Adrenal insufficiency caused by inhaled corticosteroids
Health professionals should be vigilant about the possibility
of adrenal insufficiency occurring in patients treated with inhaled corticosteroids,
experts say. In addition, attempts should be made to reduce doses of inhaled
steroids in patients with well-controlled asthma.
The recommendations follow the publication of a
report of eight cases of symptomatic adrenal insufficiency in children
on inhaled corticosteroid therapy (fluticasone, budesonide and beclomethasone).
Dr Leena Patel, department of child health, University of Manchester,
and colleagues say that two children presented with hypoglycaemia but
that this did not follow sudden withdrawal of treatment or an acute illness.
In the other six cases, presentation was insidious with symptoms including
poor weight gain and poor height growth. The dose of inhaled corticosteroid
at presentation did not exceed that recommended in step three of the British
Thoracic Society guidelines in seven of the eight cases. None had received
prolonged courses of systemic corticosteroids at any time. Although the
daily dose of corticosteroid was not excessive in seven of the eight cases,
all patients were small so the dose per area of body surface was relatively
higher. “Evidence based guidelines with doses of inhaled corticosteroids
recommended according to body surface area are needed,” they suggest.
The authors say that the case reports highlight
the occurrence of adverse effects with doses of inhaled corticosteroids
normally considered to be safe, and illustrate variations in individual
sensitivity to corticosteroids. They add that since poor growth and weight
gain were features of the cases, the importance of growth monitoring for
all children on inhaled corticosteroids should be emphasised (Archives
of Disease in Childhood 2001;85:330).
Dr George Russell, department of child health, University
of Aberdeen, comments that the two cases of acute hypoglycaemia are particularly
worrying because they suggest that acute adrenal insufficiency can occur
even when the child is still taking the corticosteroid that caused the
adrenal insufficiency in the first place.
He adds that it would be wrong to suggest a major
change to established treatment that is of immense value but rather to
pay more attention to stepping down treatment and being constantly vigilant
about side effects (ibid, p333).
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