Eosinophilic esophagitis (EoE) is a chronic, allergic/immune condition of esophagus characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation.
Despite different drugs were studied for the treatment of EoE, there is no consensus on what the most effective medical interventions. We performed a systematic review and meta-analysis of RCTs to compare the efficacy of medical interventions in patients with EoE.
We searched MEDLINE, EMBASE and the Cochrane CENTRAL (via OvidSP) published from inception to November 01, 2018, to identify RCTs assessing the efficacy of medications (PPIs, steroids, anti-IL5 agents, anti-IL13 agents, anti-IL-4Rα agents and mast cell stabilizers) in patients with EoE. Outcomes were symptoms improvement and histology improvement. Studies that only reported continuous scores were excluded. Pooled risk ratios (RR) with 95% confidence intervals (CI), using a random effects model, were calculated.
Among 1311 citations, 19 RCTs (n=1239 EoE cases) were included. 11 RCTs compared steroids vs placebo, two compared PPIs vs steroids, two compared anti- IL-13 vs placebo, two compared anti-IL-5 vs placebo, one compared anti-IL-4Rα vs placebo, and one compared mast cell stabilizer vs placebo. Steroids demonstrated significant improved in histology (63.3% vs 2.9%; RR 10.12, 95% CI 4.56–22.46) and improved EOE symptoms (39.6% vs 20.0%; RR =1.91, 1.16,3.14) compared to placebo. No difference was seen between oral and inhale steroids. No significant difference was seen between PPI vs prednisone either in symptom (RR 1.33, 0.36, 4.97) or in histology improvement (RR 1.83,0.76,4.40). Limited data suggest there is no significant difference between anti-IL-13 vs placebo; and anti-IL5 vs placebo; anti-IL-4Rα dupilumab but not mast cell stabilizer cromolyn may significantly improve histology compared to placebo. No substantial heterogeneity was seen in all analyses.
Current evidence suggests steroids significantly improve histology as well as symptoms in patients with EoE in compared to placebo. There is no significant difference between steroids and PPI. Data relate to other newer agents are limited. This meta-analysis highlights the variability in the interventions of EoE and the need for further studies to determine the optimal intervention.