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Eosinophilic esophagitis (EoE) is a chronic, immune-mediated esophageal condition affecting approximately 34.2 per 100,000 individuals. 1 With increasing clinical recognition, therapeutic approaches have evolved from proton pump inhibitors (PPIs) to topical corticosteroids, and more recently, to biologic agents. Budesonide remains a widely adopted corticosteroid treatment, while dupilumab, a monoclonal antibody targeting interleukin-4 (IL-4) and interleukin-13 (IL-13) pathways,2 has emerged as a promising alternative. However, minimal comparative evidence exists between these two therapies, reinforcing the need for a quantitative synthesis to inform clinical practice and guide future treatment decisions.A systematic review and meta-analysis was conducted to evaluate and indirectly compare the efficacy of budesonide and dupilumab versus placebo in achieving histological remission in EoE. A comprehensive search of PubMed, Scopus, and the Cochrane Library identified 3,949 records, screened in accordance with PRISMA guidelines. Screening was assisted using Rayyan.AI. Randomised controlled trials (RCTs) published in the last ten years in human subjects were included. The primary outcome was histological remission, as defined by each study. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effects model in R (version 4.5.0) via RStudio. Forest plots were generated to visualise treatment effects, and funnel plots assessed publication bias and small-study effects.Nine RCTs evaluating budesonide (n = 945) produced a pooled RR of 31.41 [95% CI: 16.13–61.15], demonstrating a substantial benefit over placebo with no observed heterogeneity (I2 = 0%). Forest plots showed consistent effects across studies. Egger’s test for funnel plot asymmetry showed no evidence of small-study effects or publication bias (p = 0.22), and visual inspection showed no asymmetry. These findings suggest a low risk of publication bias in the budesonide literature.Three RCTs assessed dupilumab (n = 199), yielding a pooled RR of 16.31 [95% CI: 5.77–46.09], also indicating strong efficacy with minimal heterogeneity (I2 = 0%). A funnel plot was generated for dupilumab, though its interpretation was limited due to the smaller number of studies, highlighting the need for further investigation and broader trial data.Both budesonide and dupilumab significantly outperform placebo in achieving histological remission in EoE. Budesonide remains a consistent and effective therapy, supported by robust and reproducible evidence across multiple trials. Dupilumab presents a promising alternative, particularly for patients with corticosteroid-refractory or intolerant disease. This review provides a timely and methodologically rigorous synthesis of current evidence and contributes to the evolving landscape of EoE management. As new therapies emerge, evidence-based comparisons such as this play a vital role in refining treatment algorithms and improving patient outcomes. Further studies will be essential to clarify the long-term positioning of dupilumab in routine clinical care.References Baldovich K. Increasing incidence rates of eosinophilic esophagitis in active component service members, U.S. Armed Forces, 2009–2021 [Internet]. Military Health System. 2023 [cited 2025 Apr 23]. Available from: https://www.health.mil/News/Articles/2023/05/01/Eosinophilic-EsophagitisD’Ippolito D, Pisano M. Dupilumab (Dupixent): an interleukin-4 receptor antagonist for atopic dermatitis. Pharm Ther. 2018 Sep;43(9):532. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110636/