Monoclonal Antibodies for Eosinophilic Esophagitis and Gastritis

INTRODUCTION: Eosinophilic Esophagitis (EoE) is a chronic immune-mediated disorder characterized by eosinophil infiltration into the esophageal mucosa. These changes lead to symptoms such as dysphagia, food impaction, and abdominal pain. Although less common, eosinophilic gastritis (EoG) shares similar inflammatory mechanisms but has fewer randomized controlled trials (RCTs) supporting treatment efficacy. Conventional treatments often fail to achieve histologic remission, whereas biological therapies targeting type 2 (T2) inflammation show promising results. This systematic review and meta-analysis evaluate the efficacy and safety of monoclonal antibodies in EoE, with a systematic review of EoG studies. METHODS: A systematic review and meta-analysis were conducted using PRISMA guidelines to assess the efficacy and safety of monoclonal antibodies in EoE and EoG. Thorough searches were conducted across PubMed, Cochrane, and Embase up to June 2025. Primary outcomes were changed in Peak Eosinophilic Count, and secondary outcomes were endoscopic reference score (EREFS), overall adverse events, and serious adverse events. RESULTS: Eight RCTs having 865 participants with EoE, treated with 6 monoclonal antibodies, were included in the meta-analysis, and 3 additional RCTs (155 participants) with EoG were included in the systematic review but not the meta-analysis. Quality assessment using the Cochrane RoB 2 tool showed overall low risk of bias. Monoclonal antibodies significantly reduced peak eosinophil count, MD was -59.17 [95% CI: (-88.88, -29.45)], and improved EREFS. Dupilimab showed the strongest efficacy among the 6 antibodies evaluated, and the adverse events were comparable to placebo. CONCLUSIONS: Monoclonal antibodies, particularly dupilumab, demonstrate efficacy in reducing peak eosinophil count and improving EREFS in EoE, with a favorable safety profile. Although the systematic review of EoG studies suggests similar trends, the limited number of RCTs precludes conducting a meta-analysis. Small sample sizes, lack of patient-reported outcomes, and high heterogeneity highlight the need for larger, standardized trials to confirm these findings and to assess long-term effects.