What is the treatment for elevated eosinophils (eosinophilia) with oral steroids?

Treatment of Eosinophilia with Oral Steroids

Oral corticosteroids are indicated for patients with elevated eosinophil counts (≥2%) who have symptomatic disease, particularly in conditions like eosinophilic esophagitis (EoE) and eosinophilic pneumonia, as they effectively reduce eosinophil counts and improve clinical outcomes.

Indications for Oral Steroid Therapy

Eosinophilic Esophagitis (EoE)

• Systemic steroids are generally not recommended as first-line therapy for EoE due to side effects 1
• However, oral steroids may be considered in:
  • Severe stricturing disease 1
  • Cases where topical steroids have failed
  • Patients requiring rapid symptom relief

COPD Exacerbations with Elevated Eosinophils

• Patients with blood eosinophil count ≥2% respond better to oral corticosteroids 1
• Treatment failure rate of only 11% with steroids vs 66% with placebo in patients with eosinophil count ≥2% 1
• In contrast, patients with eosinophil count <2% may not benefit and could have worse outcomes with steroids 1

Eosinophilic Pneumonia

• Oral corticosteroids are the mainstay of treatment 2
• Complete radiological clearing and reduction in blood eosinophil counts are more common with prednisolone treatment 2
• Inhaled corticosteroids alone are generally ineffective as monotherapy 3

Dosing and Duration

Initial Treatment

• For COPD exacerbations: 30-40 mg prednisone daily for 5-14 days 1
• For eosinophilic pneumonia: Prednisolone at higher doses (typically 0.5-1 mg/kg/day) 2
• For EoE (when indicated): Prednisolone 1 mg/kg twice daily according to age for up to 12 weeks 1

Maintenance Therapy

• For eosinophilic pneumonia: Long-term low-dose prednisolone (mean 7-8 mg/day) may be required to prevent relapses 2
• For EoE: Systemic steroids are not recommended for maintenance therapy 1

Monitoring Response

• Blood eosinophil counts should be drawn at diagnosis and again at each evaluation for response to treatment 1
• Monitor for common adverse effects:
  • Hyperphagia and weight gain (50% and 25% respectively) 1
  • Hyperactivity
  • Cushingoid appearance
  • Hyperglycemia 1
  • Adrenal suppression
  • Bone density effects with long-term use

Special Considerations

• In patients with COPD, stratification by blood eosinophil count should guide treatment decisions 1
• In EoE, topical steroids (swallowed fluticasone or budesonide) are preferred over systemic steroids due to fewer adverse effects 1
• For steroid-dependent conditions, consider steroid-sparing agents if long-term therapy is required 4
• Patients with persistent blood eosinophilia may have more severe disease, as it correlates with persistent symptoms in some conditions 1

Pitfalls and Caveats

• Avoid systemic steroids when topical therapy is effective (particularly in EoE)
• Be aware that blood eosinophil counts may not always correlate with tissue eosinophilia or disease activity 1
• Consider the underlying cause of eosinophilia before initiating treatment (allergic, drug-induced, parasitic, etc.)
• Long-term systemic steroid use carries significant risks including osteoporosis, diabetes, and adrenal suppression
• In COPD patients with eosinophil count <2%, steroids may actually worsen outcomes compared to placebo 1

Oral corticosteroids remain an important treatment for eosinophilia, but their use should be targeted to patients most likely to benefit, particularly those with eosinophil counts ≥2% and symptomatic disease.