Systematic review with network meta-analysis: comparative effectiveness of topical steroids vs. PPIs for the treatment of the spectrum of eosinophilic oesophagitis

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SUMMARYBackgroundControversy surrounds the clinical and histological response to topical steroids in patients with eosinophilic oesophagitis (EoE).AimTo perform a systematic review and network meta-analysis of randomised controlled trials to assess the efficacy of topical steroids compared with placebo or proton pump inhibitor (PPIs) for the management of eosinophilic oesophagitis.MethodsCochrane Central Register of Controlled Trials and MEDLINE from inception to 1 July 2015 was searched. Data were extracted independently by two authors. Methodological quality was assessed using the Cochrane risk of bias tool. A network meta-analysis was performed using the Bayesian methods under random-effects multiple treatment comparisons. Results were summarised as odds ratio along with credibility intervals. We also calculated the ranking probability for each treatment based on surface under the cumulative ranking curve (SUCRA).ResultsThe overall methodological quality of included studies was low. SUCRA ranking probability indicated that PPI had the highest probability of being the best treatment for achieving histological remission and mean change in eosinophils (0.81 and 0.85, respectively), followed by budesonide (0.74 and 0.63, respectively) and fluticasone (0.5 and 0.5, respectively). None of the comparisons indicated a statistically signicant difference.ConclusionsThe results from network meta-analysis show that there is no statistically significant difference between PPI, budesonide and fluticasone for the treatment of EoE as assessed by the histological and clinical response. The evidence is limited by serious risk of bias and imprecision, which emphasises the urgent need for large RCTs with adequate sample size and methodological rigour to provide conclusive evidence.

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