Recent advances in the treatment of eosinophilic esophagitis

Comparison of viscous budesonide and fluticasone in the treatment of patients with eosinophilic esophagitis: a systematic review and meta-analysis

Background

Steroids are an important pharmacologic treatment in patients with eosinophilic esophagitis (EoE). Fluticasone and budesonide are the 2 main steroid medications used in EOE treatment, but current United States (US) guidelines do not recommend one agent over the other. In this study, we conducted a meta-analysis to compare important patient outcomes when both agents are used.

Methods

A comprehensive search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus was performed from each database's inception to March 29th, 2023. Two independent reviewers systematically identified trials that compared the effect of budesonide vs. fluticasone in the management of EoE. A meta-analysis was performed using a fixed-effects model. The primary outcome was the histologic response (defined as an eosinophil count <15 per high-power field) which reflects the response to treatment.

Results

Three studies met our inclusion criteria and were included in the analysis, with a total of 272 patients. All studies were carried out in the US and 1 was a randomized controlled trial. Our meta-analysis showed no statistically significant difference with the use of budesonide compared to fluticasone in achieving a histologic response (odds ratio 1.29, 95% confidence interval 0.77-2.14; P=0.34; I2=0%).

Conclusion

Our systematic review and meta-analysis indicated no difference between budesonide and fluticasone in achieving a histologic response in patients with EoE.

Gene therapy for a murine model of eosinophilic esophagitis

BACKGROUND

Eosinophils are specialized granulocytic effector cells that store and release highly active mediators used in immune defense. Eosinophils are also implicated in the pathogenesis of allergic disorders, including eosinophilic esophagitis (EoE), a chronic disorder characterized by infiltration of eosinophils into the esophagus and release of mediators that damage tissue, resulting in gastrointestinal morbidity, food impaction, and dysphagia. Treatment with elimination diets and/or topical corticosteroid therapy slow disease progression, but are complicated by adverse effects, limited compliance, and loss of response to therapy. We hypothesized that a single administration of an adeno-associated virus (AAV) coding for an anti-eosinophil monoclonal antibody that induces eosinophil clearance (anti-Siglec-F) would treat on a persistent basis a murine model of EoE.

METHODS

A mouse model of peanut-induced EoE that mimics the human disease was established by sensitization and challenge with peanut extract. After challenge, these mice exhibited an EoE phenotype demonstrated by elevated levels of blood eosinophils, infiltration of eosinophils in the esophagus with associated esophageal remodeling and food impaction.

RESULTS

The mice were treated with a single intravenous administration (10¹¹ genome copies) of AAVrh.10mAnti-Eos, a serotype rh.10 AAV vector coding for an anti-Siglec-F monoclonal antibody. Vector administration resulted in persistent, high levels of anti-Siglec-F antibody expression. Administration of AAVrh.10mAnti-Eos to the mouse model of EoE reduced blood (P < 0.02) and esophageal eosinophil numbers (P < 0.002) protected from esophageal tissue remodeling and minimized food impaction.

CONCLUSION

These results suggest that a single treatment with AAVrh.10mAnti-Eos has the potential to provide persistent therapeutic benefit to patients with EoE.

Corticosteroids for Eosinophilic Esophagitis in Children: A Meta-analysis

CONTEXT

Treatment of eosinophilic esophagitis (EoE) is focused on dietary, pharmacologic, and endoscopic therapy options. Within the pharmacologic alternatives, topical corticosteroids are the most used, and a large number of studies evaluating their effectiveness have been published, requiring a new summary of evidence.

OBJECTIVE

To evaluate the histologic and clinical effectiveness of the use of corticosteroids in pediatric patients with a diagnosis of EoE.

DATA SOURCES

Cochrane Central Register of Controlled Trials, Medline, Embase, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, Latin American and Caribbean Health Sciences Literature, and ClinicalTrials.gov (June 2019).

STUDY SELECTION

We selected randomized controlled trials assessing corticosteroids versus a placebo or dietary treatment of EoE in children.

DATA EXTRACTION

Methodologic quality of evidence was evaluated by using the Cochrane Collaboration's risk of bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system. The primary outcomes were clinical and histologic improvement.

RESULTS

A total of 1655 studies were identified. Five studies were included (206 patients). Histologic response was 49.25% in the corticosteroids group and 4.16% in the placebo group (risk ratio 11.05 [confidence interval 3.8-32.15]; P < .0001). Symptomatic response was 33.6% in the corticosteroids group and 21.8% in the control group (risk ratio 1.62 [confidence interval 0.94-2.79]; P = .08). There were no major adverse effects.

LIMITATIONS

Heterogeneity of the diagnosis of EoE.

CONCLUSIONS

Our review revealed favorable results of corticosteroids versus placebo, mainly in histologic response. More studies are needed, by using validated clinical scores, to obtain more reliable results.