Twice-Daily vs Once-Daily Proton Pump Inhibitor for Inducing Remission in Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic clinicopathologic condition necessitating ongoing therapy to manage symptoms and limit potential fibrostenotic complications, with disease recurrence being common when therapy is withdrawn. This underscores the importance of developing effective treatment strategies with proton pump inhibitors (PPIs), food elimination diets, topical corticosteroids, and dupilumab, all options for management based on patient-centered shared decision-making. PPIs are frequently positioned as an initial therapy based on patient and provider preference, ease of use, and safety profile. However, the optimal dosing and frequency of therapy remain unclear, resulting in diverse prescribing practices.

Recognizing these issues, Muftah and Goldin et al examined optimal PPI dosing for inducing histologic remission in newly diagnosed patients with EoE. Their retrospective analysis, conducted at a large EoE referral center, compared four omeprazole dosing strategies. They found that patients receiving 20-mg or 40-mg doses twice daily showed significantly higher response rates than those receiving a 20-mg daily dose (52.8% and 54.3% vs. 11.8%; P < .0001), with no significant benefit from high dosage (40 mg) compared to moderate dosage (20 mg). Furthermore, the odds of response were 6–12 times higher with twice-daily dosing compared with once-daily 20-mg dosing, with twice-daily dosing showing superiority even when total daily dose was equivalent. Although the authors propose that this dosing regimen may optimize pharmacologic half-life when targeting possible mechanisms of acid suppression or direct anti-inflammatory effects that improve barrier function, further studies are required to fully elucidate the underlying mechanisms and to evaluate medication compliance. This study represents interesting data suggesting that frequency of dose, rather than specific dosage, may be important to achieve histologic response in certain populations with EoE; however, prospective studies with longer follow-up durations are necessary to confirm the superiority of twice-daily dosing on inducing histologic remission and on reducing fibrostenotic outcomes.