Comparative efficacy and safety of treatments for eosinophilic esophagitis: Systematic review and network meta-analysis of randomized controlled trials.

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.