    [Speaker A]: It's, it's, it's, it's, it's, it's, it's, it's.

    [Speaker B]: How are you?

    [Speaker A]: Hi. All good?

    [Speaker B]: Hi. Hi. Feeling okay?

    [Speaker A]: Yeah.

    [Speaker B]: Okay. All righty. Well, hey. Yeah, so let's definitely. Let's chat, you know, about the biopsies and everything and see how you're feeling and, you know, go from there. Yeah. So, you know, you probably saw the results in the patient portal that, like, you know, even though. So sorry, give me one second. One second. Sorry. I think I. Yeah, so you probably saw the results that, you know, even though when we looked at it physically, like it looked better than before, that, you know, we got the biopsies there, you know, and of course we're getting the exact, exact same location. Like, you get them the distal and then the pro. Like higher up in the proximal esophagus. But, you know, like, on this one, like, the eosinophils were still elevated in the upper esophagus, you know, whereas. And within the distal esophagus further down, they had improved a little bit. And there were just like, not that many there. But then the concern is that, you know, we do want to get that number down under 15. And what they commented on the report, on the pathology report is that they just said that they were still over 30, which, you know, it's just, I mean, of course we want you to feel better. Very important. But, you know, ultimately, like, we want to kind of bring that number down to really prevent long term complications. Scar tissue that can form and strict ring or narrowing that can form there. And yes, it was better than before, but there were still some rings, like, you know, some mild changes. Right. And, you know, this time we did this on June 30th. The last one, you know, was April. Like, you know, we had, like, we had waited, I would say, like two months, a reasonable amount. Like, we, you know, and you were on. Just to confirm. I mean, you were on the. You were taking. So. Yeah, so, like, let's chat and confirm that you know, how you were taking the medication, see if there's any adjustment that we're able to make there. And then, you know, we'll figure out the next steps together. Okay. Yeah. So I know you've been taking the pentoprazole. I know you were taking it twice a day. Right, when we last spoke.

    [Speaker A]: Yeah, pretty much. But, I mean, I, I do occasionally, like, miss one of the tablets. Like, I occasionally forget taking the evening tablet, but it's like, I. I don't know how Often I forget. But. And also, like, I'm not very, like, strict with what time I take the evening tablet. It's. It's pretty variable. Like when I remember I take it. But yeah, the morning tablet, I take it before, like eating anything 100% of.

    [Speaker B]: Okay. And so you're taking. But you're. Most of the days. Like what percentage of the time would you say that you're doing it twice a day?

    [Speaker A]: It's hard to say. More than 50%, but less than 75.

    [Speaker B]: Okay, so you're missing probably a good amount of them then, huh?

    [Speaker A]: Yeah.

    [Speaker B]: Okay, so it sounds like you're doing it all the time in the morning and then sometimes you're free to getting the evening dose. Okay, I understand. Yeah. And then it sounds like the evening dose also sometimes may take like maybe not before dinner. Is that right, what you're saying?

    [Speaker A]: Yeah, I mean, the, the times are pretty variable. Like some, like, it just depends on when I take it. Sorry. It just depends on whenever, whenever I remember. So sometimes it's right before bed. Yeah. Or like maybe even after a. Me.

    [Speaker B]: I hear you. So, you know, and at the moment, I know you told me you also thought a lot better when you cut out dairy. How much dairy would you say that you're having in your diet currently?

    [Speaker A]: The dairy thing was a correlation with not my EoE symptoms, but with like my hives. The. The correlation of like getting better, symptoms wise. But yeah, right now I do have dairy. I've just avoided anything that just purely milk. Like, I've cut out milk from like a breakfast and I've cut out whey protein that I usually used to take every day.

    [Speaker B]: Okay.

    [Speaker A]: Yeah, but that's it. But I still, still have cheese almost every day. Or. Yeah. Or like any dairy present in gravy still still there.

    [Speaker B]: Yeah. So, you know, these are things we'll chat about. So I, you know, so these are options. Right. So I think there's various ways we could go about it. So, you know, at the moment there's still evidence of like some inflammation there. I think it's improved compared to before, but it's not yet where we wanted to be to prevent, like, changes long term. So I think there's a few different options for what we could do. So one option is, you know, we could try to like, really increase the pentop result of doing it twice a day, you know, and really doing it before meals and seeing if that's helpful. The other option, which we could also do at the same time, is to really cut out daily dairy Fully because dairy. So dairy and gluten like we talked about before are the most common triggers for eosinophilic esophagitis in terms of food triggers. So you know, we could consider cutting out dairy fully and potentially cutting out gluten. But that is a pretty reasonable restriction which you may not want to do long term. Right. It may not be like a feasible option. Right. Like a realistic option or one that's like, you know, so those are options. Right. So we could consider, hey, like let's just have you do the pentoprazole like really faithfully, twice a day before breakfast, half an hour before dinner and consider maybe really cutting out dairy as well. Potentially plus or minus cutting out dairy versus just switching to a different treatment altogether. Like I would suggest dupixent probably, which is like that biologic option. The budesonide is like it's okay, but it's like kind of hard to take. So if you're finding finding the pantoprazole hard to take, you probably would find the budes not even harder to take because it's like a slurry and you have to take it in a very specific way and you can't eat for a while after you take it. So it's kind of a little bit involved. The problem is there is a brand of a medication called Eohelia which is easier to take but unfortunately like insurance hasn't really been covering it for patients beyond a couple of weeks. So it's kind of annoying. It's like an oral tablet that gets dispersed but unfortunately it's like a predesinate like suspension tablet. But it hasn't really people. It just like most everyone finds it's not covered long term. So I think those would be the options versus considering that medication. Do pigs in that we had kind of talked about. Yeah. What do you think?

    [Speaker A]: Honestly, I don't know. I mean I could definitely give taking the medication twice more in a more disciplined way and like cutting out dairy completely a short. But what do you think like is, is it worth switching to dupixent at this time or do you think it's worth a shot? Like since we've seen an improvement because of like maybe, maybe, maybe it wasn't the PPI that was actually helping and maybe it was me like lowering how much dairy I'm taking that helped and maybe like completely cutting it out will help any.

    [Speaker B]: Yeah. So you know, it's really a personalized choice to make. One consideration is, you know, if you have other allergic type conditions like with the Rashes and the hives that you mentioned, the food allergies, the dupixent can kind of help a bit with the rashes and things like that too to prevent that. So that's one thing, right? And it's a relatively low risk medication. It's not like, you know, going to majorly suppress your immune system. It can kind of just help like control that allergic mediated type issues as a whole. So that's one thing to consider and that it could help with the other issues going on like the rashes and stuff like that. So that's one thing to think about. And then if you said hey though, like you said, though, like it's reasonable to say hey, like, you know, I, it did get better and maybe if I took it more religiously, like it would, you know, I would feel okay. If you wanted to try that, I'm totally willing to do that with you. Like if it were, if you're like, hey, but I like cheese, I want to eat cheese. You know, that's something to think about, right? Because this is a long term plan. So it has to be something that works well for you. So if you're like, I would rather take this medication, dupixent and maybe eat some cheese and. Because I really like cheese. And that's a reasonable thing, right? Because this is not like we don't want to torture you, it's kind of the point we want you to be able to do, you know, obviously within reason, but like be able to do some of the things you enjoy. But it's kind of a personal decision to make, I think, you know, and it's like a subcutaneous medication that you know, you can take and you know, really it's like the first couple doses overly, it's just like once a week, a subcutaneous medication. And again, it can help with other issues like food allergies, rashes, even asth, things like that. So, you know. Yeah. And then you could add in other foods into your diet. Right? If you're like, so if you wanted to try it though, like, I would rather prefer to avoid a medication that may suppress my immune system a little bit. Because like that medication, I mean, in terms of risks and things, I mean, you know, it's overall like a quite safe medication, to be honest. But you know, sure, I mean, in terms of like side effects, like common side effects or like injection site reactions, like upper respiratory tract infections, maybe like joint pain sometimes there's like a slightly increased risk of like herpes infections, but you know, very rarely Maybe there's a slightly increased risk of like inflammatory arthritis and things like that or psoriasis if it's like shifting the pathway in a particular direction. But, you know, but it does seem to work quite well for patients and it is, you know, quite safe because of the way that it like, it's not like a broadly, broadly suppressing your immune system. So something think about. But if you said, hey, I would rather give the pantoprazole a full shot before I switch to like a medication that's going to even suppress my immune system a little more, then we can do that. If you want to say, I'm going to do the pentoprazole regularly for the next two months and maybe cut out dairy as well. Would you want to give. We can give it a shot and I would just say we could repeat the endoscopy in two months. What do you think?

    [Speaker A]: Right. And given both the directions, like the assessment again would just be another endoscopy after two months to see how it is, right?

    [Speaker B]: Yeah, exactly. And we would just repeat biopsy because right now your symptoms are well controlled, right?

    [Speaker A]: Yeah, symptoms are fine. I don't feel anything off.

    [Speaker B]: It might be that it's been going on for a while and maybe it's just like slowly resolving as well, you know, because like that inflammation, we know it's been there for at least a couple years. In the endoscopy you had back in 2023 where they saw eosinophils. Right. So maybe it's just, it might take a little longer, you know?

    [Speaker A]: Yeah.

    [Speaker B]: What do you think?

    [Speaker A]: Yeah. And what do you think about like, like the eosinophils going down middle or lower esophagus but not in the upper. Like, are there different pathways that affect the esophagus differently? Like, what could be the potential reason for like this disparity?

    [Speaker B]: You can have patchy involvement too. Right. So if we're not bioteching the exact, exact same area, I wouldn't put too much weight on that. I would just say this is consistent with active disease right now because you might have picked one area and like one right next to it that, you know, looks the same but perhaps, you know, look normal. So yeah, that's what I would.

    [Speaker A]: I see. Okay. Yeah. I think I would like some time to like research dupixent before and like, also think about the lifestyle decision of whether I want to like stop dairy altogether. So is it okay if I can like reach out to you via like a message on. On the portal and so really like.

    [Speaker B]: We don't start, I wouldn't start a medication like that via portal. So I would just suggest we could schedule like another follow up appointment and then we can discuss it fully because the portal is really for more simple questions that are not regarding to like biologic therapy initiation and things like that.

    [Speaker A]: Okay, okay.

    [Speaker B]: Okay.

    [Speaker A]: Okay. So like in, in case I want to consider dupixent, which right now, like as of right now I seem, it seems unlikely that I would want to do that. I would just want to give this a more disciplined shot, especially with the dairy. In case I do want to try dupixent, I'll. I will schedule another appointment with the office. Otherw I will just take, keep taking PPIs and like cut out dairy and maybe schedule another appointment in like two, two and a half months for the, for another biopsy.

    [Speaker B]: Okay, like we should probably schedule an appointment. Why don't we schedule a follow up before? Because I wouldn't want title the endoscopy without knowing the plan. And also I want to make sure that you are being able to take it consistently before we schedule an endoscopy. Because if you're like, hey, you know what, I tried but I actually wasn't that consistent. Like I've been bus and stuff, it's okay. Right? But I just want to make sure we have like a consistent use for a couple months before we do the repeat endoscopy so that you get, you know, something out of it, you know. So I think why don't we schedule a follow up for maybe. Why don't we just schedule like maybe like four to six weeks or so, just see how you're feeling and if you decide you want to like think about depiction earlier this, we can just move it to an earlier time. Okay.

    [Speaker A]: Yeah. Okay. Is it okay if we do it next to next week perhaps? Because I think I don't need that much time to like make up my mind about this.

    [Speaker B]: Oh yeah, we can definitely chat next week. Oh, I'm so sorry. I thought you were like wanting to, you know, maybe you know, just like take the medication and stuff. But. Yeah, yeah, yeah. Why don't we.

    [Speaker A]: Can we do 28th or 30th?

    [Speaker B]: Oh, like two weeks. Two weeks, yeah, of course, whatever works. Listen, one to two weeks, three weeks, four weeks. Honestly, whenever you want to chat, if you decide you want to chat about it more tomorrow, just call me. You know, I have space in my schedule, I'm pretty sure. So, you know, whatever works for you, just let me know. And I mean if I were in your. And it's hard to say because when you have other conditions that can be treated by the dupixent, it might be kind of nice. Right. Because it controls the other stuff too. So that is a consideration and it is quite safe. So. Yeah, take a look though, like, see what you think. And you know, and it's just a once a week medication. Right. For the treatment. So it might be easier to take in terms of like, versus a pantoprazole twice a day before meals if it's hard to remember. But, you know, maybe get like one of those pill boxes where it's like morning, evening dose or one box for morning dose, one box for the evening, evening dose. And just, you know, and maybe like what. That might be helpful, you know, to kind of like stay on it. Okay.

    [Speaker A]: Yeah. I just not been taking it pretty like seriously enough. Yeah. I mean, I just need to set an alarm for every day and that should solve it.

    [Speaker B]: Yeah. Or like, you know, when you wake up in the morning, take it first thing when you know. But of course, like, do your best. Right. Like you're still taking it like at least once a day.

    [Speaker A]: Yeah.

    [Speaker B]: It's not like it's not in your system.

    [Speaker A]: I'm pretty sure, like I would say the average is like 1.5 per day or more than I would pretty, pretty surely say that the average amount I take day has been greater than 1.5.

    [Speaker B]: Yeah, I hear you. But maybe a little bit extra might be helpful and maybe giving a little bit more time on it, you might get further improvement too. Right. So there is value to like continuing this plan, but optimizing it and then repeating endoscopy. You might be like, you might say, ultimately, hey, you know what? I'm not really sure if I wanted to pixen. I think I actually want to just do this plan, do it like be more adherent to this treatment and then repeat the endoscopy. And then if I am adhering to it and still elevated, then I think it makes sense for me to switch to big sense. That might be ultimately what you decide, which is very reasonable, you know?

    [Speaker A]: Yeah. Yeah. One last question. Like, are there like any statistics on like this kind of path where like patients have taken a PPI for about two months and they still see elevated levels and, and has the ppi, like further. Has further taken. Taken the PPI for a. For a. For more time helped in those cases? Like, I'm essentially asking a question about how much time it takes for the p. Like to actually solve resolve the issue or, like, see the symptoms recede? Is it.

    [Speaker B]: I'm sorry, say that one more time.

    [Speaker A]: So for patients who've done this exact thing, are there any statistics about whether continuing PPI actually helps resolve things later in time?

    [Speaker B]: Well, yes. Being adherent to the regimen can improve the treatment response. Right. So taking it more regularly, I mean, there's no exact data. It's hard to say. Right. If someone's not taking it exactly the same amount, it's hard to compare, like, you know.

    [Speaker A]: No, but let's say. Let's say. Let's assume that they were taking it in a disciplined way and they still showed signs of EOE after two months.

    [Speaker B]: Thus, at that point, I would say, do you want to consider, like, the adding in, like, the dietary, like, some elimination diet and repeating it versus switching to the big sin? Probably.

    [Speaker A]: I see. I see. So, like, it's rare for, like, the medicine to, like, start working later rather than if it hasn't worked in two months, it probably doesn't work. Right.

    [Speaker B]: Well, it's hard. Hard to discuss hypotheticals because that's not really your situation. Right. So I don't know if that's really pertinent to, like, what's going on with you, though.

    [Speaker A]: I see. I mean, I'm just curious, like, just.

    [Speaker B]: Having a number there, as you can imagine. Right. Because, like, all the variations of when people do endoscopies and stuff like that.

    [Speaker A]: I see. Okay.

    [Speaker B]: But it might. Right. Like, so it might get better. So we just kind of. I think, you know, it's not reasonable. It's reasonable to continue this time, but just be more adherent and repeat the endoscopy. Like, that's not a bad idea, you know?

    [Speaker A]: Okay. Yeah, I'll think about it. And let's schedule. Should I call the office or can you do it right now?

    [Speaker B]: Let's go. Give you a call.

    [Speaker A]: Okay. Okay.

    [Speaker B]: All right. Good to see you. And we will. And listen, it's not an emergency to make this decision, right? Like, you're on med treatment. It is. It is improved compared to before. So it's just like, hey, well, long term, we want it to be even better. Right? So that's really the thing. So it's just, you know, think about it. It's not a decision you have to rush into, but we'll just have a make a thought plan for you. Okay.

    [Speaker A]: Yeah, sounds good. Perfect.

    [Speaker B]: Okay. All righty. Good to see you. We'll talk soon. Take care. Bye.