[Speaker A]: How are you? [Speaker B]: Hi. All good. How are you feeling? [Speaker A]: Good. How have you been feeling since the last appointment? [Speaker B]: I've been fine. Like, symptomatically, it's been the same that it was with the famotadin. It's just that I'm taking the pantoprazole instead of the famotadin. [Speaker A]: So essentially doprazole twice a day. [Speaker B]: Yep. [Speaker A]: Okay. And you're doing it. And just remind me, like, when you started, because I know there was a lot of, like, I know the pharmacy. There were some issues. And then, you know, we initially had talked about doing something else before, but remind me, I guess, how long you've been on a pento. [Speaker B]: Yeah, I'll have to check. I also don't really remember. Give me a second. [Speaker A]: From what I could see in the notes, I think it was like maybe three weeks ago, something like that. May 12, I see a message about. [Speaker B]: I think I started it. [Speaker A]: Amazon Pharmacy. So I'm not sure. [Speaker B]: Oh, no, that was. That was a refill, I think. [Speaker A]: Oh, okay, great. [Speaker B]: So it's been. I started on April 25th. [Speaker A]: 25Th. Okay. Okay. Just so we have a time frame. Okay. And you've been doing it twice a day, you said, like. Like before meals and stuff. Okay. Okay. And then you feel like any improvement of your symptoms so far? [Speaker B]: Yeah, I mean, I've not been facing, like, the throat, like, the esophagus burning sensation that I used to feel if I didn't take the famotidin for like a day. So I've been symptomless essentially only like, in the first week of having the pantoprazole. I was having some reflux symptoms, but that has gone now. [Speaker A]: Okay, great. So you feel like your symptoms are well controlled right now with the pantoprazole. Okay, yeah. That's great. And you haven't had any difficulty swallowing that we talked about. Right. Like, recently, it's just been the heartburn. Yeah. Well, that's really great. I'm happy to hear, you know, that you're feeling well. I know we talked about, you know, and I know you saw your allergist. I saw their notes and everything, you know, obviously, regarding the pantoprazole. And I know that you are working with your allergist as well about possible food allergy evaluation. Right. Any updates there? [Speaker B]: No, I haven't, like, followed up with her yet. I think. I think her last recommendation was to, like, take the PPI for a long enough time and see if it's actually helping with the eoe. And then in the mean like after that's done, I should like come like report back to her essentially, like, she wanted me to fix. Get like the gi. Like prognosis. [Speaker A]: Yeah, no, of course, of course. And then I guess the other question is. I know, because we obviously kind of discussed all of the various options. It was a little bit. I mean, ideally we wouldn't typically kind of plan to do all of the treatments at the same visit. It's just, you know, so I just want to see. Because we talked about the elimination diet and stuff. Did you end up like doing any of that at the last appointment or. [Speaker B]: No, not, not particularly. I just had like a gut feeling that it was like it could be dairy related. So I had cut down like, especially milk related. So I'd cut down my consumption of like dairy based milk. So I stopped having regular milk and I stopped having whey protein and switched to plant based protein. But it's not like I've been avoiding dairy completely. I've still been having kind of cut it down. Yeah, basically cut down the milk. The basic, like high concentrations of milk essentially, like raw, like regular milk and whey protein. [Speaker A]: I hear you. And we talked about that, right. That like dairy and wheat are like gluten are the two most common triggers. So that makes sense. And you know, I think finding like a reasonable approach that works in your lifestyle is a good idea, you know, because thankfully you're feeling well, you know, and so. Yeah. So May 25th. So I would say, like we talked about, usually we would plan to kind of schedule a repeat up frontoscopy to follow up, get repeat biopsy, see if the number of eosinophils have gone down about eight weeks after. So, you know, I would recommend to set that up if you feel ready, I guess, you know, like late June probably would be like the earliest because you've been on the medication since May 20th. I'm sorry, April 25th.ish April. So it's like you know, 1, 2, 3, 4, 5. We're at about six weeks now, I guess. Right. So you've been on it for six weeks. So probably the earliest, I would say would be like June 17th or so is probably around because April 24th. [Speaker B]: Yeah. [Speaker A]: Okay. [Speaker B]: Okay. Do some. Somewhere like in the last week of June perhaps. [Speaker A]: Give me one second. So last week of June, my schedule is full at the moment, but I do have the first week of July available. If you wanted to do that on July 7th. [Speaker B]: Might be. Do you think it might be too late? [Speaker A]: No, it's not about being late. We just don't want to do it early. Right. The reason we say eight weeks is we want to give the medicine enough time to work for the esn. Supposed to go away. So we can always do it, like, later. It's just. We don't want to do it too early, really. [Speaker B]: Okay. What day is July 7th? [Speaker A]: That's a Monday. Okay. [Speaker B]: I think. Yeah. [Speaker A]: We can. [Speaker B]: Yeah. Pencil that down for now. [Speaker A]: Sure. Six. Yeah. Because I think of me one second. Because on the 23rd. So I'm just looking at what I have. Yeah. Because at 23rd, I'm not there. And so, by the way, for the 30th, lot of times, like, patients will cancel. I just. They won't. The way this office is scheduled is, like, they will not call patients or confirm till the week before. And so I. I'm not able to offer, you know, I overbook to some extent, but it's hard for me to overbook, like, a whole lot. You know. But I mean, if you really wanted to do the 30th, I could try to overbook it, you know, squeeze you in. If you really wanted the 30th, I can try. Because probably someone will, you know, if that's okay. I mean, if you really want 30th, I can. I can, you know, finagle a little bit. Is that a day that actually works for you? [Speaker B]: Yeah. But I mean, if it's possible to do it after, like, 9:00am 9 or. [Speaker A]: 10:00Am Yeah, I would probably say if you could do, like, you do like, 12:30. Like 12:30. [Speaker B]: Yeah. [Speaker A]: That's okay. Okay, let's do that for the 30th. Because again, I mean, I, like, asked them to call my patients earlier because I would love to know, because, you know, people's plans change. But. And it's nice to know, like, you know, if you need something earlier. But. Yeah, I'm just going to plan on that. Probably that'll happen. So we'll do the 30th. 12. Squeeze you in there. So we said it's probably. Yeah, let's do it again. What do you think is a good time so that we can get some sleep, get this over with, then you can have lunch. So. Okay, great. But, yeah, it's really reassuring, though, you know, that you're feeling better because that usually does correlate with improvement. We just want to confirm for sure that the numbers are low enough to where they're not going to cause damage in the long term and, you know, cause complications and stuff. So. [Speaker B]: Yeah, that makes sense. [Speaker A]: Okay. And again, I Know, we talked about a lot of the options and stuff before, but, you know, say for example, and. Well, of course we'll get the biopsies first, see what's going on. But the budesonide, it can be kind of hard in terms of a prescription and a lot of my colleagues too have been talking about it nationally that it's just kind of hard to take it. And there's a medication called Eohelia that is a prescription option, but it's usually not covered, which is very annoying. And usually insurance companies have wanted patients to try this other medication, Dupixent, which is newer, before they will approve Euhelia. And Dupixent is the monoclonal antibody, which does work great too. So. So just keeping that in mind, you know, if we do need to make a change, which I'm hoping we won't, it sounds like we probably won't, but you know, just depicts that if, that if we need to switch to something next. That's probably what I would suggest. But a lot of people do really, really great on that, you know, but probably won't even need it. But just want to think about like a, you know, plan B for the future if we need. So. [Speaker B]: Okay. [Speaker A]: Okay. [Speaker B]: Yeah, my allergist also mentioned Dupixent. Like it's been, I think she mentioned it's been approved for hives as well. [Speaker A]: So it helps for a lot of different things too. Yeah, like allergic rhinitis with polyps, eczema, severe eczema, moderate severe asthma, because it helps with all that, like allergic type mediated conditions. So, you know, if it's something like, hey, let's just take care of all this stuff with one medication. Not a terrible idea. So, yeah, you know, so. Alrighty. So. Okay, let's watch. Any other questions for me or anything else? Like, do you need a refill? Anything else I can help with? [Speaker B]: I think, yeah, I mean, yeah, I think it depends on like what happens after the biopsy, but I think a refill wouldn't hurt. Like, and could you like send in like a longer term refill because they come out to be cheaper. [Speaker A]: Like, oh yeah, they'll cover it. I'm happy to send in a 90 day. I'll send in 90 day and if they cover it, they'll fill it. If not, we'll split it up for you. Okay. [Speaker B]: Okay. [Speaker A]: Yeah, of course. And do you want this to go to the Amazon home delivery? Okay, perfect. I will do that right now. The 40 milligrams, half an hour, meals twice daily, 90 day supply. I Put one refill on that too. Okay. So you'll have like, it like, like I'm sending in pretty much like six months worth for you. [Speaker B]: Okay, thank you. And of course, one more thing was. Yeah. Like, assuming like this has sustained the eosinophil count and like, or like has reduced it, what implications does that, does that have for like, future? Like, do I. I mean, that probably means I still have to like continue using PPIs for long. For the long term, right? [Speaker A]: No, so the thing is, that's what we were talking about, right? That we may want to switch you to something else. Because if you've been taking it regularly as you have been, and your body's not responding, your body is telling us that medication is not. [Speaker B]: No, no, I meant like it does respond. Like, what if the body does respond. [Speaker A]: And well, we can talk about it. I would give it some time. We could always consider going down to once a day at some point, you know, but, you know, maybe a combination of maybe like avoiding some food triggers. But we could think about that, you know, in the future too. Okay, Sorry. I want to make sure I answer your question properly. But yeah, I wouldn't say yet because we kind of just got you started on it. But once things are well controlled, we can think about. But I mean, probably you need to be on something. We know there's no cure for eosinophilic esophageitis. It doesn't really go away. So I wouldn't say like that you're going to be off like completely. That would be a bad idea. Unless you're on a really strict elimination diet. That work? Right? That could be an option. But at minimum, I would say once daily would probably be the best case situation if we're going to do. [Speaker B]: And what are there any studied long term health effects of PPIs? [Speaker A]: Well, we talked about that, I think in detail last time. Right. [Speaker B]: I'm not, I don't really remember. [Speaker A]: Oh yeah, we talked about a lot of stuff last time. So, I mean, there's no great, like randomized controlled studies. The best one showed that there was not like a cause and effect relationship between, you know, this use and you know, there's studies that have like a lot of confounding variables that have shown evidence of maybe like dementia, risk of hip fractures, like decreased bone density. But again, confounding variables. [Speaker B]: Variables. [Speaker A]: A lot of patients were like older have other issues that contribute to these things. The best study, the only one that was like a larger study that looked at thousands of patients, there was a Randomized control study found that the only thing there was like a very slight like a really low increased risk of like C. Difficile infection, like a diarrheal illness in the short term when you use it for a few months. But it didn't really see the other things. Otherwise there's like really small risks of like low magnesium levels potentially affecting your kidneys, like with a very specific diagnosis, but those are really rare. But you know, the risks of not treating eosinophilic esophagitis, I would say far, far outweigh the use of this medication long term. [Speaker B]: Okay. [Speaker A]: It just gives a bad rep because a lot of people end up on it that don't need it and they're like 20 medicines and you know, someone's doctor may be more worried about the blood thinner and so on and so forth. And the portal pentoborzole falls to bottom list and just gets carried on for years and years for people that don't need it. And then if you really don't need it, you're really assuming all the risks of any medication you take. Right. So. But yeah, very safe taking long term, it just kind of gets a better rep for different reasons. But I mean it's like going to be like less risk of this than like you know, a monocle antibody medication. Medication. Right. Like, like dupixent for example. I mean it is a safe medication, but it's still a monoclonal antibody that is going to be affecting your immune system. Right. So it's sort of about like the kind of like looking at all the different options and kind of optimizing your benefits and minimizing your risks with whatever treatment we choose. [Speaker B]: Okay. [Speaker A]: So. Yeah, so, yeah, so, all right. I will have my assistant give you a call to set up the endoscopy key and you know, if you need anything else, you know, just please let me know. Anything changes, if you need to change the date, we just ask that you call these like five days in advance. And again, if the dirty like you know something, it works for now. But you need anything to change, just you know, give us a call in case. [Speaker B]: Okay, perfect. Thank you so much. [Speaker A]: Okay. You're welcome. And I sent that, the 90 day prescription with an inbreed one that to the Amazon pharmacy for you. [Speaker B]: Yeah, thanks for that. [Speaker A]: Okay. Yeah, you're welcome. I'm really happy to hear you're feeling, you're starting to feel better and you know, we will figure out a good long term plan. [Speaker B]: Okay. Y. Thank you. [Speaker A]: Okay. You're welcome. Have a great day. See you soon. [Speaker B]: Bye. [Speaker A]: Bye.