What is the primary approach to managing eosinophilia in patients with Crohn's disease?

Managing Eosinophilia in Crohn's Disease

The primary approach to managing eosinophilia in patients with Crohn's disease should focus on treating the underlying Crohn's disease with appropriate anti-inflammatory therapy, while considering specialized treatment for persistent eosinophilia that causes symptoms or organ damage. 1, 2

Diagnostic Considerations

• Eosinophilia in Crohn's disease patients may be related to increased response of blood eosinophils to various chemotactic agents, particularly PAF and Eotaxin, even during clinically quiescent disease 1
• Before initiating specific treatment for eosinophilia, secondary causes must be ruled out, including food allergies, medications, parasitic infections, and other inflammatory disorders 3
• Hypereosinophilia is generally defined as a peripheral blood eosinophil count greater than 1,500/mm³ and may be associated with tissue damage 4, 5

Treatment Algorithm

First-Line Approach

• Control the underlying Crohn's disease inflammation with appropriate therapy (corticosteroids, immunomodulators, biologics) as the primary strategy 2
• For mild to moderate eosinophilia (<1,500/mm³) without symptoms or signs of organ involvement, a watch and wait approach with close follow-up may be undertaken 4, 5
• Proton pump inhibitors (PPIs) may be considered as complementary therapy, with a recommended dose of omeprazole 20 mg twice daily for 8-12 weeks 3

Second-Line Approach

• For persistent symptomatic eosinophilia despite control of Crohn's disease:
  • Corticosteroids are first-line therapy for hypereosinophilic syndrome (HES) and should be considered for persistent eosinophilia 4, 5
  • Topical steroids are highly effective for eosinophilic inflammation in the gastrointestinal tract 6

Refractory Cases

• For steroid-refractory cases:
  • Hydroxyurea and interferon-alpha have demonstrated efficacy 4, 5
  • Consider dietary elimination therapy under supervision of an experienced dietitian if food allergies are suspected as contributing factors 3
  • Novel biologics such as anti-IL-5 agents (mepolizumab, benralizumab) may be considered for severe cases 3, 5

Monitoring and Follow-up

• Regular clinical visits to assess symptoms, compliance with therapy, and adverse effects 7
• Endoscopy with biopsy is recommended to evaluate histological response, as symptoms do not always correlate with histological activity 3
• If symptoms recur during treatment, repeat endoscopy should be performed for evaluation 7

Special Considerations

• Patients with eosinophilic inflammation refractory to treatment and/or with significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 7
• The psychological impact of dietary therapy should be appreciated and discussed with patients, as anxiety and depression can affect patients due to persistent symptoms and social restrictions 7
• For patients with fibrostenotic disease, endoscopic dilatation combined with effective anti-inflammatory therapy yields better clinical outcomes 7

Potential Complications

• Eosinophilic inflammation can lead to fibrosis and stricture formation if left untreated 7
• Eosinophilic disorders are the most common cause of spontaneous perforation of the esophagus, which can occur at any age 7
• Systemic side effects of topical steroids should be monitored, particularly in children and adolescents 7

By following this structured approach to managing eosinophilia in Crohn's disease, clinicians can effectively address both the underlying inflammatory bowel disease and the eosinophilic component, improving outcomes and quality of life for patients.