Comparative Efficacy and Safety of Swallowed Topical Corticosteroids in Eosinophilic Esophagitis: A Network Meta-Analysis

<b>Background</b>: Swallowed topical corticosteroids (STCs) are used as the first-line therapy for eosinophilic esophagitis (EoE) and have been extensively studied in randomized controlled trials (RCTs); however, the presentation and doses varied widely among the studies. <b>Aim</b>: The goal of this study was to compare the safety and effectiveness of the different STC-based options in EoE patients. <b>Methods</b>: We performed a literature search for RCTs, spanning a time period from database inception to July 2024, in order to compare the efficacy and safety of all STCs used to induce or maintain EoE remission each other and also with placebo or proton pump inhibitors (PPIs) in a network meta-analysis. Outcomes are expressed as pooled risk ratios (RRs) of failure and 95% confidence intervals (CIs), and we aimed to evaluate histological remission at <15-20 eosinophils per high-power field (eos/hpf), <5-6 eos/hpf, and <1 eos/hpf. The effect sizes for symptomatic improvement and the mean differences for endoscopic EREFS improvement with 95% CIs were also measured. Adverse events were evaluated using RRs, and these included oropharyngeal and esophageal candidiasis and adrenal suppression. <b>Results</b>: Twenty studies involving 1455 patients with active EoE reported on STC effectiveness to induce remission; three additional studies on 232 patients assessed the maintenance of remission. Budesonide 1 mg orodispersible tablets ranked highest in SUCRA in terms of all histological remission endpoints. Budesonide from inhalation devices was the only option superior to placebo in improving symptoms. Budesonide viscous suspension was the only option superior to placebo in improving endoscopy. No therapy was significantly associated with the risk of any adverse event. Significant inconsistencies and small study effects were detected in multiple comparisons. <b>Conclusions:</b> Budesonide orodispersible tablets were the best option for achieving EoE histological remission, but not symptomatic or endoscopic improvement. STC formulations were as safe as placebo or PPI.