Comparative efficacy and safety of treatments for eosinophilic esophagitis: Systematic review and network meta-analysis of randomized controlled trials
In brief
Dupilumab and swallowed steroids rank among top EoE treatments
In a review of 48 trials involving 3,963 people, high-frequency dupilumab and swallowed topical corticosteroids ranked among the most effective treatments for symptoms and quality of life. Several therapies also reduced esophageal eosinophils, but that improvement did not always translate to patient-important benefits; evidence for broader elimination diets was low certainty, with added burden.
- Journal
- The Journal of allergy and clinical immunology (Q1)
- Published
- 20 October 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Yetiani Roldan, Isabella Silang, Daniel Rayner, Vanessa Wong, Alexandro W L Chu, Nazmul Islam, et al.
- PMID
- 42901296
- DOI
- 10.1016/j.jaci.2026.09.031
Why clinicians should know about it
- Picked for Immunology and Allergy (paper of the day, 21 October 2026): Comparative evidence for biologic, dietary, and drug therapy in EoE
Abstract
BACKGROUND: Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease characterized by esophageal dysfunction and eosinophilic inflammation. Comparative efficacy and safety of therapies remain uncertain. OBJECTIVE: To compare efficacy and safety of treatments for EoE in children and adults. METHODS: We conducted a systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing pharmacologic, dietary, and mechanical interventions. We searched MEDLINE, EMBASE, and CENTRAL to March 17, 2026. Reviewers screened studies, extracted data, and assessed risk of bias. We conducted random-effects NMA; assessed certainty using GRADE. RESULTS: We included 48 RCTs (3,963 participants). High-frequency dupilumab [mean difference (MD) -11.08, 95% confidence interval (CI) -15.14 to -7.03; high certainty] and swallowed topical corticosteroids (STCs) (MD -6.86, 95%CI -9.17 to -4.56; moderate certainty) are likely among the most effective for symptoms. Similarly, high-frequency dupilumab (MD 6.57, 95%CI 3.42 to 9.71; moderate certainty) and STCs (MD 7.20, 95%CI 1.01 to 13.39; moderate certainty) are among the most effective for quality-of-life. Certain biologics and epicutaneous immunotherapy are likely not different from placebo for symptoms (moderate certainty). Multiple interventions reduce peak eosinophil counts (high certainty) and likely do not increase harms versus placebo (moderate or high certainty). Four- and six-food elimination diets (FEDs) may be better than 1FED for symptoms (low certainty), but not other outcomes, with greater burden. CONCLUSIONS: High-frequency dupilumab and STCs are among the most effective therapies across patient-important and inflammatory outcomes. Histologic improvements do not guarantee patient-important outcome improvement. FED benefits are modest and low certainty, and traded off by burdens.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.