What is the proper dosing of Proton Pump Inhibitors (PPIs) for Eosinophilic Esophagitis (EoE)?

From the Guidelines

For eosinophilic esophagitis (EoE), the recommended PPI dosing is omeprazole 20 mg two times per day for at least 8-12 weeks, as this regimen has been shown to be effective in inducing remission. This recommendation is based on the British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines, which suggest that proton pump inhibitor therapy should be given two times per day for at least 8-12 weeks prior to assessment of histological response while on treatment 1. The guidelines also note that a meta-analysis in 2015 described a non-significant trend towards increased efficacy for two times per day dosing compared with a one time per day dose, and that a significant difference in clinicopathological response rates was reported in patients with EoE prescribed high-dose PPI, such as omeprazole 20 mg two times per day.

Some key points to consider when using PPI therapy to manage EoE include:

• The use of omeprazole at a dose of 20 mg two times per day, as this is the only PPI that has been assessed for the treatment of EoE 1
• The importance of explaining the indication for PPI therapy to patients and their general practitioners, as PPI therapy is not licensed for use in EoE 1
• The need for regular follow-up with a gastroenterologist to assess treatment response, which may include repeat endoscopy with biopsies to evaluate histological improvement
• The potential for dose reduction to lower doses after the initial treatment period, but only if there is a good response to treatment, and under the guidance of a gastroenterologist.

It's also important to note that PPIs work in EoE by reducing acid production, which decreases esophageal permeability and allergen penetration, and they may also have direct anti-inflammatory effects independent of acid suppression 1.

From the Research

PPI Dosing for Eosinophilic Esophagitis (EoE)

• The optimal dosing of proton pump inhibitors (PPIs) for the treatment of EoE is an area of ongoing research, with various studies examining the efficacy of different dosing regimens 2, 3, 4, 5, 6.
• A systematic review and meta-analysis found that PPI therapy results in clinical and histological remission in approximately 50% of EoE patients, with higher response rates observed in patients receiving twice-daily dosing compared to once-daily dosing 5, 6.
• Specifically, a study published in 2024 found that twice-daily PPI dosing induces a higher remission rate in EoE than once-daily regimen, regardless of the total daily dose 6.
• Another study published in 2025 found that double PPI doses compared to standard doses led to significantly higher histological remission rates (51.7% vs. 28.3%, p < 0.005) 5.
• The current evidence suggests that twice-daily PPI dosing may be more effective than once-daily dosing for inducing and maintaining remission in EoE patients, although further research is needed to confirm these findings and establish optimal dosing guidelines.

Key Findings

• PPI therapy is effective in inducing clinical and histological remission in approximately 50% of EoE patients 5.
• Twice-daily PPI dosing is associated with higher histologic response rates than once-daily dosing 6.
• Double PPI doses compared to standard doses lead to significantly higher histological remission rates 5.
• Maintenance half doses of PPIs can lead to sustained histological remission in approximately 68% of patients 5.

Study Implications

• The findings of these studies have implications for the treatment of EoE, suggesting that twice-daily PPI dosing may be a more effective regimen than once-daily dosing 5, 6.
• Further research is needed to confirm these findings and establish optimal dosing guidelines for PPIs in the treatment of EoE.