Meta-Analysis
Copyright ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Meta-Anal. Jun 18, 2025; 13(2): 107171
Published online Jun 18, 2025. doi: 10.13105/wjma.v13.i2.107171
Swallowed topical steroid maintenance therapy for eosinophilic esophagitis: A systematic review and meta-analysis
Yi-Zhong Wu, Megan Kudlak, Manuel Garza, Alexander Grieme, Kyle S Liu, James J Kwon, Eric R Smith, Erica Yatsynovich, Bryce Bushe
Yi-Zhong Wu, Megan Kudlak, Alexander Grieme, Eric R Smith, Department of Internal Medicine, Baylor Scott & White, Round Rock, TX 78665, United States
Manuel Garza, Bryce Bushe, Division of Gastroenterology, Baylor Scott & White, Round Rock, TX 78665, United States
Kyle S Liu, Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO 63110, United States
James J Kwon, College of Medicine, Texas A&M University Health Science Center, Bryan, TX 77807, United States
Erica Yatsynovich, General Medicine, Faculty of Medicine, Masaryk University, Brno 62500, Czech Republic
Co-first authors: Yi-Zhong Wu and Megan Kudlak.
Author contributions: Wu YZ, Smith ER, Kudlak M, Bushe B contributed to conceptualization and design; Wu YZ, Kudlak M, Grieme A, and Garza M contributed to manuscript drafting. Wu YZ and Kudlak M contributed to article screening. Wu YZ, Kudlak M, and Garza M contributed to data extraction. Wu YZ and Garza M contributed to statistical analysis. Wu YZ, Yatsynovich E, and Grieme A contributed to tables and figures. Wu YZ and Grieme A contributed to quality of evidence assessment. Liu KS, Kwon JJ, Smith ER, and Bushe B contributed to critical revision of manuscript. Wu YZ contributed to guarantor of article; All authors contributed to final review and approval of the manuscript.
Conflict-of-interest statement: All authors of this study have no conflicts of interest to disclose.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Yi-Zhong Wu, MD, Department of Internal Medicine, Baylor Scott & White, 300 University Blvd., Round Rock, TX 78665, United States. yizhong.wu@bswhealth.org
Received: March 18, 2025
Revised: April 12, 2025
Accepted: May 13, 2025
Published online: June 18, 2025
Processing time: 91 Days and 5.9 Hours
Abstract
BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder presenting as symptoms of dysphagia, esophageal food impaction, chest pain, and heartburn. After an initial trial of proton pump inhibitor (PPI) therapy, swallowed topical corticosteroids (STC) are effective as induction therapy for EoE. However, outcome data for STC as a maintenance strategy is limited.

AIM

To systematically evaluate the long-term outcomes and safety of maintenance treatment with STC.

METHODS

A systematic search of PubMed, EMBASE, Cochrane, and Web of Science was performed from inception to January 2025 for studies comparing long term or maintenance treatment with STC for EoE compared to placebo. We included studies that investigated patients who underwent successful induction therapy. Pooled data was analyzed for histologic recurrence, symptom recurrence, need for repeat esophageal dilation, use of concomitant PPI, and candida infection rates. A random effects model was used, and the data was presented using odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Three randomized control trials and one observational study were included, involving 303 patients (189 in the STC group, 114 in the placebo-controlled group). Analysis showed that histologic recurrence was significantly lower with STC (OR: 0.04, 95%CI: 0.01-0.28, P < 0.00001, I2 = 78%). Overall symptom recurrence was similar between groups (OR: 0.23, 95%CI: 0.02-3.54, P = 0.29, I2 = 92%). On sensitivity analysis, symptom recurrence was significantly lower in the STC group (OR: 0.05, 95%CI: 0.02-0.17, P = 0.00001, I2 = 39%). Odds of repeat dilation were significantly lower in the STC group (OR: 0.14, 95%CI: 0.02-0.91, P = 0.04, I2 = 0%). Candida infection rates were similar between groups (OR: 6.13, 95%CI: 0.85-44.26, P = 0.07, I2 = 24%). Proportion of concomitant PPI use was similar between groups (OR: 1.64, 95%CI: 0.83-3.21, P = 0.15, I2 = 0%).

CONCLUSION

For patients who successfully achieved remission of EoE with STC induction therapy, maintaining treatment is effective in sustaining histologic remission, while newer regimens may be effective in preventing symptom recurrence compared to placebo. We found no significant difference for oropharyngeal/esophageal candidiasis with STC maintenance therapy. Future studies with longer follow-up periods are needed.

Keywords: Eosinophilic esophagitis; Maintenance; Therapy; Swallowed topical corticosteroids; Histologic; Recurrence; Symptoms

Core Tip: This meta-analysis seeks to perform a focused review of swallowed topical corticosteroid maintenance therapy for eosinophilic esophagitis. The results showed that the steroid group compared to placebo had significantly lower odds of disease recurrence histologically and lower odds of requiring repeat esophageal dilation. Our sensitivity analysis suggests that newer formulations of swallowed topical corticosteroids have favorable symptom outcomes. The groups were similar in candidal infectious outcomes. Thus, the existing literature shows that swallowed topical corticosteroids are safe and effective as maintenance therapy for eosinophilic esophagitis.