Will eosinophilic esophagitis be visible in a Complete Blood Count (CBC) and what is the course of treatment with topical corticosteroids, such as fluticasone propionate (Flovent) or budesonide (Pulmicort)?

Eosinophilic Esophagitis: Diagnosis and Steroid Treatment

Eosinophilic esophagitis (EoE) is not typically detectable on a complete blood count (CBC), and treatment involves topical corticosteroids such as fluticasone or budesonide administered by swallowing the medication rather than inhaling it.

Diagnosis and CBC Findings

• EoE is diagnosed by endoscopy with biopsy showing ≥15 eosinophils per high-power field in the esophageal epithelium 1

• CBC is not a reliable diagnostic tool for EoE:

  • Peripheral eosinophilia is absent in many EoE patients
  • The diagnosis requires tissue biopsy of the esophagus
  • Blood eosinophil counts may not correlate with tissue eosinophilia or disease activity 2

• Definitive diagnosis requires:

  • Symptoms of esophageal dysfunction (dysphagia, food impaction)
  • Endoscopic findings (rings, furrows, white plaques, strictures)
  • Histopathology showing ≥15 eosinophils per high-power field 1

Topical Corticosteroid Treatment

Medication Options

1. Fluticasone propionate (Flovent):

   • Dosage: 880 μg twice daily (440-880 μg for children based on age/weight) 2, 3
   • Administration: Puff into mouth and swallow (do not inhale)
   • Duration: Initial course of 8-12 weeks 3

2. Oral viscous budesonide (Pulmicort):

   • Dosage: 1 mg twice daily for adults (0.5-1 mg twice daily for children) 2, 4
   • Administration: Mix with sucralose (Splenda) or Neocate Duocal to create a slurry that coats the esophagus 5
   • Duration: Initial course of 8-12 weeks 4

Administration Instructions

• For fluticasone:

  • Use the MDI (multi-dose inhaler) without a spacer
  • Spray directly into mouth, then swallow
  • No food or drink for 30 minutes after administration

• For budesonide:

  • Mix respules with 4-5 packets of sucralose or appropriate mixing agent
  • Swallow the mixture slowly
  • No food or drink for 30 minutes after administration

Efficacy Comparison

• Both medications are effective for initial treatment of EoE 4

• A randomized controlled trial showed no significant difference between oral viscous budesonide and fluticasone MDI in:

  • Post-treatment eosinophil counts (15 vs. 21 eos/hpf)
  • Histologic response rates (71% vs. 64%)
  • Symptom improvement 4

• Some studies suggest budesonide may have slightly better outcomes in children 5

Monitoring and Side Effects

• Common side effects:

  • Esophageal candidiasis (12-16% of patients)
  • Oral thrush (2-3% of patients) 4

• Monitoring:

  • Follow-up endoscopy with biopsy after 8-12 weeks of treatment
  • Regular clinic visits to assess symptoms, compliance, and adverse effects 1

• Long-term considerations:

  • Systemic side effects are rare with topical steroids
  • Continued monitoring of bone mineral density and adrenal function is recommended in children and adolescents 1

Treatment Duration and Follow-up

• Initial treatment: 8-12 weeks

• For persistent symptoms or eosinophilia:

  • Continue treatment or consider alternative approaches (dietary therapy)
  • The goal of therapy should be symptom improvement, ideally accompanied by resolution of esophageal eosinophilia 1

• EoE tends to be a chronic disease with persistent or relapsing symptoms, often requiring long-term management 1

Important Caveats

• Topical steroids are preferred over systemic steroids due to fewer adverse effects 2
• Candida infection may occur in a small proportion of patients and should be managed with topical antifungals while continuing topical steroids 1
• Untreated EoE can lead to esophageal strictures and food impaction 1
• EoE is the most common cause of spontaneous perforation of the esophagus 1

Remember that EoE diagnosis requires endoscopy with biopsy, as CBC findings are not diagnostic for this condition.