What is the treatment for non-asthmatic eosinophilic bronchitis?

Treatment of Non-Asthmatic Eosinophilic Bronchitis

Inhaled corticosteroids are the first-line treatment for non-asthmatic eosinophilic bronchitis, with budesonide 400 μg twice daily demonstrating significant improvement in cough symptoms and reduction in sputum eosinophils within 4 weeks. 1

Initial Treatment Approach

First-Line Therapy: Inhaled Corticosteroids

• Start inhaled corticosteroids immediately as the mainstay therapy for non-asthmatic eosinophilic bronchitis, which produces both symptomatic improvement and significant reduction in sputum eosinophil counts 1
• Budesonide 400 μg inhaled twice daily has been specifically studied and shown to normalize capsaicin cough sensitivity after 4 weeks of treatment 1
• The eosinophilic airway inflammation is causally associated with heightened cough sensitivity, which responds directly to inhaled corticosteroid therapy 1

Treatment Duration

• Administer inhaled corticosteroids for at least 2-3 months to reduce relapse rates, as shorter durations lead to significantly higher recurrence 2
• The 1-month treatment group showed a 41.9% relapse rate versus only 12.0% in the 3-month treatment group at 1-year follow-up 2
• The 2-month treatment group demonstrated an intermediate relapse rate of 20.0% 2

Alternative First-Line Strategy: Allergen/Occupational Avoidance

When a causal allergen or occupational sensitizer is identified, avoidance is the best treatment and should take priority over pharmacotherapy. 1

• Always consider occupation-related causes in patients with non-asthmatic eosinophilic bronchitis 1
• Implement avoidance strategies when inflammation is due to occupational exposure or inhaled allergen 1

Escalation for Refractory Cases

When to Use Oral Corticosteroids

• Reserve oral corticosteroids for patients with persistently troublesome symptoms despite high-dose inhaled corticosteroids or when eosinophilic inflammation progresses despite maximal inhaled therapy 1
• Oral corticosteroids are only occasionally required to control symptoms and eosinophilic inflammation 1
• This represents a small minority of cases, as most patients respond adequately to inhaled therapy 3

Critical Clinical Pitfalls

What NOT to Do

• Do not use inhaled corticosteroids for eosinophilic pneumonitis, as treatment failure occurs in 100% of cases—this is a distinct condition from non-asthmatic eosinophilic bronchitis 4
• Do not stop treatment after only 1 month, as this leads to a 42% relapse rate within one year 2
• Do not expect improvement in patients with chronic cough without sputum eosinophilia, as they do not respond to inhaled corticosteroids 1

Monitoring Response

• Confirm diagnosis by demonstrating improvement in cough following corticosteroid therapy along with presence of airway eosinophilia 1
• Monitor sputum eosinophil counts and clinical symptoms to assess treatment response 1
• The treatment-induced change in cough sensitivity correlates positively with reduction in sputum eosinophil count 1

Unanswered Questions in Current Evidence

The ACCP guidelines acknowledge several gaps in the evidence base 1:

• No data currently guide which specific inhaled corticosteroid to use
• Optimal dosing remains undefined beyond the studied budesonide 400 μg twice daily regimen
• Whether therapy should be discontinued when symptoms resolve is unclear, given evidence of airway remodeling 1
• The role of antihistamines and antileukotrienes needs further exploration 1

Given these uncertainties, the pragmatic approach is to use budesonide 400 μg twice daily (or equivalent dose of another inhaled corticosteroid) for a minimum of 2-3 months, then reassess for symptom control and consider longer-term maintenance therapy. 1, 2