The Pharmaceutical Journal
Vol 269 No 7226 p770
30 November 2002

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Archives of Disease in Childhood: abstract (more)
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Fluticasone linked to adrenal crisis

Inhaled corticosteroids, especially fluticasone, should be titrated to their lowest effective maintenance dose in order to reduce the likelihood of adverse events, according to the authors of a British study.

Almost 3,000 consultant paediatricians and adult endocrinologists in the United Kingdom were audited to determine how many cases of acute adrenal crisis associated with inhaled corticosteroids had occurred among asthmatic patients.

The researchers identified 28 children and five adults who met the criteria for acute adrenal crisis — until recently there had only been two such reports. All 33 patients had been prescribed between 500–2,000µg a day of inhaled corticosteroids, with fluticasone being the drug used in 30 of the 33 cases (Archives of Disease in Childhood 2002;87:457).

The researchers advise caution in cases where fluticasone doses greater than 400µg a day are being used in children, or 1000µg a day in adults.

However, they warn that patients should not suddenly stop taking their treatment as this could precipitate adrenal crisis. Although the condition is much less common among patients taking beclometasone and budesonide, the researchers say their findings support the need to titrate down doses of all inhaled corticosteroids.

Current guidelines on asthma management recommend doses of up to 1,000µg fluticasone a day for children aged five years and over with severe asthma, but the drug is only licensed for use at doses of up to 400µg a day in children. Last year, the Medicines Control Agency highlighted the risk of adverse systemic effects associated with doses of fluticasone above 1,000µg a day (PJ, 1 September 2001, p283).

In an accompanying editorial, Professor George Russell, Royal Aberdeen Children's Hospital, suggests that where high dose inhaled corticosteroids are thought necessary, it may be advisable to avoid fluticasone for the time being (ibid, p455).

Updated British Thoracic Society guidelines, expected in January, will emphasise the need to use the lowest doses of medicines necessary to control the disease.