P0296 - Efficacy of Topical Corticosteroids in Achieving Histologic, Clinical, and Endoscopic Remission in Patients With Eosinophilic Esophagitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Sunday, October 24, 2021

3:30 PM – 7:00 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Presenting Author(s)

Nabil El Hage Chehade, MD

MetroHealth Medical Center
Cleveland, OH, United States

Nabil El Hage Chehade, MD¹, Anastasia Chahine, MD², Sara Ghoneim, MD³, Nour El Hage Chehade, MD⁴, Josue Davila, MD⁵, Sherif Saleh, MD⁵, Fahmi Shibli, MD¹, Ronnie Fass, MD¹
¹Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; ²H. H. Chao Comprehensive Digestive Disease Center, University of California Irvine, Orange, CA; ³University of Nebraska Medical Center, Omaha, NE; ⁴Cleveland Clinic Foundation, Cleveland, OH; ⁵MetroHealth Medical Center, Cleveland, OH

Introduction: Eosinophilic esophagitis (EoE) is an immune-mediated inflammation that causes esophageal dysfunction. Current approaches to the management of EoE comprise dietary elimination, proton pump inhibitors, and topical corticosteroids (NSAIDs). No formulation of topical NSAIDs has been approved for eosinophilic esophagitis in the United States. In this meta-analysis, we evaluated various outcomes in patients with EoE who either received topical NSAIDs or placebo.

Methods: Scopus, PubMed/MEDLINE, and Cochrane databases were searched from inception to May 2021. Studies included involved adult patients with EoE who either received various formulations of topical NSAIDs or placebo and then were followed over a specified period of time. Analysis was conducted using the Mantel-Haenszel model and the odds ratio (OR) to assess histologic, endoscopic, and clinical response rates. The results were pooled together using Reviewer Manager 5.4 software, and inconsistency was quantified using I²statistics.

Results: 11 moderate-to-high quality randomized-controlled clinical trials involving 898 patients were included in the final analysis. Topical NSAIDs were effective in inducing both complete (OR 44.75, 95% CI [20.54, 148.53], P< 0.00001) and partial histologic response (OR 30.80, 95% CI [9.98, 95.06], P< 0.00001) compared with placebo. Subgroup analysis showed no significant differences among the mode of topical NSAIDs delivery (oral suspension, spray, or orodispersible tablet) or the NSAID agent used (budesonide or fluticasone) in achieving complete histologic response (P=0.2 and P=0.4, respectively). Topical NSAIDs were effective in achieving a clinical response rate (OR 3.02, 95% CI [1.41, 6.47], P=0.005) and endoscopic remission (OR 8.28, 95% CI [2.83, 24.22], P=0.00001). Further analysis revealed considerable reduction in esophageal eosinophil count, with a mean difference (MD) to placebo of 86.19 (95% CI [46.90, 125.49], P< 0.00001). Generally, topical NSAIDs were well tolerated. The most common adverse event was oroesophageal candidiasis (OR 5.31, 95% CI [1.94, 14.52], P=0.001).

Discussion: Topical NSAIDs were effective in inducing histological, clinical and endoscopic remission response in patients with EoE with tolerable adverse events. This is the first meta-analysis that compiled the most recent moderate-to-high quality randomized controlled trials and investigated various parameters with regards to different outcomes in patient with EoE treated with topical NSAIDs.

Figure: Forest plot comparing the rate of complete histologic remission in patients with eosinophilic esophagitis who received topical corticosteroids using different modes of delivery versus placebo. CI, confidence interval; M-H, Mantel-Haenszel.

Outcome	Subgroups	Included studies	OR & 95% CI P-value	P-value	I²
Complete Histologic Remission		10	44.75 [20.45, 97.93]	< 0.00001	11%
Mode of Delivery	Spray	3	25.12 [5.46, 115.62]	< 0.0001	0%
	Oral Suspension	6	38.71 [14.84, 100.94]	< 0.00001	8%
	Orodispersible Tablet	1	236.73 [31.54, 1776.93]	0.00001	NA
Type	Fluticasone	3	25.12 [5.46, 115,62]	0.0001	0%
Type	Budesonide	7	55.24 [20.54, 148.53]	0.00001	26%
Partial Histologic Remission		10	30.80 [9.98, 95.06]	0.00001	74%
Endoscopic Remission		6	8.28 [2.83, 24.22]	0.0001	63%
Clinical Remission		9	3.02 [1.41, 6.47]	0.005	79%
Oroesophageal Candidiasis		6	5.31 [1.94, 14.52]	0.001	0%

Table: Data summarizing the main outcomes of the study. OR, odds ratio.

Disclosures:
Nabil El Hage Chehade indicated no relevant financial relationships.
Anastasia Chahine indicated no relevant financial relationships.
Sara Ghoneim indicated no relevant financial relationships.
Nour El Hage Chehade indicated no relevant financial relationships.
Josue Davila indicated no relevant financial relationships.
Sherif Saleh indicated no relevant financial relationships.
Fahmi Shibli indicated no relevant financial relationships.
Ronnie Fass indicated no relevant financial relationships.

Nabil El Hage Chehade, MD¹, Anastasia Chahine, MD², Sara Ghoneim, MD³, Nour El Hage Chehade, MD⁴, Josue Davila, MD⁵, Sherif Saleh, MD⁵, Fahmi Shibli, MD¹, Ronnie Fass, MD¹. P0296 - Efficacy of Topical Corticosteroids in Achieving Histologic, Clinical, and Endoscopic Remission in Patients With Eosinophilic Esophagitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.