"Our reviews support the use of corticosteroids, but more research needs to be performed, including other therapies, especially the exclusion diet (closely monitored by a physician to avoid unnecessary dietary restrictions)," Dr. Juan Cristobal Gana of Escuela de Medicina, Pontificia Universidad Catolica de Chile, in Santiago, told Reuters Health by email.
The mainstays of treatment of EoE include a diet that excludes wheat, milk, egg, nuts, soy, fish and shellfish and pharmacologic measures including topical corticosteroids, which decrease esophageal infiltration by eosinophils, mast cells and lymphocytes. Randomized clinical trials of corticosteroids, however, have yielded inconclusive results.
Dr. Gana and colleagues assessed the benefits and harms of corticosteroids versus placebo or exclusion diets for EoE in children in their meta-analysis of five randomized controlled trials that enrolled a total of 206 patients.
Histologic response rates were significantly higher in the corticosteroids group (66/134, 49%) than in the placebo group (3/72, 4%), regardless of whether the corticosteroid was budesonide or fluticasone.
However, symptomatic response rates did not differ significantly between corticosteroid treatment (39/116, 34%) and placebo control groups (12/55, 22%), the researchers report in Pediatrics.
Across the included studies, six patients developed oropharyngeal or esophageal candidiasis in association with corticosteroid treatment.
Limitations of the analysis include the heterogeneity of the diagnosis of EoE, inconsistent inclusion of the use of proton pump inhibitors before diagnosis, and wide variability in the exclusion diet criteria.
"We can recommend the use of corticosteroids in patients with EoE, since the benefit of their use would outweigh the risks," Dr. Gana said. "More studies, specifically of the pediatric population, are needed, ideally with clinical evaluation using validated and standardized scores, in order to obtain more reliable results."
He added, "We were unable to perform, in our systematic review, a subgroup analysis comparing corticosteroids versus exclusion diets because of the lack of appropriate studies, and we think this is an important research topic that needs to be addressed."
Dr. Jonathan M. Spergel of Children's Hospital of Philadelphia, who recently reviewed EoE in children but was not involved in the new analysis, told Reuters Health by email, "Corticosteroids are effective in the treatment of EoE (50% effective), which has been seen in both pediatrics and adults. More studies need to examine safety issues."
Dr. Jonathan E. Markowitz of Prisma Health Children's Hospital-Upstate and University of South Carolina School of Medicine-Greenville, who has also reviewed eosinophilic esophagitis in children and adults, said, "I consider corticosteroids one of several treatment options for children with EoE. This disease does not fall under the 'one-treatment-fits-all approach' and so the right treatment choice depends on several factors, including the patient's age, severity of disease, and what foods they are sensitized to, among others."
"I personally consider corticosteroids a second-line treatment for patients who fail (or are unable to adhere to) dietary therapy, but for certain patients steroids may be a better first-line option (and may be further down on the list of options for others)," he told Reuters Health by email.
Dr. Markowitz, who was not involved in the new research either, added, "Given our rapidly expanding understanding of EoE, I feel we should be constantly re-evaluating the way we treat patients, and this report will hopefully spur further thought about all treatments."
By Will Boggs MD
SOURCE: https://bit.ly/35Brh3G Pediatrics, online October 28, 2020.
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