The role of proton pump inhibitor therapy in the management of eosinophilic esophagitis

Abstract

Eosinophilic esophagitis (EoE) is a chronic esophageal disease characterized by a Th2 inflammatory response triggered by food/environmental allergens. Solid data confirm that up to half of patients with suspected EoE achieve complete remission on proton pump inhibitors (PPI) therapy. This disease phenotype is currently labelled as PPI-responsive esophageal eosinophilia (PPI-REE). Albeit initially believed to represent gastro-esophageal reflux disease (GERD), evolving evidence has underscored that PPI-REE and EoE show a significant overlap regarding clinic, endoscopic, histologic, Th2 immune-mediated inflammation and gene expression features. Moreover, PPI therapy can effectively reverse Th2 inflammation and the EoE transcriptome expression in PPI-REE patients. Therefore, EoE and PPI-REE likely represent a common allergic disorder, where PPI therapy should be considered a short- and long-term therapeutic asset, along with diet and topical steroids.

New developments in patients with eosinophilic gastrointestinal diseases presented at the CEGIR/TIGERS Symposium at the 2018 American Academy of Allergy, Asthma & Immunology Meeting

“…There is still controversy surrounding the entity and extent to which it overlaps with or is a subtype of EoE. 20,21 Clinically, a number of conditions can cause esophageal eosinophilia. However, when patients present with typical symptoms of esophageal dysfunction, atopy, endoscopic findings suggestive of EoE and biopsy specimens with marked esophageal eosinophilia, they appear to have EoE.…”

ALOX15 Immunohistochemistry Aids in the Diagnosis of Eosinophilic Esophagitis on Pauci-eosinophilic Biopsies in Children

“…This category is being increasingly recognized in the medical community as a group of patients with overlapping features of GERD and EoE. 2,20,21 A prospective study of patients within this clinical category would be necessary to establish whether ALOX15 IHC could be used to predict the likelihood of that patient to respond favorably to antireflux therapy or to antigen elimination/topical steroids treatment.…”

“…Since these cases were clinically classified as GERD based on their response to therapy with PPI and the lack of sufficient eosinophilia in their esophageal biopsies, it is likely that they belong to the so-called group of “PPI responsive esophageal eosinophilia.” This category is being increasingly recognized in the medical community as a group of patients with overlapping features of GERD and EoE. 2,20,21 A prospective study of patients within this clinical category would be necessary to establish whether ALOX15 IHC could be used to predict the likelihood of that patient to respond favorably to antireflux therapy or to antigen elimination/topical steroids treatment.…”

New Developments in the Diagnosis and Treatment of Eosinophilic Esophagitis

“…A recent meta-analysis of 33 studies, comprising 619 patients with symptomatic esophageal eosinophilia, demonstrated that PPI therapy induced clinical response and histologic remission in 60.8% and 50.5% of patients, respectively [91]. On PPI maintenance, sustained remission has been observed in 73-86% of pediatric and adult PPI-REE patients [92]. Low-dose PPI maintenance with esomeprazole at 1 mg/kg (maximum of 40 mg) daily dosing in 57 EoE children, who responded initially to an 8-week esomeprazole trial at 1 mg/kg dose (maximum of 40 mg) twice daily, achieved clinical response in 86% and histologic remission in 70.1% of these children at 1 year with an adequate safety profile [93].…”