Medical Treatment of Eosinophilic Esophagitis: A Cochrane Review

ABSTRACT

Background Current therapies for pediatric and adult eosinophilic esophagitis (EoE) include dietary elimination, proton pump inhibitors, swallowed corticosteroids, and biologics. Our aim is to systematically assess the efficacy and safety of published randomized controlled trials (RCTs) of medical therapies for EoE that compare active treatments to placebo or to an active comparator. We consider RCTs that target the induction and maintenance phases of therapy, separately. Methods A search was designed by a Cochrane information specialist and included Cochrane Gut Register, CENTRAL, MEDLINE, Embase, and clinicaltrials.gov databases, from inception to May 2022. Studies that met our search criteria were imported into Covidence for title and review. All authors participated in study screening, and each study was independently evaluated by two authors. Reports of RCTs that met the inclusion criteria were selected for full text review. Multiple reports of the same RCT were collapsed into the parent study. Data from these studies was then extracted to RevMan Web to assess study characteristics, including study design, EoE definition, inclusion / exclusion criteria, age range, interventions, number of patients randomized, number of patients who completed the study, primary and secondary outcomes and conflicts of interest. Studies were also assessed for potential sources of bias including baseline imbalance, selection, performance, detection, attrition, and reporting biases. We used Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) to assess the overall certainty of evidence supporting the primary outcome. Results As of May 2022, we identified 2,638 reports that met our search criteria of which 14 were duplicates, giving a total of 2,624 reports that were imported into Covidence for further review. Following title and screening, 259 reports were selected for full text review, which were collapsed into 46 distinct RCTs that met the inclusion criteria. The primary outcomes for our systematic review were histological improvement, endoscopic improvement, and clinical symptom improvement, all as defined by the study at study endpoint, and withdrawals due to adverse events. The secondary outcomes of our analysis were serious adverse events, endocrine complications, growth concerns, infections, and health-related quality of life. Study outcomes were analyzed on an intention-to-treat basis. Risk ratios (RRs) and corresponding 95% confidence intervals (95% CI) are reported for dichotomous outcomes, and mean difference and standard deviation are reported for continuous outcomes. The data will be presented in full. Conclusions Results of this analysis inform clinicians about the efficacy and potential side effects of different medical therapies for EoE in both pediatric and adult populations. Deficiencies in our current knowledge will be highlighted and will provide direction for design of future RCTs in the field. Future research should continue to explore factors that influence initial and subsequent medical therapy selection for people with EoE.