1. Introduction
Eosinophilic esophagitis (EoE) is an immune-mediated disease characterized by an eosinophil-predominant inflammation restricted to the esophagus and by the appearance of symptoms of esophageal dysfunction [
1]. It is considered a type 2 inflammatory response mainly triggered by food antigens [
1,
2]. In EoE, dietary allergens activate the esophageal epithelium and trigger the production of T-helper (Th)-2 cytokines that stimulate different immune cells. Interleukin (IL)-4 and IL-13 locally produced activate the signal transducer and activator of transcription 6 (STAT6), which induces eotaxin-3 (also called
CCL26) expression. Eotaxin-3 promotes the recruitment of eosinophils from blood to esophageal tissues, leading to eosinophilic inflammation [
3]. Additionally, lymphocytes in the esophagus produce other Th-2 cytokines, such as IL-5 and IL-15, that contribute to the perpetuation of inflammation, altering the barrier function, increasing esophageal permeability to dietary antigens, and promoting tissue remodeling [
2], which in the long term results in fibrosis that is manifested as rings and strictures in endoscopy. These alterations determine a variety of symptoms that include dysphagia, food impaction, heartburn, regurgitation, vomiting, nausea, and abdominal pain [
1,
4].
Fist-line treatment options for EoE include dietary modifications, proton pump inhibitors (PPIs), and swallowed topical corticosteroids [
4]. PPIs are widely accessible and convenient drugs, therefore representing the most commonly used therapy at all ages and in most settings [
5,
6,
7]. The primary mechanism of action of PPIs is the blockage of the gastric H, K-ATPase, thereby inhibiting gastric acid secretion [
8]. The CYP2C19 genotype-informed metabolic phenotype was shown to impact PPI pharmacokinetics, safety, and efficacy in several diseases, including peptic ulcer, gastroesophageal reflux disease, and
Helicobacter pylori eradication. For this reason, the Clinical Pharmacogenetics Implementation Consortium (CPIC) has published a pharmacogenetic guideline recommending omeprazole, pantoprazole, and lansoprazole dose adjustments based on the CYP2C19 phenotype [
9]. To further optimize and personalize EoE treatment with PPIs, other biomarkers have been proposed [
10,
11], albeit their clinical relevance has not yet been proven. One of these biomarkers is
STAT6, which has been identified as a PPI target in EoE patients, as it is involved in drug pharmacodynamics since PPIs block STAT6 binding to the
CCL26 promoter [
10]. Therefore, the aim of this research was to analyze the impact of
CYP2C19 and
STAT6 genetic variation (and variation in other relevant pharmacogenes such as
CYP3A4,
CYP3A5, or
ABCB1) on PPI response, and of
STAT6 variants on EoE baseline status (i.e., peak eosinophils count, endoscopic phenotype, and symptoms) and comorbidities. It should also be noted that with
STAT6, as with other pharmacogenes, there is a fine line between human genetics and pharmacogenetics; some biomarkers can be both diagnostic and pharmacogenetic. Thus, this research also aimed to understand the role of
STAT6 genetic variants in the development and progression of EoE. This research is part of the La Princesa Multidisciplinary Initiative for the Implementation of Pharmacogenetics (PriME-PGx) [
12].
3. Discussion
PPIs are the most widely used first-line treatment for EoE due to their safety profile, easy administration, and low cost [
5,
6]. However, it is estimated that only 50% of patients under PPI treatment reach histological remission [
13], and personalizing pharmacological therapy might be a key tool to increase this rate of response. Thus, the objective of this research was to find useful predictors of PPI response in patients with EoE, which might be useful not only to guide drug selection but also dose optimization, which is common and highly relevant in the treatment of EoE with PPIs.
Eighty-nine percent of patients included in this research were men (8:1 ratio), which is concordant with the well-defined higher incidence of EoE among males [
14,
15,
16]. As in other series [
17], omeprazole was the most commonly used PPI (53.6%), and it led to higher PEC reduction compared to other active ingredients. These results are partially consistent with previous research, in which a trend towards a higher omeprazole and esomeprazole effectiveness was observed [
17]. In Spain, the cost for an omeprazole 20 mg capsule is EUR 0.09, compared to EUR 0.45, 0.57, and 0.62 for esomeprazole 20 mg, lansoprazole 30 mg, and pantoprazole 40 mg, respectively [
18]. This five- to seven-fold price difference might justify omeprazole predominance. The better response observed in patients treated with omeprazole may be explained by their lower disease duration, as longer disease duration is associated with a transition to a fibrotic state, resulting in a lower response to pharmacological therapy [
19].
Several studies have shown the role of STAT6 in the eosinophilic inflammation of EoE by inducing
CCL26 expression [
3]. However, its role as a pharmacogenetic biomarker in this disease and the association with its symptoms and comorbidities have not been widely studied. In this work, the g.18453G>C far upstream variant in
STAT6 (rs12368672) was related to lower baseline PEC and to lower EREFS score reduction. In a previous article, an association between this variant and higher eosinophil/hpf levels previous to PPI treatment was found [
11]. Although these results appear to be contradictory, it should be taken into account that
STAT6 is located in the reverse strand of DNA, the probe used in both studies (C_31186828_10, Applied Biosystems, Thermofisher, Waltham, MA, USA) provides the genotype in the forward strand, and this variant entails a change between complementary nucleotides, which might act as a cofounding factor [
20]. Thus, a clear description of the nomenclature and reference sequence is needed to enable comparison and conclusion drawing. Additionally, differences in the study populations (adult versus pediatric) should also be considered. In addition, three articles have supported the relevance of this variant in food allergy, which is consistent with the trend observed in our work towards a higher prevalence of food allergy in patients with the
STAT6 g.18453G>C (rs12368672) C/C genotype compared to the G/G and G/C genotypes [
21,
22,
23]. The lack of a clear description of the reference sequence used, as mentioned above, prevents us from jointly weighing the direction of the association. Nevertheless, the fact that different and independent articles have reported an effect of the same
STAT6 variant suggests its potential relevance, not only in EoE but in its comorbidities and other allergic or atopic diseases. Additionally, patients with the
STAT6 g.27148G>A (rs167769) G/G genotype suffered from heartburn with higher frequency than patients with the G/A genotype, and a similar trend was observed for the g.28741G>A (rs324011) and g.18453G>C (rs12368672) G/G genotypes, probably due to its high, although not complete, linkage disequilibrium with rs167769 [
11]. Lastly, patients with the
STAT6 g.41214A>G (rs1059513) A/A genotype had a higher frequency of food impaction improvement after treatment compared to those with the A/G genotype. To our knowledge, this is the first work to find such associations. Although these results should be considered cautiously, they suggest the relevance of
STAT6 genetic variation in EoE baseline status, symptoms, and comorbidities, shedding some light onto its impact on EoE mechanism of action. Due to the fine line between human genetics and pharmacogenetics, these results may open a way to predicting the risk of EoE development, thus facilitating early diagnosis, which would possibly lower the progression to a fibrotic phenotype, and the discovery of new targets for the treatment of this illness.
In our research, PEC reduction was approximately 35% lower in CYP2C19 RMs compared NMs, IMs, and PMs, although this difference was not statistically significant, likely due to the reduced sample size. However, CPIC only considers dose adjustments for ultrarapid metabolizers (UMs) [
9], a phenotype absent in our study and which shows even higher enzymatic activity than that of RMs; therefore, greater differences with respect to NMs, IMs, and PMs could be expected. Further research with increased sample sizes and including UMs is needed to assess whether CYP2C19 RMs may also benefit from a PPI dose increase in EoE treatment, as shown in a different study [
24].
Lastly, PPIs are proposed to be substrates and inhibitors of the
ABCB1-coded transporter, P-glycoprotein (P-gp) [
25]. In this research, a nominal association between the
ABCB1 g.186947T>G/A (rs2032582) G/G, G/A, and A/A genotypes and lower EREFS reduction was observed compared to the T/T and T/G genotypes. Concordantly, these
ABCB1 genetic variants were found to alter PPI pharmacokinetics or pharmacodynamics in previous studies [
26,
27]. However,
ABCB1 structural and functional characterization is required prior to concluding the clinical relevance of variant–phenotype associations.
This study is intended as an exploratory and descriptive study, where statistical significance does not imply clinical relevance, especially in light of the limited sample size. Therefore, the main limitation of this study was the small sample size available, especially for the variants with a low prevalence within the population, which reduces the statistical power. This, along with the low incidence of ADRs associated with PPI treatment at standard doses [
28,
29], led to the lack of meaningful conclusions in the analysis of drug tolerability. Nevertheless, further research is needed on the safety of long-term treatment with high-dose PPIs [
30,
31] and on the ability of
STAT6 genetic variants to predict this response. In addition, a better analysis of the linkage disequilibrium between
STAT6 variants should be performed, which might lead to allele and posterior phenotype definition, and a clear description of the reference sequence used is also needed to allow for comparison between results [
32,
33]. Furthermore, a functional characterization of
STAT6 variants (i.e., their impact on STAT6 expression and/or function) would also be of interest to better predict their clinical consequences. Thus, further research is warranted to clarify the impact and clinical relevance of these associations, not only in adult patients but also in pediatric EoE patients. However, this study also has some strengths. It is a prospective study analyzing the main candidate genes for PPI response and EoE development in a population representative of the real EoE population, and in which variability was reduced by standardizing PPI treatment, duration, and dose. Additionally, this research also sheds some light on the impact of
STAT6 genetic variation on the EoE mechanism of action, which might open an avenue to its study as a diagnostic and pharmacogenetic biomarker.