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Meta-Analysis
. 2017 Sep;62(9):2408-2420.
doi: 10.1007/s10620-017-4642-7. Epub 2017 Jun 12.

Six-Food Elimination Diet and Topical Steroids are Effective for Eosinophilic Esophagitis: A Meta-Regression

Cary C Cotton  1 , Swathi Eluri  1 , W Asher Wolf  1 , Evan S Dellon  2
Affiliations
Meta-Analysis

Six-Food Elimination Diet and Topical Steroids are Effective for Eosinophilic Esophagitis: A Meta-Regression

Cary C Cotton et al. Dig Dis Sci. 2017 Sep.

Abstract

Background: Topical corticosteroids or six-food elimination diet is recommended as initial therapy for eosinophilic esophagitis (EoE).

Aims: We aimed to summarize published manuscripts that report outcomes of these therapies for EoE.

Methods: We performed a systematic review in MEDLINE, Web of Science, and Embase of published manuscripts describing topical fluticasone, topical budesonide, and six-food elimination diet as therapies for EoE. We conducted meta-analysis of symptom improvement and the change in peak mucosal eosinophil count, with heterogeneity between studies examined with meta-regression analysis.

Results: Systematic review yielded 51 articles that met inclusion criteria. Summary histologic response rates were 68.3% [95% prediction limits (PL) 16.2-96.0%] for fluticasone, 76.8% (95% PL 36.1-95.1%) for budesonide, and 69.0% (95% PL 31.9-91.4%) for six-food elimination diet. Corresponding decreases in eosinophil counts were 37.8 (95% PL 19.0-56.7), 62.5 (95% PL 125.6 to -0.67, and 44.6 (95% PL 26.5-62.7), respectively. Symptom response rates were 82.3% (95% PL 68.1-91.1%), 87.9% (95% PL 42.7-98.6%), and 87.3% (95% PL 64.5-96.3%), respectively. Meta-regression analyses decreased the initially large estimate of residual heterogeneity and suggested differences in histologic response rate associated with study populations' baseline eosinophil count and age.

Conclusions: The literature describing topical corticosteroids and six-food elimination diet consists of small studies with diverse methods and population characteristics. Meta-analysis with meta-regression shows initial histologic and symptomatic response rates on the same order of magnitude for topical corticosteroids and six-food elimination diet, but heterogeneity of study designs prevents direct comparison of modalities.

Keywords: Corticosteroids; Dietary elimination therapy; Eosinophilic esophagitis; Meta-analysis; Outcomes.

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Conflict of interest statement

Disclosures and potential conflicts of interest: The other authors have no potential conflicts related to this manuscript to report.

Figures

Figure 1
Figure 1
Inclusion of 36 Articles for Meta-analysis and 51 Articles for Systematic Review from the 1533 Unique Articles Retrieved May 12, 2016 from MEDLINE, Web of Science, and Embase Search.
Figure 2
Figure 2
Proportion of Subjects with Histologic Response Defined as a Threshold of Eosinophils per High-Power Field of or Near Fifteen After Therapy in Studies of Topical Fluticasone (A), Topical Budesonide (B), and Six-Food Elimination Diet (C) With Additional Study Details and Summary Estimates with 95% Prediction Limits. Studies are sorted in order of the statistically significant meta-regression moderator or by year if no moderator was significant at a threshold p < 0.05. Studies from systematic review that included the proportion of patients with response at a threshold of or near 15 eosinophils per high-power field without missing values for meta-regression variables were included.
Figure 2
Figure 2
Proportion of Subjects with Histologic Response Defined as a Threshold of Eosinophils per High-Power Field of or Near Fifteen After Therapy in Studies of Topical Fluticasone (A), Topical Budesonide (B), and Six-Food Elimination Diet (C) With Additional Study Details and Summary Estimates with 95% Prediction Limits. Studies are sorted in order of the statistically significant meta-regression moderator or by year if no moderator was significant at a threshold p < 0.05. Studies from systematic review that included the proportion of patients with response at a threshold of or near 15 eosinophils per high-power field without missing values for meta-regression variables were included.
Figure 2
Figure 2
Proportion of Subjects with Histologic Response Defined as a Threshold of Eosinophils per High-Power Field of or Near Fifteen After Therapy in Studies of Topical Fluticasone (A), Topical Budesonide (B), and Six-Food Elimination Diet (C) With Additional Study Details and Summary Estimates with 95% Prediction Limits. Studies are sorted in order of the statistically significant meta-regression moderator or by year if no moderator was significant at a threshold p < 0.05. Studies from systematic review that included the proportion of patients with response at a threshold of or near 15 eosinophils per high-power field without missing values for meta-regression variables were included.
Figure 3
Figure 3
Mean Difference for Eosinophils Before and After Therapy in Studies of Topical Fluticasone (A), Topical Budesonide (B), and Six-Food Elimination Diet (C) in Order of Publication Date or, if Present, Selected Meta-Regression Moderator. Studies are sorted in order of the statistically significant meta-regression moderator or by year if no moderator was significant at a threshold p < 0.05. Studies from systematic review that included the mean and standard deviation of eosinophils per high-power field before and after therapy without missing values for meta-regression variables were included.
Figure 3
Figure 3
Mean Difference for Eosinophils Before and After Therapy in Studies of Topical Fluticasone (A), Topical Budesonide (B), and Six-Food Elimination Diet (C) in Order of Publication Date or, if Present, Selected Meta-Regression Moderator. Studies are sorted in order of the statistically significant meta-regression moderator or by year if no moderator was significant at a threshold p < 0.05. Studies from systematic review that included the mean and standard deviation of eosinophils per high-power field before and after therapy without missing values for meta-regression variables were included.
Figure 3
Figure 3
Mean Difference for Eosinophils Before and After Therapy in Studies of Topical Fluticasone (A), Topical Budesonide (B), and Six-Food Elimination Diet (C) in Order of Publication Date or, if Present, Selected Meta-Regression Moderator. Studies are sorted in order of the statistically significant meta-regression moderator or by year if no moderator was significant at a threshold p < 0.05. Studies from systematic review that included the mean and standard deviation of eosinophils per high-power field before and after therapy without missing values for meta-regression variables were included.
Figure 4
Figure 4
Proportion of Patients with Symptom Response in Studies of Topical Fluticasone (A), Topical Budesonide (B), and Six-Food Elimination Diet (C) in Order of Publication Date or, if Present, Selected Meta-Regression Moderator. Studies are sorted in order of the statistically significant meta-regression moderator or by year if no moderator was significant at a threshold p < 0.05. Studies from systematic review that included the proportion of patients with symptom response without missing values for meta-regression variables were included.
Figure 4
Figure 4
Proportion of Patients with Symptom Response in Studies of Topical Fluticasone (A), Topical Budesonide (B), and Six-Food Elimination Diet (C) in Order of Publication Date or, if Present, Selected Meta-Regression Moderator. Studies are sorted in order of the statistically significant meta-regression moderator or by year if no moderator was significant at a threshold p < 0.05. Studies from systematic review that included the proportion of patients with symptom response without missing values for meta-regression variables were included.
Figure 4
Figure 4
Proportion of Patients with Symptom Response in Studies of Topical Fluticasone (A), Topical Budesonide (B), and Six-Food Elimination Diet (C) in Order of Publication Date or, if Present, Selected Meta-Regression Moderator. Studies are sorted in order of the statistically significant meta-regression moderator or by year if no moderator was significant at a threshold p < 0.05. Studies from systematic review that included the proportion of patients with symptom response without missing values for meta-regression variables were included.
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