Abstract
Introduction: At least one third of patients with clinical, endoscopic and histological findings suggestive of eosinophilic esophagitis (EoE) achieve clinicopathologic remission after proton pump inhibitor (PPI) therapy. This new condition is termed PPI-responsive esophageal eosinophilia (PPI-REE). The durability and long-term efficacy of PPI therapy for these patients is unknown. Methods: Observational study in a cohort of adult patients with PPI-REE, defined by baseline symptoms of esophageal dysfunction (dysphagia/food impaction) and esophageal eosinophilia (> 15 eos/HPF), both resolved (clinical remission and < 15 eos/ HPF) after a course of PPI therapy for at least 8 weeks. PPI dosage was defined as: quadruple (e.g. omeprazole 40 mg bid or its equivalent), double (omeprazole 40 mg/day) and single (omeprazole 20mg/day). After initial PPI response, acid suppressive therapywas progressively tapered based on clinical symptoms and maintained at the lowest dose with the target endpoint of clinical remission. Follow-up endoscopy was performed at 12 months or longer on PPI maintenance dose with histologic examination of both the distal and proximal esophagus. Results: 40 PPI-REE patients have been included to date with a median followup time of 27 months (12-79). Baseline characteristics: 88% males, median age 39 yearsold (19-71), heartburn and/or regurgitation (49%), reflux esophagitis (14%), pH monitoring in 7 patients (4 normal/3 pathological). PPI dosage in the initial PPI trial for diagnosing PPI-REE was quadruple-dose in 18 patients and double-dose in 22 patients. Regarding the step-down process, 19 patients were maintained on double-dose PPI and 21 on single-dose PPI. Overall, 26 out of 40 (63%) maintained clinical and histologic (< 15 eos/HPF) remission during follow-up. Among the 14 relapsers, 8 occurred on double-dose and 6 on single-dose PPI. In 10/14 of the relapsers, esophageal eosinophilia recurred exclusively at the distal esophagus, but not at proximal esophagus. Intensification to quadruple-dose PPI was carried out in 8 out of these 10 distal relapsers, all of whom achieved clinical and histological remission. Conclusions: Sustained clinico-histological remission on low-dose maintenance PPI therapy was observed in 64% of adult PPI-REE patients. A majority of relapsers showed recurrent eosinophilic inflammation limited to the distal esophagus, which resolved after PPI-dose intensification. It is rare for adult PPI-REE patients to fully lose PPI response and be reclassified as EoE.
Published Version
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