title: PPI Trial for Eosinophilic Esophagitis: Chaos in the Community.
abstract: Despite consensus eosinophilic esophagitis (EoE) statement published in 2011 calling for a 2-month trial of protons pump inhibitor (PPI), the guidelines are not followed by many. We studied the practice patterns in our community and response to a PPI retrial in patients previously diagnosed with "idiopathic EoE."
  
  
  
  All patients presenting to the senior author's practice with suspected EoE from 2011 to 2015. Two cohorts were studied: (1) patients diagnosed in the community as "idiopathic EoE"; (2) treatment naïve patients given a PPI trial at University of South Florida. PPI responsive eosinophilia was defined after 2 months of high dose PPIs after initial diagnosis of mucosal eosinophilia and histologic response of <15 eosinophils per HPF. SPSS v19.0 was used to calculate mean difference and odds ratios (OR) and 95% confidence intervals.
  
  
  
  In total, 78 patients met inclusion criteria, 46 patients had outside diagnosis of "idiopathic EoE," and 41 patients received a PPI trial at University of South Florida. In total, 34/46 (73.9%) community patients were placed on a PPI, 3/46 (6.5%) were placed on elimination diets, 31/46 (67.4%) steroids, and 21/46 (45.7%) were treated with both steroids/PPIs. Fewer patients received PPI trials in the community 3/46 (6.5%) versus 26/34 (76.5%) at our center [OR, 46.6 (95% CI, 11.3-191.5); P<0.0001]. In total, 12/26 (46.2%) were PPI responders on our retrial despite previously being diagnosed with idiopathic EoE. The group initially diagnosed at our center had a higher PPI response rate 12/15 (80%) versus 12/26 (46.2%) in the community group [OR, 7.58 (1.42, 40.55; P=0.018)].
  
  
  
  The importance of a PPI trial is misunderstood and may be confused with the more traditional PPI trial for gastroesophageal reflux disease. This algorithm is critical and should be done before empiric steroids/diet therapies.
authors.affiliation: Division of Digestive Diseases and Nutrition.
authors.forename: Seth
authors.initials: S
authors.lastname: Lipka
authors.affiliation: Department of Medicine, Division of Evidence Based Medicine and Outcomes Research.
authors.forename: Ambuj
authors.initials: A
authors.lastname: Kumar
authors.affiliation: Department of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL.
authors.forename: Joel E
authors.initials: JE
authors.lastname: Richter
mesh_terms: D000465:Algorithms; D003153:Community Health Services / Q000592:standards; D019091:Critical Pathways; D003938:Diagnostic Techniques, Digestive System / Q000592:standards; D057765:Eosinophilic Esophagitis / Q000175:diagnosis / Q000188:drug therapy*; D005431:Florida; D000072102:Gastroenterologists / Q000592:standards; D019983:Guideline Adherence; D006801:Humans; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards; D011237:Predictive Value of Tests; D054328:Proton Pump Inhibitors / Q000627:therapeutic use*; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D054328:Proton Pump Inhibitors