy; at some point, I expect that they will become the most frequently used.

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“Layering two less specialized masks on top of each other can provide comparable protection [to N95]. Dr. Marr recommended wearing face-hugging cloth masks over surgical masks, which tend to be made with more filter-friendly materials but fit more loosely. An alternative is to wear a cloth mask with a pocket that can be stuffed with filter material, like the kind found in vacuum bags.”

Unrelated from NY Times: One Mask Is Good. Would Two Be Better? (Yes)

How Effective Are PPIs for Eosinophilic Esophagitis?

Emilio J. Laserna‐Mendieta et al. AP&T 2020; https://doi.org/10.1111/apt.15957.  Full article link: Efficacy of proton pump inhibitor therapy for eosinophilic oesophagitis in 630 patients: results from the EoE connect registry

“This cross‐sectional study collected data on PPI efficacy from the multicentre EoE CONNECT database.” Overall, 630 patients (76 children) received PPI as initial therapy (n = 600) or after failure to respond to other therapies (n = 30)

Key findings:

  • PPI therapy achieved eosinophil density below 15 eosinophils per high‐power field in 48.8% and a decreased symptom score ≥50% from baseline in 71.0% of patients.
  • More EoE patients with an inflammatory rather than stricturing phenotype accomplished clinico‐histological remission after PPI therapy (OR 3.7; 95% CI, 1.4‐9.5)
  • PPI treatment is more effective in achieving clinico‐histological remission of the disease when used in higher instead of standard or lower doses (50.8% vs 35.8%), and when the duration of therapy is prolonged from 8 to 12 weeks (50.4% vs. 65.2%)

My take: This study confirms previous studies which have generally found that PPIs are effective in 40-50% of patients with eosinophilic esophagitis.  Higher doses of PPIs are needed to achieve the highest response rates.

“Bar chart for histological (A) and symptomatic (B) responses for proton pump inhibitor (PPI) mono‐therapy to induce and maintain remission in patients with eosinophilic oesophagitis. For induction of remission, patients were classified according to the PPI dosage prescribed: high dose was double dosage or higher, and low dose was standard dosage or lower. For maintenance therapy, only patients with dosage reduction from that used for induction were included. eos/hpf: eosinophils per high power field”

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Favorable “Break”through Data for Proton Pump Inhibitors and Bone Density

Franklin Roosevelt’s secretary of state, Cordell Hull, wrote: “A lie will gallop halfway round the world before the truth has time to pull its breeches on.”

This saying came to my mind as I read a recent study (KE Hansen et al. Gastroenterol 2019; 156: 926-34) titled: “Dexlansoprazole and esomeprazole do not affect bone homeostasis in healthy postmenopausal women.”

In this study, the authors performed a prospective double-blind study with 115 healthy postmenopausal women who were treated with one of these two PPIs or placebo daily for 26 weeks.

Key findings:

  • PPI therapy did not reduce true fractional calcium absorption
  • There were no significant difference between groups in serum or urine levels of minerals, bone mineral density, or parathyroid hormone

Previous studies have found conflicting results of PPIs on bone density.  Studies suggesting that PPIs could affect bone density have been questioned due to “low odds ratios (<2), lack of dose response, biological implausibility, and uncontrolled potential confounders.”  The authors note that they chose bone turnover rather than changes in BMD as a primary outcome as bone turnover precede changes in BMD and should serve as an early marker of adverse effects.

My take: This study, while short in duration and with limited numbers of participants found no harmful effects of PPIs on skeletal health.

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Tajo River, Toledo Spain

Association and Causation: Early Life Risk Factors for Eosinophilic Esophagitis

A recent case-control study (CP Witmer et al. JPGN 2018; 610-5) using the Military Health System Database examined 1410 cases of eosinophilic esophagitis (EoE) and matched them with 2820 controls; the study period was 2008-2015.

  • The authors found that early exposure to proton pump inhibitors (PPIs), histamine-2 receptors (H2RAs), and antibiotics were all associated with an increased risk of developing EoE with adjusted odds ratios of 2.73, 1.64, and 1.31.
  • In addition, among atopic problems, milk protein allergy had an adjusted odds ratio of 2.37 and eczema 1.97. –for developing EoE.

My take: This study does not determine whether the use of PPIs, H2RAs or antibiotics are involved in causation of EoE or whether patients with EoE simply receive these medications more frequently.  Nevertheless, the findings reinforce the idea that these medications should be used less frequently in infants.

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Somewhere near Banff

PPIs NOT Linked to Cognitive Decline/Dementia & PPIs NOT Linked to Heart Attacks

In a prospective study (M Wod et al. Clin Gastroenterol Hepatol 2018; 16: 681-89), data on middle-aged (n=2346, 46-67 yrs) and older individuals (n=2475) were collected in the Longitudinal Study of Aging Danish Twins.  This study showed that there was no difference in cognitive decline between PPI users and non-users.

The second study (SN Landi et al. Gastroenterol 2018; 154: 861-73) used a large administrative database and reviewed more than 5 million new  users of prescription PPIs and prescription H2RAs.  The authors found no significant difference in myocardial infarctions (MIs) between PPIs and H2RAs over a 12 month period.

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Last Year’s Most Popular Posts

I want to thank the many people who have helped me with this blog –now with 2180 posts over more than 6 years.  This includes my wife, my colleagues at GICareforKids, and colleagues from across the country who have provided critical feedback as well as useful publications to review.  I hope this blog continues to be a useful resource.

Here are the top dozen most popular blog posts from 2017: