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Inhaled corticosteroids (ICS) have been shown to cause clinical adrenal insufficiency. Following two serious cases of acute adrenal insufficiency due to ICS, Paton et al evaluated adrenal function in children prescribed fluticasone proprionate above the maximum UK licensed dose (>400 μg/day).
One hundred and ninety four children with asthma who were taking >500 μg/day fluticasone proprionate were tested using a low dose synacthen test (LDST). Responses to LDST were defined as normal (peak cortisol >500 nmoll−1), impaired (peak <500 nmoll−1) or flat (peak <500 nmoll−1 with increment <200 nmoll−1 and basal morning cortisol <200 nmoll−1).
Six patients (3%) had a flat response, in 82 (42%) it was impaired and 104 (54%) had a normal response. All six patients who had a flat response were taking >1000 μg/day fluticasone proprionate. There was a weak but significant inverse correlation between peak cortisol and total daily dose (r = −0.213; p = 0.002). There was no relation between the number of rescue oral steroid courses and peak cortisol.
This study demonstrates that a significant proportion of children receiving fluticasone proprionate at above the licensed dose have biochemical adrenal suppression. Compliance with medications was not evaluated and therefore the effects of ICS on adrenal function may well have been underestimated.