Proton Pump Inhibitor Therapy in Eosinophilic Esophagitis: Predictors of Nonresponse
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ORIGINAL ARTICLE
Proton Pump Inhibitor Therapy in Eosinophilic Esophagitis: Predictors of Nonresponse Ryan Alexander1 · Jeffrey A. Alexander1 · Joseph Akambase1 · William Scott Harmsen2 · Debra Geno1 · Crystal Tholen1 · David A. Katzka1 · Karthik Ravi1 Received: 14 July 2020 / Accepted: 20 September 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Background Identification of clinical predictors of response to first-line therapies for EoE is needed to guide initial medical management. Study Design A retrospective analysis of patients diagnosed with EoE from 2011 to 2018 was conducted. Clinical and diagnostic variables including demographics, endoscopic, and esophagram findings were compared between PPI responders and PPI nonresponders. All patients underwent a standard 8-week twice-daily PPI trial, with PPI responsiveness defined as 460 per m m3 as predictive thresholds for PPI-NR. The probability of PPI-NR was 72.4–84.5% with 1 risk factor, 87.9–93.8% with 2 risk factors, and 97.2% with all 3 risk factors. Conclusions Young age, reduced BMI, elevated peripheral eosinophil count, and likely inability to pass an endoscope predict lack of response to PPIs in patients with EoE. Keywords Eosinophilic esophagitis · Proton pump inhibitor · Risk factor · Age · Body mass index · Peripheral eosinophil count
Introduction Eosinophilic esophagitis (EoE) is an antigen or immunedriven clinicopathological condition characterized by symptoms of esophageal dysfunction and ≥ 15 eosinophils per high-power field (eos/hpf) on esophageal biopsy. While initial clinical guidelines defined EoE through a lack of proton pump inhibitor (PPI) response [1, 2], recent studies have * Karthik Ravi [email protected] 1
Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
2
identified a more complex relationship between PPI efficacy and EoE [3–12]. The United European Gastroenterology and the American Gastroenterology Association practice guidelines on EoE now recognize PPI responsive esophageal eosinophilia as a spectrum within rather than a distinct entity from EoE [13, 14]. Consequently, PPIs are recommended as one of three potential first-line medical treatments for EoE, alongside topical steroids and diet elimination therapy. However, each of these medical options has different advantages and disadvantages, necessitating an individualized treatment approach. For example, topical steroids have a 60–95% rate of efficacy but are not FDA approved, can be expensive, and are dependent on an optimized but more challenging to use delivery system [15–18]. There are also short-term risks such as candida esophagitis and theoretical long-term risks such as osteoporosis and adrenal insufficiency [19–21].
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Diet therapy avoids the risk of pharmacologic therapy but poses compliance issues and the risks an
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