Evaluation of swallowed topical corticosteroids for eosinophilic esophagitis

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Created On: 20/02/2026

For eosinophilic esophagitis (EoE), swallowed topical corticosteroids (STCs) are widely recommended as the first-line intervention.

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Key take away

Budesonide orodispersible tablets are the most effective swallowed topical corticosteroids for histological healing in eosinophilic esophagitis.

Background

For eosinophilic esophagitis (EoE), swallowed topical corticosteroids (STCs) are widely recommended as the first-line intervention. This study aimed to systematically determine the efficacy and safety of all available STC formulations for both induction and maintenance of remission in EoE, using placebo and proton pump inhibitors (PPIs) as reference treatments.

Method

A comprehensive search of randomized controlled trials (RCTs) was performed. A network meta-analysis was executed to explore STC-based therapies utilized for active and maintenance treatment of EoE. Primary endpoints included treatment failure risk, expressed as pooled risk ratios and 95% confidence intervals.

Histological remission was assessed via 3 thresholds: <15–20, <5–6, and <1 eosinophils per high-power field (eos/hpf). Secondary outcomes included clinical symptom improvement, endoscopic severity assessed by the eosinophilic esophagitis endoscopic reference score (EREFS) score, and treatment-related adverse events, including oropharyngeal and esophageal candidiasis and adrenal suppression.

Result

Overall, 20 RCTs comprising 1,455 subjects with active EoE evaluated STCs for remission induction, while 3 additional trials involving 232 subjects examined remission maintenance. Across all histological remission thresholds, budesonide 1 mg orodispersible tablets achieved the highest surface under the cumulative ranking curve (SUCRA) scores, indicating superior mucosal healing.

Budesonide administered via inhalation devices was the only STC that portrayed a statistically significant benefit over placebo for symptom improvement, whereas budesonide viscous suspension was uniquely associated with substantial endoscopic improvement when compared with placebo. Across all comparisons, no STC formulation amplified the chances of overall or specific adverse events. However, significant heterogeneity, inconsistency, and small-study effects were witnessed in several network comparisons.

Conclusion

Among STCs, budesonide orodispersible tablets yielded the most consistent histological remission in EoE, although improvements in symptoms and endoscopic findings varied by formulation. Overall, STC therapies depicted a safety profile comparable to placebo and PPIs, reinforcing their role as a cornerstone treatment in EoE care.