00:00:00: So we're back again with Professor Alex Strahmann and were talking on the second part about rise in fall of eosinophilic esophagitis.

00:00:09: Welcome back, professor!

00:00:11: We left at their treatment options... ...and reached a consensus that we are starting with topical steroids….

00:00:18: …and then maybe do some experimentation with food.

00:00:22: but the thing is that deep remission can only be achieved in, let's say ten per cent of the patients.

00:00:29: So what can we offer to the vast majority or the rest?

00:00:33: The problem is you need food allergy and as soon your esophagus surface exposed through this to the culprit protein, the symptom will have a relapse.

00:00:48: that means I understand no symptoms, no inflammation over a prolonged period.

00:01:00: Without any treatment does not

00:01:04: exist.".

00:01:05: Yeah it's incurable!

00:01:06: It is written like this in literature...

00:01:08: "...it's not curable.

00:01:09: that correct either you treat with diet or you treated drugs.

00:01:17: the topical steroids are with biologics but do have to follow these over

00:01:23: months?".

00:01:24: Years, years.

00:01:26: As soon as you stop it the relapse is programmed.

00:01:32: We have so far no hints that EOE can be cured.

00:01:39: That's not very optimistic.

00:01:42: Yeah.

00:01:42: So it can be managed.

00:01:44: Yes Exactly!

00:01:47: If we are able to achieve the remission what happens afterwards in a short term?

00:01:53: Do you discontinue treatment and then see what happens, or do you continue it indefinitely?

00:01:59: What's your approach to

00:02:01: this?".

00:02:01: We have to inform the patient that they need a long-term management.

00:02:07: And if we have a remission under an ongoing treatment... ...we have to move forward with these treatments in efficient therapy.

00:02:22: depending on the situation in half a year or one-year, and to see.

00:02:27: And if the patient is not anymore motivated to move forward with either medication or diet then we have to stop but inform that the relapse will come within sometime few days sometimes for weeks few months.

00:02:53: Professor, what do you do when you achieve histological remission but there are still severe symptoms because they're discordant?

00:03:03: What do you with the symptoms?

00:03:04: how to address those?

00:03:06: we have two reasons for symptoms or problems of swallowing solid food.

00:03:13: one is if the inflammation it is likely the remodeling because in chronic aeosinophilic inflammation, there's strong stimulus for fibrosis.

00:03:31: A wall thickening of that esophagus and loss of distensibilities... And this is second reason to have a transport problem.

00:03:43: One reason is the inflammation itself, the other is the remodeling of the organ.

00:03:51: And in this situation a dilation is helpful.

00:03:56: we perform so-called Bouginards and then almost always symptoms decrease.

00:04:05: first step treat.

00:04:09: inflammation has gone and the symptoms persist, then we make a dilation of the esophagus.

00:04:18: Step by step carefully!

00:04:21: We use this boujee nage because... ...we can start with small diameters And don't risk injuries on the Esophagus.

00:04:36: We do it gentle step-by-step And the final goal is to have a diameter of the esophagus, or at least sixteen millimeters.

00:04:47: That's fair enough!

00:04:49: Professor, okay these are the patients that either we achieve symptoms and or histological remission... ...and then most probably maintain the treatment in regards to patient wishes.

00:05:02: but what do we do with the patients where we cannot achieve neither histological nor a clinical remission.

00:05:11: What can we offer them?

00:05:13: If both symptoms and inflammation persists, then we have to change the anti-inflammatory treatment.

00:05:21: Standard are topical acting corticosteroids.

00:05:25: Then We Have To Switch To Biologics And IL-III Blockade With Tupilumab is the alternative.

00:05:37: In our cohort of several hundred EOA patients, we achieve treatment goals with topical corticosteroids in about eighty percent of the patient's.

00:05:52: and if you don't achieve both goals then use Topiloma

00:05:58: And success rate on this case?

00:06:01: Almost a hundred per cent.

00:06:04: Okay, so it's not that dire.

00:06:06: But as I said about twenty percent of the patients need biologics to plume up?

00:06:15: The huge difference is the price.

00:06:19: Indeed.

00:06:19: Topical cortic cost theories are not for free but the costs are about seven bucks per day!

00:06:34: more than thirty thousand bucks per year.

00:06:37: It's another category and therefore we reserve this for severe diseased patients or For patients with a severe allergic comorbidity.

00:06:51: if the patient have in addition, A severe asthma Or an allergic rhinitis With a polyposis of the sinus a severe etopic dermatitis, then it makes sense to use the biologics.

00:07:11: Then you have two or even three flies per one batch because you act systemically and not only topical.

00:07:22: And

00:07:22: talking about systemic and interleukins, if one opens the scheme about eosinophilicus phagitis there are so many interleukeans signaling molecules.

00:07:33: So do you think that we could steal concepts from allergists to develop new treatment modalities?

00:07:41: Yes!

00:07:42: Which

00:07:42: ones?!

00:07:43: We

00:07:43: have two things Allatis use for atopic dermatitis and the skin, and the esophagus have many similarities.

00:07:57: We can copy first that topical vagotreatment.

00:08:02: The dermatologists used ointments we use liquids but topical access...we have both!

00:08:11: And second-the same drugs acting for atopic dermatitis for E.U.E as well, not only steroids but for instance calcinoirine inhibitors.

00:08:27: yeah we can look to dermatologist what is successful in a topic dermatitis.

00:08:34: topical treatment and we can copy

00:08:38: paste say having said that there are avenues potentially would be successful.

00:08:50: Where do you see the future in managing EOE?

00:08:53: Let's say, the unmet needs... Today it is extremely cumbersome to figure out the culprit food.

00:09:03: I'd absolutely happy if we had an allergic test.

00:09:09: We can see that in patient X. This food is the trigger, the culprit.

00:09:15: Food in patient Epsilon it's this one today.

00:09:19: we have to make a diet three months exclude that and ask for symptoms to scope the patients.

00:09:29: And really its time consuming.

00:09:32: It's costly Its cumbersome.

00:09:34: I would be happy if he had tests To figure out.

00:09:39: i'd be happy if we could induce a tolerance with immunotherapy.

00:09:46: But so far, we have no hints that an immunotherapy would be successful in EOE.

00:09:54: but if it could immunize the patients... If he knew its milk or its gluten and soy and we can perform an induced tolerance of immunotherapy.

00:10:09: this is great!

00:10:11: And then based on the crucial question, why did EUI not exist fifty years ago?

00:10:21: I have a concept in my head that industrialized food production is critical point to increase the allergenicity of The modern milk production, if you see the modern wheat production.

00:10:42: I think this is the backside of the metal that now based on these new techniques... ...the food has more had an increased allergenicity and If he could move back to traditional production methods it would solve the problem.

00:11:05: Well, that's a big game.

00:11:07: So Professor you already divulged one of your tips and tricks on how to reveal the actual symptom burden in patients and how they conspicuously hide their symptoms.

00:11:21: but do have any other tips or tricks to guide your EUE management?

00:11:27: Monitoring the symptoms.

00:11:29: we've validated questionnaires But this is complex.

00:11:34: I don't like it.

00:11:35: But we offer the patient a visual analogue scale from zero, right?

00:11:42: Completely free of symptoms... ...I can eat sandwich without any mineral water and ten!

00:11:48: I never would eat dry rice or steak and so on.

00:11:53: And then we ask to patients within this zero-to-ten scale where you will locate them today.

00:12:01: The other critical because all the manoeuvres that patients develop.

00:12:08: They drink a lot, they chew carefully.

00:12:12: this reduce their velocity of eating.

00:12:16: and we ask if you... If your original eating speed, eating velocity was hundred kilometers per hour on which level are you?

00:12:29: then we receive very precise answers.

00:12:33: I would think, sixty-five... Then we start treatment.

00:12:37: two months later We ask the patient now i'm on eighty kilometers per hour.

00:12:43: they easily can understand but you have to make it intra individual because The eating speed has a huge variability.

00:12:55: some are Very fast and others are very slow.

00:12:59: And you cannot say compared with your colleagues, You have to ask before we started year velocity was one hundred kilometers per hour!

00:13:11: Now today on which level?

00:13:16: This is the easiest way to monitor symptoms.

00:13:20: These are good.

00:13:21: I will definitely try those the next time i encounter these patients.

00:13:26: Professor, thank you so much.

00:13:29: It was a huge honor and pleasure to have with us And an incredible journey that we had The only other person To have seen it from just histopathology screaming at you That what is he doing?

00:13:45: With the use of a phylloxin esophagus to current advancements.

00:13:49: So thank you.

00:13:50: so, so much for sharing this with us.

00:13:52: Aigli I have to say Thank You!

00:13:54: You prepared it very well and we could laugh together.

00:13:58: It was great.

00:13:59: Thank you.

00:14:00: Yeah...

00:14:01: Thank you Professor Hope is useful for our audience And We will see in the next one.

00:14:07: Yes Okay Have a nice afternoon.