1-Minute Summary: A Network Meta-Analysis of Randomised Controlled Trials on the Treatment of Eosinophilic Esophagitis in Adults and Children

Expert Name
Dr Theodore Rokkas
Expert Affiliation
Henry Dunant Hospital, Athens, Greece
Journal of Clinical Gastroenterology

Rokkas T, et al. A network meta-analysis of randomized controlled trials on the treatment of eosinophilic esophagitis in adults and children. J Clin Gastroenterol 2020; published ahead of print.

For eosinophilic esophagitis (EoE), apart from steroids [1], newer therapeutic interventions and relevant randomised controlled trials (RCTs) are available that have not been included in previous meta-analyses [2-6]. Network meta-analysis (NWM) is an evidence synthesis tool for comparing RCTs with multiple treatments [7-9]. The aim was to evaluate the comparative efficacy of various drug therapies in EoE and to re-examine the current evidence concerning EoE treatment in adults and children.

FIGURE. Rankograms for the eosinophilic esophagitis intervention network showing the cumulative rank order for each of the 15 therapeutic interventions. BOT, budesonide orodispersible tablet; NS, nebulised steroid; OBS, oral budesonide suspension.

A NWM was performed to combine direct and indirect data to investigate the efficiency of drug therapies, which were evaluated in relevant RCTs for EoE.

Seventeen eligible studies (14 two-arm and 3 multiple-arm) were introduced to the meta-analysis [10-26]. A total of 1,011 patients were included, in whom 15 therapeutic interventions were used, namely: (1) budesonide oral suspension, (2) budesonide 1 mg orodispersible tablet twice daily, (3) budesonide 2 mg orodispersible tablet twice daily, (4) esomeprazole, (5) fluticasone, (6) nebulised steroid, (7) placebo, (8) prednisone, (9) anti-IL-5-mab (mepolizumab), (10) anti-IL-5-mab [reslizumab 1 mg/kg], (11) anti-IL-5-mab [reslizumab 2 mg/kg], (12) anti-IL-5-mab [reslizumab 3 mg/kg], (13) anti-IL-13-mab (QAX 576), (14) anti-IL-13-mab [RCP 4046 (180)], and (15) anti-IL-13-mab [RCP 4046 (360)]. Budesonide 1 mg orodispersible tablet twice daily showed the highest efficacy (surface under the cumulative ranking [SUCRA] 0.91), whereas placebo was the least effective (see Figure).

This NWM suggests that overall among various therapeutic interventions tested in RCTs, budesonide 1 mg orodispersible tablet twice daily is the best therapeutic intervention for EoE. Subgroup NWM of RCTs according to patient’s age demonstrated that budesonide 1 mg orodispersible tablet remained the optimal therapeutic approach in adults, whereas the respective optimal treatment in paediatric patients was fluticasone, due systemic bioavailability.


  1. Liacouras CA, et al. Primary eosinophilic esophagitis inchildren: successful treatment with oral corticosteroids. J Pediatr Gastroenterol Nutr. 1998;26: 380–385.
  2. Rothenberg ME, et al. Treatment of patients with the hypereosinophilic syndrome with mepolizumab. N Engl J Med. 2008;358:1215–1228.
  3. Plotz SG, et al. Use of an antiinterleukin-5 antibody in the hypereosinophilic syndrome with eosinophilic dermatitis. N Engl J Med. 2003;349:2334–2339.
  4. Gevaert P, et al. Nasal IL-5 levels determine the response to anti-IL-5 treatment in patients with nasal polyps. J Allergy Clin Immunol. 2006;118: 1133–1141.
  5. Haldar P, et al. Mepolizumab and exacerbations of refractory eosinophilic asthma. N Engl J Med. 2009;360:973–984.
  6. Nair P, et al. Mepolizumab for prednisone-dependent asthma with sputum eosinophilia. N Engl J Med. 2009;360:985–993.
  7. Salanti G, et al. Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial. J Clin Epidemiol. 2011;64:163–171.
  8. Chaimani A, et al. Graphical tools for network meta-analysis in STATA. PLoS One. 2013;8: e76654.
  9. Brown S, et al. A Microsoft-Excel-based tool for running and critically appraising network meta-analyses an overview and application of NetMetaXL. Syst Rev. 2014;3:110.
  10. Konikoff MR, et al. A randomized, double-blind, placebo-controlled trial of fluticasone propionatefor pediatric eosinophilic esophagitis. Gastroenterology. 2006;131: 1381–1391.
  11. Schaefer ET, et al. Comparison of oral prednisone and topical fluticasone in the treatment of eosinophilic esophagitis: a randomized trial in children. Clin Gastroenterol Hepatol. 2008;6:165–173.
  12. Dohil R, et al. Oral viscous budesonide is effective in children with eosinophilic esophagitis in a randomized, placebo-controlled trial. Gastroenterology. 2010;139: 418–429.
  13. Peterson KA, et al. Comparison of esomeprazole to aerosolized, swallowed fluticasone for eosinophilic esophagitis. Dig Dis Sci. 2010;55:1313–1319.
  14. Straumann A, et al. Budesonide is effective in adolescent and adult patients with active eosinophilic esophagitis. Gastroenterology. 2010;139:1526–1537.
  15. Straumann A, et al. Anti-interleukin-5 antibody treatment (mepolizumab) in active eosinophilic oesophagitis: a randomised, placebo-controlled, double-blind trial. Gut. 2010;59:21–30.
  16. Dellon ES, et al. Viscous topical is more effective than nebulized steroid therapy for patients with eosinophilic esophagitis. Gastroenterology. 2012;143:321–324.
  17. Alexander JA, et al. Swallowed fluticasone improves histologic but not symptomatic response of adults with eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2012;10:742–749.
  18. Spergel JM, et al. Reslizumab in children and adolescents with eosinophilic esophagitis: results of a double-blind, randomized, placebo-controlled trial. J Allergy Clin Immunol. 2012;129:456–463.
  19. Moawad FJ, et al. Randomized controlled trial comparing aerosolized swallowed fluticasone to esomeprazole for esophageal eosinophilia. Am J Gastroenterol. 2013;108:366–372.
  20. Butz BK, et al. Efficacy, dose reduction, and resistance to high-dose fluticasone in patients with eosinophilic esophagitis. Gastroenterology. 2014;147:324–333.
  21. Gupta SK, et al. Efficacy and safety of oral budesonide suspension in pediatric patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2015;13:66–76.
  22. Rothenberg ME, et al. Intravenous anti- IL-13 mAb QAX576 for the treatment of eosinophilic esophagitis. J Allergy Clin Immunol. 2015;135:500–507.
  23. Miehlke S, et al. A randomised, double-blind trial comparing budesonide formulations and dosages for shortterm treatment of eosinophilic oesophagitis. Gut. 2016;65:390–399.
  24. Dellon ES, et al. Budesonide oral suspension improves symptomatic, endoscopic, and histologic parameters compared with placebo in patients with eosinophilic esophagitis. Gastroenterology. 2017;152: 776–786.
  25. Lucendo A, et al. Efficacy of budesonide orodispersible tablets as induction therapy for eosinophilic esophagitis in a randomized placebo-controlled trial. Gastroenterology. 2019;157:74–86.
  26. Hirano I, et al. RPC4046, a monoclonal antibody against IL13, reduces histologic and endoscopic activity in patients with eosinophilic esophagitis. Gastroenterology. 2019;156:592–603.

24 thoughts

  1. Howdy would you mind letting me know which web host you’re working with? I’ve loaded your blog in 3 different internet browsers and I must say this blog loads a lot faster then most. Can you suggest a good web hosting provider at a fair price? Thank you, I appreciate it!|

Leave a Reply

Your email address will not be published.