S357 Esophageal Lichen Planus: The Efficacy and Safety of Tacrolimus in Reducing Inflammation and Need for Dilation

Abstract

Introduction: Esophageal Lichen Planus (ELP) is a rare inflammatory disease most commonly seen in middle-aged white women. It manifests with sloughing mucosa, thick white exudate, and proximal strictures. Most case reports and small series highlight the use of steroids, which are not preferred long-term. Other immunosuppressants have been reported with variable results. To our knowledge, oral tablet tacrolimus has not been studied. Our aim was to assess the change in ELP (inflammation, stricture, and disease extent) after treatment with oral tacrolimus. Methods: This was a retrospective cohort study. Consecutive adults with a confirmed diagnosis of ELP who underwent EGD by 2 esophagologists between 01/2011-07/2020 were eligible. Inflammation and fibrostenotic disease were graded using the ELP Severity Score, which we developed (Table). Difference in ELPSS across groups was assessed using Mann-Whitney U test and for categorical variables using the Fisher exact test. Time-to-recovery was assessed using the log-rank test. Statistical significance was 5% for all comparisons. Results: Twenty-2 patients underwent more than one EGD and were included in the study. Half (11) received tacrolimus (dose 1-2 mg BID) and half (11) received other therapy (i.e. cyclosporine, topical steroids, or none). There were no statistically significant differences in baseline characteristics between the groups (Tac and No-Tac). In the Tac group, mean age was 63, BMI 26, and 100% were female. The No-Tac group had mean age of 73, BMI 24, and 72% female. Extraesophageal manifestations in Tac and No-Tac were oral (100% vs 82%), anogenital (63% vs 27%), and skin (36% vs 9%). Most common symptom was dysphagia (100% both groups) followed by weight loss (27% both groups). Mean ELPSS on first EGD was similar between groups with 5.8 points (±1.8) for Tac and 5.9 points (±1.9) for No-Tac (P=0.9). Among patients on Tac vs No-Tac, there was a statistically significant improvement in ELPSS (mean difference 1.8 pts; 95% CI 0.25-3.38; P=0.02). Response rate was 89% with Tac vs 30% with No-Tac (P=0.025). See Figures 1A and 1B. All 22 patients underwent bougie dilation safely with a mean diameter of 16 mm achieved. Patients on Tac also required less frequent dilation compared to No-Tac. Conclusion: The use of oral tablet tacrolimus reduced the inflammatory and fibrostenotic components of ELP. Thus, utilizing low-dose oral tacrolimus (50-75% less than transplant dosages) is safe and should be considered in patients with severe disease.Figure 1.: Left image (A) shows the change in ELP Severity Score (ELPSS) between the 2 groups. Right image (B) represents the time-to-event function of the 2 groups.Table 1.: ELP Severity Score. Score range: 1-10. Interpretation: Mild (1-2), Moderate (3-4), Moderate-Severe (5-6), Severe (7-10). Superscripts: 1. Sloughing or peeling is spontaneous or with passage of scope only - not following dilatation. 2. Exudate classification: Mild describes scattered punctate exudates. Moderate disease shows short serpiginous plaques. Severe describes long, thick, serpiginous plaques. 3. ‘Multiple narrowing’ suggests strictures or general narrowing involving more than one location in esophagus.