Real-world data show efficacy of PPIs in EoE
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Patients with eosinophilic esophagitis achieved clinical and histological remission after undergoing treatment with proton pump inhibitors, according to study results.
Emilio J. Laserna-Mendieta, of the department of gastroenterology at Hospital General de Tomelloso in Spain, and colleagues wrote that PPIs are frequently used in EoE, but a lot about their efficacy in that setting is still unclear.
“Many of the aspects related to the efficacy of PPIs in EoE are still unknown, largely because all the evidence to date has been provided by observational studies, generally involving small numbers of patients,” they wrote. “Through an analysis of EoE CONNECT, the largest multicenter registry of patients with EoE, this study aims to provide data on the efficacy of PPI treatment for EoE in actual clinical practice, and to help clarify some of the questions that remain regarding this anti-inflammatory treatment approach.”
Researchers analyzed data from the EoE CONNECT database to determined which factors were associated with the effectiveness of PPIs in EoE. They defined clinical remission as a decrease of at least 50% in dysphagia symptom score and histological remission as a peak eosinophil count below 15 eosinophils per high-powered field.
Among 630 patients who received PPIs either as an initial therapy or after failing another treatment, 48.8% achieved histological remission and 71% achieved clinical remission.
More patients with an inflammatory phenotype achieve clinico-histological remission compared with those with a stricturing phenotype (OR = 3.7; 95% CI, 1.4-9.5). Patients who received PPIs for between 71 and 90 days also had higher chances of achieving clinico-histological remission than patients who received between 56 and 70 days of treatment (OR = 2.7; 95% CI, 1.3-5.3).
Among patients who achieved clinico-histological remission, 69.9% were able to effectively maintain PPI dosage reduction, but it was less effective among patients with a stricturing phenotype.
“We provide evidence that high PPI doses are an effective anti-inflammatory therapy that achieves histological and clinical remission in half of the patients with EoE, with around 70% of responding patients being able to maintain long term remission after dose reduction,” Laserna-Mendieta and colleagues wrote. “All PPI drugs were similarly effective, with high doses used for 10-12 weeks providing the highest benefit for induction of remission.”
Perspective
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Scott Gabbard, MD
This interesting study, with use of a large registry, addresses a few important aspects of use of PPIs in treatment of eosinophilic esophagitis. The article makes several relevant points for the practicing clinician. The three major therapies we have in 2020 are PPIs, topical corticosteroids, and diet therapy. PPIs have been shown to be an effective therapy for use in treatment of the inflammatory component of eosinophilic esophagitis, and this study provides more evidence for use of PPIs as a potential therapy.
In this study, about half of patients on PPIs were able to achieve remission. It should be noted that higher doses of PPIs (40mg and above) worked better than doses less than 40 mg, and the data suggested that extending the use of PPIs to 12 weeks rather than 8 weeks did result in more remission. However, the authors found that PPIs did not work as well in patients with stricturing disease. Patients who have strictures may require alternative therapies, such as topical corticosteroids, or combination therapy of corticosteroids, PPI, and/or diet.
We need to clearly discuss with our patients the risk vs. benefit of all of these therapies – topical corticosteroids, PPIs, and diet – because there are clear pros and cons for each of those therapies. We use PPIs very commonly to treat eosinophilic esophagitis, and certainly that disorder is one of the clear clinical indications for a patient to be on long-term PPI therapy. Today, especially with concerns of PPI side effects, physicians are looking at PPI use, particularly in patients who are prescribed PPIs for inappropriate indications. But, EoE is one condition where there's a clear indication for PPI use. This article strengthens that stance.
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