[Speaker A]: Hello. I'm fine. How are you? [Speaker B]: Good. How have you been feeling since the endophy? [Speaker A]: I've been feeling fine. About the same. Yeah. [Speaker B]: Okay. Well, hey, you know, I'm really glad that we did the procedure because, you know, I don't know. I just released the results on the portal. I don't know if you're able to see them, but they did actually show that you had kind of like, you know, eosinophils in both the upper and lower part of the esophagus. And there was like more than 30 of them. So, you know, because I know that when we looked at the biopsys from before, that they had taken some from the lower part, but not upper, and they were eosinophils there. [Speaker A]: Yep. [Speaker B]: And so this is actually consistent with that allergic kind of type mediated condition called eosinophilic esophagitis. And so, you know, we definitely want to chat about that because, you know, it's the type of thing that if we don't, you know, treat it properly, that, you know, in most cases, you know, the inflammation there will progress and can cause damage and things like that over time. And, you know, incidentally, there's like, the initial options for treatment include medications for most people, you know, like omeprazole. There's also like a swallowed, like topical, like steroid that can be taken. And then there's a newer medication called dupilumab, which is like a biologic therapy. But it's kind of not clear at what point someone should try that medication, you know, whether they should try the other ones first and then move on to that if the initial ones don't work, etc. But with you, you know, I know the concern is regarding omeprazole. Right. Because I know that you had some hives. Right. And you're working with your allergist. [Speaker A]: Yeah. [Speaker B]: Figure out what was going on. [Speaker A]: Yeah. The thing is, I mean, I'm not really sure whether I had an allergic reaction to omeprazole. It could have been something else, but I just stopped omeprazole because that was the only thing that was I had newly introduced in my diet at the time. But like, my girlfriend also pointed out to me that I'd forgotten about this. But during the time when I was on omeprazole, I used to get like, stomach aches, like intense abdominal pain around the time a little bit after eating the omeprazole, which is why the doctor then like shifted me to pantoprazole, which, I mean, I. I didn't really try taking because femotidin was working fine. [Speaker B]: Ah, so you never tried the pantoprazole. Thanks for the Martin. So, yeah, so I think, you know, if this was just acid reflux then that will be totally fine. Controlled your symptoms. Great. However, the famotidine doesn't really have a role for controlling eosinophilic esophagitis or EoES. So that's the thing. I mean if you. What did your allergist think about it, about the omeprazole? [Speaker A]: She, I mean she said it's like too, too little data and like it's, it's probably not that because the second time hives happened without the omeprazole. [Speaker B]: Yeah. So, you know, I guess it would be nice if she could perhaps confirm that again and maybe if you could just send me like her notes and stuff when you see her. [Speaker A]: Okay. [Speaker B]: I would say to. If you could send her notes to our. I sent you the email address for our records department. [Speaker A]: Yeah, I mean I feel like there's no harm in like trying omeprazole again. But like, like I said it was, it wasn't just the allergy. I was also like having abdominal pain with when I had it. [Speaker B]: That's true. So it doesn't have to be omeprazole. We can always try a different medication, that same class. However, the concern would be that if you possibly had an allergic reaction to it once, if you retry it, you then you can have a much more serious life threatening reaction the second time. So XY or allergist to confirm that she thinks it's okay for us to try that class of medications, not specifically Microsoft, like pantoprazole, lansoprazole, ethylmeprazole. There's a bunch of other ones because I think that one's going to be easier than the swallowed. Like the budesonide is like an oral swallowed medication and you swallow it and then you don't eat or drink anything for half an hour. Then you have to rinse out your mouth and stuff. It's a little bit more involved. So that's another way of you know, managing, you know, of managing eosinophilic esophagitis. The other thing that can be done is you know, like a food elimination but that's very involved where you end up like theoretically having to repeat endoscopies every time you like add feedback and things like that. So it's kind of a lot of work. But there is like an elimination diet. That's a possible option if that's Definitely something I wanted to try. However, if you're like, hey, I'd really rather not cut those things out, like, common ones, like dairy, gluten, things like that, you know. So if you were to say, hey, I'd rather try to, you know, take a medication and control it so that I can have more flexibility with my food, then, you know, that will be something to consider. [Speaker A]: Yeah, I mean, I did my research as well and, like, arrived at, like, similar conclusions like you're suggesting, which is, like, you can take the medication to control your symptoms and have them go into remission, but, like, the allergic triggers probably still remain. And the only way to, like, get to the root of that is through elimination diet. Um, so. But, like, I mean, I honestly do want to, like, pursue it and, like, pursue the elimination diet approach and, like, get to the root of it. [Speaker B]: Yeah, so say that one more time. Sorry, I didn't quite hear you. [Speaker A]: I mean, I did want to pursue, like, the elimination diet approach and, like, and, like, get to the root cause of what, What. What is causing me, like, what's causing the EOE and, like, try and eliminate it from a diet for my lifetime. [Speaker B]: Then you prefer to do the elimination diet, Is that what you're saying? [Speaker A]: Yeah, I mean, definitely the medications would still help with the symptoms, but I do want to still, like, go ahead with the elimination diet stuff. [Speaker B]: Yeah. So that would be something to discuss with the allergist. Oftentimes allergists will help manage that and we can work together with them. So I would see them and say, I'd like to start that process. You know, again, it's. It's. It's reasonable to do. But again, it usually requires, like, if you're okay to do, like, a few upper endoscopies in between, as we add food back to follow up for a response, then that's feasible, you know? [Speaker A]: Yeah, yeah. I mean, that's what I was thinking about, like, two years ago, I was in the same spot, and I think the doctor, like, advised, like, yeah, you'll have to get, like, multiple endoscopies done. Go on a diet, rigorous diet and stuff. And I just, like, punted on that. I feel like if I just followed it up, then I could have probably, like, known what was causing this, like, two years ago. So I might just, like, start now and actually, like, get it done. But, like, is this. Is this a common, like, thing that people with EOE actually end up doing, like, getting multiple endoscopies after each, like, food addition? [Speaker B]: It's. There are different ways to do it. So again, we could try just cutting out the two most common triggers like wheat, the gluten and milk products, and try that for eight to 10 weeks. And then we could repeat the endoscopy after that and see if the number of the eosinophils have gone down. We could do that, but I think I. You know, if. Give me one second. [Speaker A]: Yep. [Speaker B]: Give me one moment. Sorry. Okay, so. So again, we could just, you know, if you're okay with this, we could just remove those two and then plan a repeat endoscopy, like eight to ten weeks after. Shall we try? Go ahead and do that. [Speaker A]: Yeah, probably. Let me just. Yeah, I can obviously, like, you. Will you have to, like, schedule the endoscopy or can I get it? Like, can I call in and get it done? [Speaker B]: You're saying, do we have to schedule it right now? No, no, no, no. Because, I mean, that's like two and a half months down the line, so there's no rush. I can say, like, I can put in, like a general date because whenever we put an order in, it's good for 30 days. So I can put the order in tentatively to start, like eight weeks from now, and then that would kind of fall. Well, I can even put in nine weeks if you want to have gluten and dairy for a few days or something like that. And then I'll put the order in for maybe nine weeks. Then it'll be good for a whole month. You could just call and schedule it for any time in that month. [Speaker A]: Okay, I see. Okay. And. And is there like. Like, like any kind of nutritionist, do you. That you work with that like, specializes in something like this, or should I just go to any nutritionist? [Speaker B]: Yeah, so, you know, I can. There's one that we work with quite often. Her name is Sherry Shen. I will put in a referral to her if you like. I think she takes your insurance, Blue CrossFit, but she doesn't take every single insurance. So, I mean, I think she takes yours. So let me put the referral in for her and you can chat with her about this. Sure. And then. And. And if you just take your insurance, just like, send that. Send me a message, and I can refer you to someone else. Okay. [Speaker A]: Okay, perfect. And like, do you think. Okay, I'll reach back once I, like, talk to the allergist. But I was also looking like butyricenide. It seems like. I don't know. I just read some reports, but, like, seems like a more efficacious, like, medication compared to PPIs in like for EOE specifically. So do you think is that something that is. That's something we could experiment with at least for the symptoms. [Speaker B]: So that's kind of what I mentioned earlier in terms of I wouldn't do the PPI at this moment, given just the possibility of, you know, but that would really kind of confuse the picture because if I give you that medication and then we do the endoscopy, we're not going to know whether the elimination diet worked. You know what I mean? [Speaker A]: No, no, I meant budesonide, not the PPIs. [Speaker B]: Right, same thing. [Speaker A]: Right. [Speaker B]: So for treating it with the budesonide and then we do elimination diets in time, we're not going to know if cutting out the food is helpful because the budget is going to mask it. Right. Because it's basically a steroid. So, you know, whether you cut the food out or not, the budest night should work. Right, I see. [Speaker A]: So the elimination diets are always like done without any kind of medication just so that you can monitor it accurately. [Speaker B]: Well, there will be no way to know if the elimination diet is working if you're doing the medication treatment at the same time. [Speaker A]: Yeah, I see. You know, yeah, makes sense. Okay. [Speaker B]: Because theoretically, if you're cutting out the foods that are causing the inflammation, then the inflammation should be also going down at the same time. [Speaker A]: Yeah, yeah, yeah. [Speaker B]: But here's the thing. It doesn't have to be one way or another. If you're like, hey, I'm really having a lot of symptoms, can we just try the medication for a while and maybe I'll switch the elimination diet later. We can do that too. It doesn't have to be exactly one way, you know. [Speaker A]: Okay, I see. And like, what would you recommend? Like, isn't like, I don't foresee like budesonide or the PPIs really being a long term solution to the problem. Right. [Speaker B]: Like they are, they are a long term solution for a lot of people. So how probably the most commonly used treatment is like the ppi. [Speaker A]: I see, so how does it work? Like how does it actually solve the problem? [Speaker B]: Like, so the Budesmar is literally a steroid. So this kind of calms down the inflammation. Right. Whereas the proton pump inhibitors, hard to say exactly how they work, but they do. And a lot of people end up doing that long term, you know, and they do really well on it. So, you know, personally, I think the PPI is going to be easier to take. Of course, it tolerated over the bedes night. Right. Could you just Take it half an hour full meals and you're good. Whereas if you d. You got to swallow it, wait a half an hour before you eat anything, you got to rinse it out. It's just a little bit more involved to do twice a day, you know, so. And also I think like that's going to have less possible side effects like you just knives like a steroids if you don't wash it out fully, you know, you can have increased risk of like fungal infections and things like that. So you know personally if I were to choose I would probably do the ppi. And then if you really do identify clear food trigger, you know, you could try like limiting intake of that maybe not avoiding it all the time. That might be nice in between, you know, but that's the option I would choose in terms of ease of use and, and so on. In terms of you know, long term just being doable. But you know it's a personal decision so. [Speaker A]: Yeah. And what about like. So like even then it's not like a long term solution as in I will still have to take the PPI forever. Right. It doesn't would this, this situation wouldn't go away just because I take PPS for long enough. Right. [Speaker B]: Cure for eosinophilic esophagitis. [Speaker A]: So do you work. [Speaker B]: There's no cure. So none of these measures are going to cure the problem. And if you stop the treatment it's probably going to come back. [Speaker A]: Yeah. [Speaker B]: So whether that's elimination diet or the medication option. [Speaker A]: I see. But would it be possible for you to prescribe the like any PPI to me right now so I can get them and like, and then wait for the allergist because I don't want to like have to like repeat having to like reach out to you again. [Speaker B]: Yeah. But I don't feel comfortable right now given that you mentioned that, you know, so I, it's just liability wise I don't feel comfortable to do that. So you know, I would prefer to review their records and things like that first. [Speaker A]: Okay. [Speaker B]: Yeah. Before I were to prescribe it. [Speaker A]: Okay. Is it possible like once I send them send the records to you at the email you send, would it be possible for you to like just directly prescribe me the medication then or do we need another visit? [Speaker B]: Well, I guess it depends on if that's the treatment you want to do because I wasn't sure you said you want to try to. Yeah, I'm still not sure tonight and now we're talking about that. So I'm, I'm not really sure what the plan was at this point, so. [Speaker A]: Yeah, I'm not sure either. But yeah, just curious whether it would be possible one if. If I need the PPIs. [Speaker B]: Well, if you're not sure which option to do, then we should probably rediscuss it, right? I mean, don't. Do you want to think about the treatment options and then chat again? Because if you're not sure, I guess. [Speaker A]: Yeah, you know, fair enough. [Speaker B]: That would probably be the best way, right? [Speaker A]: Yeah. Okay. Sure. Okay. Makes sense, right? Yeah. [Speaker B]: If you're not sure and then, you know, we should probably then figure out which thing to do. But at the same time, I sent in the. I mean, the referral for the dietitian so we could chat with her. So see what you think about the diet. Maybe chat more about what the long term, you know, how difficult it could be potentially. And then, you know, again, I mean, I'm okay to send in the budesonide right now if you wanted me to send that in for you, if you wanted to try that. But I wouldn't feel comfortable at the moment to send. Send in the PPI because of the possible thing. [Speaker A]: I think. Yeah, that would be nice. Like to have the butes and I. I can travel sometime. [Speaker B]: No problem. That one, I'm totally fine to send in, you know, so let me send that in for you and then that like twice a day you take it. We kind of talked about it. The instructions will be there as well. And of course you can discuss it with the pharmacist and then maybe we can. Do you want to touch base in like maybe three to four weeks to see how you're feeling? [Speaker A]: Yeah, maybe even less. Like I'll probably try to meet the allergies this week. Maybe we can do next week. [Speaker B]: Yeah. Do you want to chat though, with. [Speaker A]: The nutritionist as well? [Speaker B]: Maybe here, listen, we can plan for up with two to four weeks. If you want to change it, no problem. I'm always happy to. Steve. It's not like a hard and fast forward. [Speaker A]: Yeah, perfect. [Speaker B]: So anytime, anytime. Because I know it's a lot of stuff to think about and we just want to make sure we, you know, come up with the right plan. And there's different, you know, pros and cons to each option and it's not something you have to make an immediate decision on. But we kind of talked about it and, you know, I think revisiting is good because we want to have a plan that's, you know, then we can move forward with the plan. Right? And then we go back and forth and then my kind of. [Speaker A]: Yeah, I'm just going to like research and review like all the options again and obviously discuss with the allergist and, and the nutritionist. And when you say you've put in a reference, how exactly does that information. [Speaker B]: Get conveyed to me since gonna email it to you? All right, so but when I put that in, I thought you had wanted to try the elimination diet. But just chat with her about it and say I put in initially because you mentioned you want to try the elimination diet. [Speaker A]: I am definitely like leaning more towards the amination diet, just to be clear. Yeah. [Speaker B]: Okay. So yeah, chat with her again and I'll send in the Vida tonight and then we'll find a follow up soon and my assistant will call you to schedule and she'll email you the referral. Okay. [Speaker A]: Okay, perfect. Thanks so much. [Speaker B]: Okay. You're welcome. Good to see you. [Speaker A]: Yeah, thank you again. Bye. [Speaker B]: You're welcome. Bye.