Alimentary Pharmacology and Therapeutics Invited Commentaries Patients treated with at least 6 weeks of twice-daily PPI were included.1 It is possible that some of the EOE patients may require a longer duration of treatment (up to 3 months), before full response to PPI could be achieved. In addition, comparison with nontreated EOE patients could have helped to determine the contribution of the natural course of the disease to fluctuations in oesophageal eosinophilic count. The main finding of the study is that, with the exception of a response to PPI treatment, there are no other unique characteristics that can identify the PPI-responsive oesophageal eosinophilia group. Consequently, the PPI test, which was found to have a diagnostic value in gastroesophageal reflux disease and noncardiac chest pain, may also have a pivotal role in EOE.5, 6 Future studies should look into the role of the PPI test in this challenging patient population.
ACKNOWLEDGEMENT Declaration of personal and funding interests: None.
Commentary: the proton pump inhibitor test – does it have a role in eosinophilic oesophagitis? Authors’ reply F. J. Moawad* & A. M. Schoepfer† *Gastroenterology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA. † Department of Gastroenterology, University of Lausanne, Lausanne, Switzerland. E-mail: [email protected] doi:10.1111/apt.12676
We thank Drs Fass and Maradey-Romero for their interest in our paper.1 To address their first comment,2 the sample size of our study was relatively small because we focused on cases of oesophageal eosinophilia diagnosed since the publication of the 2011 consensus statement, in which proton pump inhibitor responsive oesophageal eosinophilia (PPI-REE) was formally recognised.3 Our study was retrospective in design; however, the data from both study sites were obtained from clinical databases, which are carefully maintained by the authors who prospectively enrol and collect data on patients with eosinophilic oesophagitis (EoE) and PPI-REE. Additionally, all enrolled patients complete one or more clinical questionnaires at index endoscopy and during follow-up visits. Aliment Pharmacol Ther 2014; 39: 894-898 ª 2014 John Wiley & Sons Ltd
REFERENCES 1. Moawad FJ, Schoepfer AM, Safroneeva E, et al. Eosinophilic oesophagitis and proton pump inhibitor-responsive oesophageal eosinophilia have similar clinical, endoscopic and histological findings. Aliment Pharmacol Ther 2014; 39: 603–8. 2. Desai TK, Stecevic V, Chang CH, Goldstein NS, Badizadegan K, Furuta GT. Association of eosinophilic inflammation with esophageal food impaction in adults. Gastrointest Endosc 2005; 61: 795–801. 3. Moawad FJ, Veerappan GR, Dias JA, Baker TP, Maydonovitch CL, Wong RD. Randomized controlled trial comparing aerosolized swallowed fluticasone to esomeprazole for esophageal eosinophilia. Am J Gastroenterol 2013; 108: 366–72. 4. Molina-Infante J, Ferrando-Lamana L, Ripoll C, et al. Esophageal eosinophilic infiltration responds to proton pump inhibition in most adults. Clin Gastroenterol Hepatol 2011; 9: 110–7. 5. Fass R, Fennerty MB, Ofman JJ, et al. The clinical and economic value of a short course of omeprazole in patients with noncardiac chest pain. Gastroenterology 1998; 115: 42–9. 6. Fass R, Ofman JJ, Gralnek IM, et al. Clinical and economic assessment of the omeprazole test in patients with symptoms suggestive of gastroesophageal reflux disease. Arch Intern Med 1999; 159: 216–8.
Treatment goals in EoE include both clinical improvement and reducing oesophageal inflammation. Drs Fass and Maradey-Romero raise a valid point on whether duration and dosage of PPI may alter histological response. Indeed, we have observed that some patients with suspected EoE who respond clinically to a PPI, yet continue to demonstrate eosinophilia on endoscopy at 8 weeks, may achieve histological resolution on repeat endoscopy at 1 year with maintenance PPI. A similar concept is observed in patients with inflammatory bowel disease and coeliac disease, where improvement in clinical symptoms often precedes endoscopic and histological change. However, in cases where clinical symptoms persist after 6 to 8 weeks, we do not believe that a longer duration of PPI (e.g. 3 months) will change their clinical course. In the setting of persistent symptoms and eosinophilia, these patients are diagnosed with EoE and require an alternate form of therapy, such as topical steroids or specialised diets. We agree with the comment that the ‘PPI test’ has a role in EoE. However, in the classic sense, this test is based on symptom response alone. On the other hand, EoE cannot be diagnosed clinically; it requires histological confirmation.3 The use of PPI is not only a necessary step in differentiating EoE from PPI-REE, but also up to
897
Invited Commentaries 50% of patients with oesophageal eosinophilia, to include those with an EoE phenotype,4–6 respond to PPI and obviate the need for steroids and dietary therapy.
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.1 REFERENCES 1. Moawad FJ, Schoepfer AM, Safroneeva E, et al. Eosinophilic oesophagitis and proton pump inhibitor-responsive oesophageal eosinophilia have similar clinical, endoscopic and histological findings. Aliment Pharmacol Ther 2014; 39: 603–8.
898
2. Fass R, Maradey-Romero C. Commentary: the proton pump inhibitor test – does it have a role in eosinophilic oesophagitis? Aliment Pharmacol Ther 2014; 39: 896–7. 3. Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011; 128: e6. 4. Moawad FJ, Veerappan GR, Dias JA, Baker TP, Maydonovitch CL, Wong RK. Randomized controlled trial comparing aerosolized swallowed fluticasone to esomeprazole for esophageal eosinophilia. Am J Gastroenterol 2013; 108: 366–72. 5. Molina-Infante J, Ferrando-Lamana L, Ripoll C, et al. Esophageal eosinophilic infiltration responds to proton pump inhibition in most adults. Clin Gastroenterol Hepatol 2011; 9: 110–7. 6. Dellon ES, Speck O, Woodward K, et al. Clinical and Endoscopic Characteristics do Not Reliably Differentiate PPI-Responsive Esophageal Eosinophilia and Eosinophilic Esophagitis in Patients Undergoing Upper Endoscopy: a Prospective Cohort Study. Am J Gastroenterol 2013; 108: 1854–60.
Aliment Pharmacol Ther 2014; 39: 894-898 ª 2014 John Wiley & Sons Ltd
ACKNOWLEDGEMENT Declaration of personal and funding interests: None.
Commentary: the proton pump inhibitor test – does it have a role in eosinophilic oesophagitis? Authors’ reply F. J. Moawad* & A. M. Schoepfer† *Gastroenterology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA. † Department of Gastroenterology, University of Lausanne, Lausanne, Switzerland. E-mail: [email protected] doi:10.1111/apt.12676
We thank Drs Fass and Maradey-Romero for their interest in our paper.1 To address their first comment,2 the sample size of our study was relatively small because we focused on cases of oesophageal eosinophilia diagnosed since the publication of the 2011 consensus statement, in which proton pump inhibitor responsive oesophageal eosinophilia (PPI-REE) was formally recognised.3 Our study was retrospective in design; however, the data from both study sites were obtained from clinical databases, which are carefully maintained by the authors who prospectively enrol and collect data on patients with eosinophilic oesophagitis (EoE) and PPI-REE. Additionally, all enrolled patients complete one or more clinical questionnaires at index endoscopy and during follow-up visits. Aliment Pharmacol Ther 2014; 39: 894-898 ª 2014 John Wiley & Sons Ltd
REFERENCES 1. Moawad FJ, Schoepfer AM, Safroneeva E, et al. Eosinophilic oesophagitis and proton pump inhibitor-responsive oesophageal eosinophilia have similar clinical, endoscopic and histological findings. Aliment Pharmacol Ther 2014; 39: 603–8. 2. Desai TK, Stecevic V, Chang CH, Goldstein NS, Badizadegan K, Furuta GT. Association of eosinophilic inflammation with esophageal food impaction in adults. Gastrointest Endosc 2005; 61: 795–801. 3. Moawad FJ, Veerappan GR, Dias JA, Baker TP, Maydonovitch CL, Wong RD. Randomized controlled trial comparing aerosolized swallowed fluticasone to esomeprazole for esophageal eosinophilia. Am J Gastroenterol 2013; 108: 366–72. 4. Molina-Infante J, Ferrando-Lamana L, Ripoll C, et al. Esophageal eosinophilic infiltration responds to proton pump inhibition in most adults. Clin Gastroenterol Hepatol 2011; 9: 110–7. 5. Fass R, Fennerty MB, Ofman JJ, et al. The clinical and economic value of a short course of omeprazole in patients with noncardiac chest pain. Gastroenterology 1998; 115: 42–9. 6. Fass R, Ofman JJ, Gralnek IM, et al. Clinical and economic assessment of the omeprazole test in patients with symptoms suggestive of gastroesophageal reflux disease. Arch Intern Med 1999; 159: 216–8.
Treatment goals in EoE include both clinical improvement and reducing oesophageal inflammation. Drs Fass and Maradey-Romero raise a valid point on whether duration and dosage of PPI may alter histological response. Indeed, we have observed that some patients with suspected EoE who respond clinically to a PPI, yet continue to demonstrate eosinophilia on endoscopy at 8 weeks, may achieve histological resolution on repeat endoscopy at 1 year with maintenance PPI. A similar concept is observed in patients with inflammatory bowel disease and coeliac disease, where improvement in clinical symptoms often precedes endoscopic and histological change. However, in cases where clinical symptoms persist after 6 to 8 weeks, we do not believe that a longer duration of PPI (e.g. 3 months) will change their clinical course. In the setting of persistent symptoms and eosinophilia, these patients are diagnosed with EoE and require an alternate form of therapy, such as topical steroids or specialised diets. We agree with the comment that the ‘PPI test’ has a role in EoE. However, in the classic sense, this test is based on symptom response alone. On the other hand, EoE cannot be diagnosed clinically; it requires histological confirmation.3 The use of PPI is not only a necessary step in differentiating EoE from PPI-REE, but also up to
897
Invited Commentaries 50% of patients with oesophageal eosinophilia, to include those with an EoE phenotype,4–6 respond to PPI and obviate the need for steroids and dietary therapy.
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.1 REFERENCES 1. Moawad FJ, Schoepfer AM, Safroneeva E, et al. Eosinophilic oesophagitis and proton pump inhibitor-responsive oesophageal eosinophilia have similar clinical, endoscopic and histological findings. Aliment Pharmacol Ther 2014; 39: 603–8.
898
2. Fass R, Maradey-Romero C. Commentary: the proton pump inhibitor test – does it have a role in eosinophilic oesophagitis? Aliment Pharmacol Ther 2014; 39: 896–7. 3. Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011; 128: e6. 4. Moawad FJ, Veerappan GR, Dias JA, Baker TP, Maydonovitch CL, Wong RK. Randomized controlled trial comparing aerosolized swallowed fluticasone to esomeprazole for esophageal eosinophilia. Am J Gastroenterol 2013; 108: 366–72. 5. Molina-Infante J, Ferrando-Lamana L, Ripoll C, et al. Esophageal eosinophilic infiltration responds to proton pump inhibition in most adults. Clin Gastroenterol Hepatol 2011; 9: 110–7. 6. Dellon ES, Speck O, Woodward K, et al. Clinical and Endoscopic Characteristics do Not Reliably Differentiate PPI-Responsive Esophageal Eosinophilia and Eosinophilic Esophagitis in Patients Undergoing Upper Endoscopy: a Prospective Cohort Study. Am J Gastroenterol 2013; 108: 1854–60.
Aliment Pharmacol Ther 2014; 39: 894-898 ª 2014 John Wiley & Sons Ltd
