We have some questions pouring in from the Q&A, so I just want to get to that for a little bit. We can come back to some of these discussion points as well, but I want to fit in some of these questions from the audience. There have been a couple that I want to pose to the panel in regards to whether or not you taper down. So after that eight-week course, does the panel typically stop altogether or taper down to once a day? And in this case, there was an endoscopy done, but does the panel always repeat the endoscopy after that first course? So this is scoping a lot, I mean, it is my opinion, but he's the hard one, or one of the harder ones, and one of the more difficult ones. It's ideal to be able to endoscope people every eight to 12 weeks, but the practicality really makes it, to be perfectly honest, a case-by-case decision for me. I think every time you make a major change, you should scope them once. I'm not a big steroid wheel, so I'm not sure if that's a good way to put it. Lonnie, I can say it's a great, and it's a key question. Somebody interrupt me? I, any time, oh, I'm sorry, Phil. Go ahead, David. I'm done. Thank you. Any time I change the doses of a patient, I do endoscope. I do try to taper, although I'm not aggressive on tapering. So for someone on twice-daily budesonide, I try to get them down to the nighttime dose. Someone on twice-daily PPI, I try to get them down to one dose a day. We fully know with PPIs, you'll lose about 30% of the response when you decrease the dose. Whether it's true of budesonide, I'm not so sure. But particularly in young patients where they're facing so many years of disease, I want to know it works. I don't want to guess, because we know from the studies that symptoms have such poor correlation with histology. So unfortunately, we can't rely on that at all. And as Shivangi nicely pointed out, dilation is a very effective therapy, but of course, it doesn't treat histology. So I'm rather aggressive in scoping patients any time I make a change to see if it's working. Right. I agree. I do the same. I'd scope after a major change in therapy. Try to get them to the least effective dose that holds them together and make sure that they're maintaining their remission on that dose. So a number of questions have come in on where PPIs now fit in into this regimen. If someone's not responding, do you add them, do you start with them, do you keep them on them? How do you interpret the eosinophilia if they're not on PPIs? I would say for just, and we all have our opinions, and maybe they're all the same. I don't know. It's so hard to say. I would say in the past, treatment used to be doing a test. We start now with PPIs. And so that really is, in general, more often, at least in my practice, a start, unless there are specific, people are able to identify specific allergies, obviously, which is rarer in an adult, right? It's just rare to find. But if they were able to identify those for us, we would, of course, start with that as a treatment, potentially. It also has to do, though, with stricturing. I mean, based upon the severity of symptoms also dictates how much you need to add on at the beginning. But we often will start with PPIs at the beginning. And then, like I asked, if the patient's on it, and they're on BID dosing, then we, at a point in time, stop, because we recognize this is not being effective. So if he'd been on BID, PPI, and taking it at that point in time, then we might, at that point in time, recognize we need to go on for something more. We need to move on in our treatment. So I agree with Felice. I think the definition, though, of using PPI in the diagnosis of EOE has kind of been in the flux, right? So we do it differently compared to how Europeans do it. But I think, in general, the consensus has been that PPI is just not rule out. It's more like falls in the therapeutic category as well. So the first line would be PPI, regardless. And depending on severity, you can add butycinide or food elimination, whatever the patient would prefer. And another question from the audience, does the presence of a stricture in EOE alter your treatment recommendations, is what you might consider, for example, steroids versus diet? Or how about dilation? Dilation. David. Thank you, Phil. So I agree with what Felice and Sravanti said as far as the PPIs, although they're all first line therapies, and that's in the agreed guidelines. Having said that, I think there are some situations where I try to individualize the beginning therapy. So, for example, as you just mentioned, if a patient comes in with a critical stricture or small caliber esophagus or repeated food impactions, this is someone who I want to get into remission as soon as possible. So I will start that patient on steroids. Sometimes even steroids and PPIs if they're severely symptomatic, and then I'll worry later on what's going to be their more or less sustained therapy. The second issue is that even if, although I offer diet therapy up front as well, my style, I have no data to back this up like most things I do in medicine, is I still use PPIs or steroids first. And the reason I do that is because I want to try to find a medical that works so I have an ace in the hole. So if it's three months down the line and the diet's not working and this patient's getting worse and worse, I know something I can use to get them into remission immediately. Or they're on diet therapy and they want to eat at every four-star restaurant in Paris and go off the diet, I know what to put them on when they go to Paris. So although I think diet therapy is very good for these people, my style, particularly if they have strictures, as you mentioned, Bonnie, is to find something that works and works effectively and quickly for them, be it steroids or PPI. If they have a stricture that I think may be from reflux, or if they're an older person, they have erosive esophagitis, other binaries that go along with reflux, certainly I'm going to start that person on a PPI first. If it's a younger person, critical stricture, younger, lots of atopic diseases, I might start steroids first. So there's a little, at least in my practice, there's a little bit of individualization as regards to what my starting point is. Fantastic. This has been an excellent discussion. We obviously had more to talk about and there's more questions coming in. And our faculty will post the questions on the Q&A, so we will do that. So thank you for posting those questions. I'm going to let Dave get the last word if he wants to make a plug-in for the ASGE consensus process. And then we're going to take a break for 10 minutes and come back for our last section, which is esophageal potpourri. Dave. Thank you, Bonnie. What an opportunity. So stay tuned because one of the key missing guidelines in EOE, and Shivangi gave a wonderful talk on this, is the role of endoscopic treatment. We have randomized trials on medical treatments and things like that, but there hasn't been a guideline on the fine points of dilation, which to use as Phil discussed, therapeutic endoscopy, stenting, all these things. So Bonnie and Pratik are the overhead people for this ASGE guideline, which is currently in process with the Delphi process to tackle a lot of these difficult questions of endoscopic approach to EOE. So hopefully in the next few months, we'll have that finished and have further guidance for what's more an experiential decision now, as opposed to a data-driven decision. So thank you, Bonnie, for the plug.

tapering off medication

endoscopy frequency

Eosinophilic Esophagitis

PPIs

strictures