[Speaker A]: So how are you doing?

[Speaker B]: Fine, actually, since our last meeting, we got. I went to the GI and got an endoscopy done and I think I've sent you the reports already.

[Speaker A]: Yeah, yeah, I just called them to speak to them. The report? Yeah, I need some more information about it.

[Speaker B]: Oh, okay.

[Speaker A]: And so what did your GI doctor say?

[Speaker B]: Essentially that like, it's almost like a confirmed diagnosis of eoe.

[Speaker A]: Okay.

[Speaker B]: And like her first suggestion of like, treatment is PPIs.

[Speaker A]: She said PPIs?

[Speaker B]: Yeah. And yeah, I think you already replied to this, but like, she wanted a note from you just so that I.

[Speaker A]: I sent her, I sent her a copy of my note that said I don't think it was related to the. The highs are related to omeprazole.

[Speaker B]: Yeah.

[Speaker A]: But you haven't started that yet.

[Speaker B]: No, not yet. She. I think she'll get back to me this week, hopefully.

[Speaker A]: And are you. So last time I saw you had stopped having dairy, right?

[Speaker B]: Yeah, but like, it's not very. Been very strict. I, I've, I've. I had limited the major daily things in my life. Like I stopped having yogurt, raw milk, I mean milk, or like the whey protein I used to have.

[Speaker A]: Okay.

[Speaker B]: But I still still consume like cheese or like, I'm not being very like strict about it.

[Speaker A]: And how are your symptoms?

[Speaker B]: They have receded a lot and like, but I still feel the like tingling sensation sometimes, maybe like once or twice a week.

[Speaker A]: Where?

[Speaker B]: Usually on my arms here sometimes and on my legs. Those are the two hot spots. And like maybe in the last one and a half month I've had like hives show up to two times maybe, but I haven't like even been able to like correlate it with like any kind of specific things thing that I've eaten. My suspicion, like, even though I don't have any empirical evidence for it, is still that it's daddy related. Right.

[Speaker A]: Okay. The fact that you're still having highs, you're not on the omeprazole then. Yeah, definitely it's not related to meprazole.

[Speaker B]: Yep.

[Speaker A]: Any reflux symptoms?

[Speaker B]: Nothing except like the usual. I start getting a burning sensation, but then I take my femotidin and I'm fine.

[Speaker A]: Bloing? You said bloating?

[Speaker B]: No, no burning sense.

[Speaker A]: Burning. How often is that?

[Speaker B]: That's been a recurring thing since like the last two and a half years.

[Speaker A]: Which is how often you get that.

[Speaker B]: It happens like 24 hours in. In 24 hours? Roughly. And then that's like kind of almost. Yeah. Every tear and it essentially is a reminder that I need to take my.

[Speaker A]: Pepcid and it makes it better.

[Speaker B]: Yeah.

[Speaker A]: You're only on Pepcid once a day?

[Speaker B]: Yep.

[Speaker A]: And is it not related to, like, you having the dairy at all? Like, are you having dairy every day?

[Speaker B]: Like I said, like, I've cut out most like, the big dairy stuff, but I still have cheese or sometimes, like, there must be some dairy in, like, a dressing that I'm having. Oh, stuff like that.

[Speaker A]: But do you have, like, cheese every day?

[Speaker B]: I think so, yeah.

[Speaker A]: Okay. Okay. And other foods you're eating, you're fine, right?

[Speaker B]: Yep.

[Speaker A]: Are you taking any antihistamine? Are you taking a LEC or a ZH or anything?

[Speaker B]: Yeah, when I do get the tingly sensations, I do take a Zyrtec, usually at night.

[Speaker A]: Okay. Is it every night?

[Speaker B]: No, it's not every night. Like I said, once or twice a week.

[Speaker A]: Okay. Does it help?

[Speaker B]: Hard to say, because I usually take it, like, a little before bedtime and.

[Speaker A]: Then you fall asleep and then you're fine.

[Speaker B]: Yeah.

[Speaker A]: Okay. So did the. Did the GI want to scope you again?

[Speaker B]: No.

[Speaker A]: No, she said just do the PPI and then you're fine.

[Speaker B]: Yeah. Because the. The scoping just happened, like, happened like two weeks ago, right?

[Speaker A]: No. So of. They'll, you know, they'll put you on a PPI and then scope you again in six to eight weeks to see if you've improved.

[Speaker B]: Yeah, Yeah, I haven't started yet. But that is the plan, right?

[Speaker A]: That's the plan. So she would scope you after.

[Speaker B]: Yes. I mean, we would look out for both, like, symptomatic results as well as, like.

[Speaker A]: And you never had problems swallowing food?

[Speaker B]: I had, like. But that was, like, once in May 2023, which is when I first went to the DI.

[Speaker A]: But nothing since then?

[Speaker B]: No, nothing since then.

[Speaker A]: Trying to see if I went to a talk on someone with the. Just talked about eua. Hold on. Because I talked. I mean, milk is really. Dairy is really the main one you have to strictly avoid, which I probably would have you. Because the scope she did, you had already been to cut out most of the dairy.

[Speaker B]: Yeah, but like I said, I wouldn't. Yeah. I wouldn't say I was strict about it.

[Speaker A]: So let me just see if. Sorry, I'm going to see what the picture is. I took pictures of that talk. Hold on.

[Speaker B]: I also look like hives are like, IgE mediated, whereas, like, the EOE symptoms. EOE isn't.

[Speaker A]: Well, I mean, there is. It's different. Eosinophils versus IgE dupixent is for EOE, is once a week injection. But it's also just been approved to treat hives.

[Speaker B]: Oh.

[Speaker A]: So it's not necessarily bad medication for you because it treats your, your EOE and it treats your hives. So, I mean, I don't know how GI wants to do it. I mean, I think you would probably have to strictly avoid all dairy. Like, I think that, I mean, any bit of dairy, unfortunately can trigger the eoe. So, like, you have to. Can't have any. You can't have any butter or can't have any cheese. Can have anything. You really have to be strict about it. The thing about the Dupixent is you don't have to be as strict because you're sort of treating, you're decreasing the eosinophils locally and so you can have some more stuff. I do find with adults it is hard, hard to be on restricted diets. Kids are a little easier.

[Speaker B]: That's kind of the plan with the PPIS too. Right. Like, the PPIs can get the symptoms into remission while you continue to have.

[Speaker A]: Right.

[Speaker B]: Your usual.

[Speaker A]: But with the hives, also, the having dupixa is not bad because that treats the hives as well.

[Speaker B]: Okay.

[Speaker A]: I mean, I guess you can do the PPI and then get rescoped and see how you are and see how your symptoms are. I would say depends how you're doing whether or not you'd want to stop the PPIs and like start dupixent. It also depends how the hives are. But I would say that would sort of treat both things that do pixen. And I do think it's. I mean, I'll write in my note again that it's okay to do meprazole because you have hives and you had a history of hives on and off. And I don't think it's related. I mean, the underlying disease can trigger hives and the inflammation could trigger highs, but I don't think it's an allergic reaction to meprazole. I think you're fine. I would start with once a day omeprazole. Sometimes they go up to twice a day, but I just make sure you're fine with it. I mean, even if your highs get a little worse, I'd still treat through it. I mean, unless it's really bad, I would just, you know, if it makes the eyes a little worse, I would just take an antihistamine every day because the PPI is going to give you much more relief than The Pepcid. Pepcid is not as strong the medicine. And I would, I guess, do the ppi, get the rescope, see where you're at. And if you're not in a good place or you're still symptomatic, then I would say dupixent would be my next stop.

[Speaker B]: Okay.

[Speaker A]: And that would be for the hives and for the eoe.

[Speaker B]: Okay. And do you think, like, since it's IG mediated, would like doing a skin prick test help us like, localize what the actual.

[Speaker A]: I mean, for the hive? With chronic hives, it's usually very clear. When you eat the food, you have the hives. When you don't, you don't have the hives. Usually chronic hives, I don't find there's one trigger because usually I identify it. Right. I mean, when was the last time you took your Zyrtec or Allegra?

[Speaker B]: Day before yesterday night, I think.

[Speaker A]: Yeah. You need to offer it for five days for allergies. I could do that if he had blood work done. So the blood work did show some things positive. And that will also be positive on skin testing.

[Speaker B]: Oh, okay.

[Speaker A]: So it's just a different way of measuring the same thing. Let's see what was positive, Wrote them down. This was some of the nuts are positive peanuts, but you're still eating those. You're not avoiding that egg. I mean, as I said, dairy is really the main trigger for adults. I mean, I guess you can try in terms of the hives and the tingling stuff, you can just try going completely dairy free for a full week or so or no more. I mean, and just to see if the frequency of symptoms are less. Just like, no cheating, no nothing, just for a finite amount of time and see if those symptoms are better. And if you're still having those symptoms and you're completely dairy free, then that's not the only issue.

[Speaker B]: Yeah. So I was just wondering, like, is isn't like the skin break test like a shortcut to getting that information?

[Speaker A]: I mean, I don't know because, I mean, it was. If it was positive in the blood work, it's going to be positive on skin testing. And it's not. It's a different way. It's measuring the histamine release due to the ige. It doesn't necessarily tell me much because I already have the blood work.

[Speaker B]: Okay, but like in the blood work, like my milk isn't positive, which is like over mucoid.

[Speaker A]: Right. Is soy, almond, egg white, over mucoid, sesame, peanut, hazelnut, walnut, Wheat. Yeah. Milk wasn't positive and for EOE it won't be positive because that's not the mechanism. Whether or not it caused the hives. I would think it would. You'd have hives the nights you have cheese or something. I would think it would be much more closely related to times when you're cheating and not having the dairy.

[Speaker B]: Yeah, yeah.

[Speaker A]: I mean you can try.

[Speaker B]: I can try for a week.

[Speaker A]: I would try a week or so of completely dairy free and then you know, you can come in if you hold off on the antihistamine, you come and I can skin test you to the milk. And I would see though if symptoms still break through with no dairy. It's very unlikely even if you tested positive for milk that that's the main issue. But I would just go completely dairy free for like a week, probably two weeks. Because if you're sitting, you're having symptoms a couple times, like once a week or a couple.

[Speaker B]: Yeah, once or twice a week.

[Speaker A]: You may want to give up like two weeks of off of it because it gives you more data. Right?

[Speaker B]: Yeah.

[Speaker A]: And strictly. And if you find you're still having hives then obviously that little amount of dairy doesn't help, doesn't mean anything. But also if you're symptomatically have less burning or anything, maybe it's sort of proof that you need to be more strict about the dairy.

[Speaker B]: Okay.

[Speaker A]: So I would, let's see, I would, I'll write that it's okay to do the ppi. I don't think it's related. Is okay without medication. I would say I would try a strict dairy free diet for two weeks if high slash reflux is better. Consider the dupixent injections if repeat EGD shows persistent or worsening of the eoe. And then we can kind of skin test to milk Interested antihistamines for five days. I would try the milk avoidance first because if you still have hives with milk avoidance then, then I don't think it's related.

[Speaker B]: Yeah, right.

[Speaker A]: If you find you really all the tingling in the eyes go away completely when you're strict with the dairy then you know we can try to skin test to confirm that. But I would say I would continue to avoid it if you're doing better off of it.

[Speaker B]: Yeah. Okay.

[Speaker A]: I would just give it like a two week trial of severe and you know I, I'll send a message. We can, I'll email this to you. We can also send it to the GI as well saying that I think OMEPRAZOLE is fine to start.

[Speaker B]: Okay.

[Speaker A]: And again, if you do have highs with omeprazole, just let me know how bad they are. If you, if it's like still the same frequency of hives and you know you're not having it very often, you can just take Allegra. And if it looks like it's really that you are reacting to it, then we'll switch to something else. But I don't think so because you're having hives without it. You had history or hives before it. So I don't think it's related unless it's you, the underlying condition, and that's it. Okay. So more strict dairy avoidance. Okay. To start the omeprazole, I'll send an updated message to the doctor saying that I don't think it's related. And then you could definitely come in for skin testing if you want. For the milk. I would see after this little trial and see how you do.

[Speaker B]: Okay. Yeah.

[Speaker A]: And then dupixence. In the back of my mind, if it looks like this is EOE still persisting, it's getting worse, you're sort of the diet control is hard or that the PPI is really not tolerating, then I would do dupixent.

[Speaker B]: Okay. Yeah.

[Speaker A]: So I'll send you this information. You'll let me know what you want to do. And definitely, I mean, I do recommend you being re scoped after you do whatever treatment they want, whether it's in two months or whatever. And then make sure I get those results. Results too. I want to follow up and see if it's getting better or. I mean, it wasn't terrible. You definitely had some features of it. And I'm trying to get. I mean, they said they're greater than 30 EOs per high power field, which is really not helpful to me because I don't know if it was 31 or if it was 150. All right, so 150 is more concerning than like 30. So I need more for them to tell me. I mean, anything over 15 could potentially be EOE and some features. But you also were cut back on a bunch of your milk. So I don't know if this was also partially avoiding the trigger. And you already had some improvements because you had like sort of almost like a two year break between scopes.

[Speaker B]: Yeah.

[Speaker A]: And just being off it, you were off it when you saw me for like two weeks already. And then you had probably another month or so. So you had just decreasing. That could have made a difference. Also how it Looked on the scope because it. Look, you see it, but you don't see it. Crazy. And you're not having strictures, which are good. And you're not having food impaction, which is good. So. Which is good. So ppi, strict dairy avoidance for now. See if the hives or any of the reflux gets better, you can come in for testing. If you want to just be off the antihistamine, the omeprazole is fine to be on. Any issues with the omeprazole, let me know. But I do think you should be okay. If it even is mild hives, like, I would just take a LIPRA daily and you let me know.

[Speaker B]: Sounds good.

[Speaker A]: And we'll follow up once the nest. Nest. Next endoscopy is done. Or if you're like really having a lot of symptoms and you don't like that and you want to go on to do Pixins, you just let me know.

[Speaker B]: Okay?

[Speaker A]: Yeah, yeah, yeah.

[Speaker B]: That sounds like a plan.

[Speaker A]: That's a plan.

[Speaker B]: And so for like, let's say I've got the endoscopy done and like, my hives have not gone away with the milk. That's probably when we want to do the skin test.

[Speaker A]: Yeah, we can do skin testing. I can also do blood work. I mean, I do like a workup for just chronic hives anyway. Why?

[Speaker B]: Okay. No, we. We did that.

[Speaker A]: Oh, we did the workout.

[Speaker B]: Yeah, it did. Everything was negative. I also went to the rheumatologist afterwards.

[Speaker A]: Okay. And that was fine.

[Speaker B]: And that was. Everything was normal.

[Speaker A]: Everything's fine. Okay, so then. Yeah, I mean, it depends how bad. I mean, normally I like Zoler for chronic highs. If it's bad. Zoler is a once a month injection. However, Dupixent was just approved for hives. And being that you have eoe, it'd probably be. I'd probably go for Dupixent if the highs were really more of an issue.

[Speaker B]: Yeah, they haven't been like a huge.

[Speaker A]: Yeah, I was gonna say if they're not too bad, you're taking antistamine here and there, then I would just get. Continue with that as long as we. We don't see anything else going on. But if the highs become more cumbersome and you're taking antihistamine several times a day, then probably Dupixent would be my next option. Just because of the EOE and just sort of kill two.

[Speaker B]: Do I need, like a special kind of appointment that if I want a skin break test?

[Speaker A]: No, just. No, just make a follow up appointment. Just make sure you're off the anti.

[Speaker B]: That's all.

[Speaker A]: That's all? Yeah.

[Speaker B]: Okay, perfect.

[Speaker A]: It's about the same. It takes about 15, 20 minutes to skin test.

[Speaker B]: Okay.

[Speaker A]: Yeah. But try to, try to strictly avoid dairy. I know it's not easy, but just like read labels, just do it for a couple weeks and take note of symptoms. Because if you are better, I mean it's sort of. You pick your poison. If you end up being better off of it, you can decide to continue with that strict diet or if it's like really not significant of a difference, you go back to having that. But pay attention to how much heartburn, you have, pay attention to the hives and that sort of tingling feeling. And if it is better then you know, a strict dairy should be sort of continued. And then we can always contest after. But. Okay, so that's the plan. I'm going to email that to you and also we'll forward a copy of this note to the gi. And I think you should be okay on the omeprazole.

[Speaker B]: Sounds good.

[Speaker A]: Okay. And then I'll see you probably in a couple months.

