Acute adrenal insufficiency after discontinuation of inhaled corticosteroid therapy

Zwaan, C. Michel; Odink, Roelof J.; Waal, Henriëtte A. Delemarre-van de; Dankert-Roelse, J.E.; Bokma, Jan Alle

doi:10.1016/0140-6736(92)92991-n

Cited by 58 publications

(18 citation statements)

References 7 publications

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“…Case reports have been published showing serious growth suppression during maintenance therapy with BDP [59,60] BUD [61] and FP [62]. Although the risk of such growth suppression is higher when high doses of ICS9s are used, clinically significant growth suppression may occur at any dose of ICS in any patient.…”

Section: Applicability Of the Evidence To The Individual Casementioning

confidence: 99%

Inhaled corticosteroids reduce growth. Or do they?

Brand

2001

Eur Respir J

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The class label warning in the United States for inhaled corticosteroids (ICS's) states that these drugs may reduce growth velocity in children. In this paper, the evidence for this warning is reviewed from a clinical point of view.Children with asthma tend to grow slower than their healthy peers during the prepubertal years because they go into puberty at a later age. However, asthmatic children do achieve a (near) normal adult height. In randomized controlled clinical trials, the use of inhaled beclomethasone, budesonide and fluticasone is associated with a reduced growth during the first months of therapy, in the order of magnitude of approximately 0.5–1.5 cm·yr−1. It is, however, unlikely that such an effect continues or persists because accumulating evidence shows that asthmatic children, even when they have been treated with ICS for years, attain normal adult height. Individual rare cases have been reported, however, where ICS use was associated with clinically relevant growth suppression.Inhaled corticosteroids are the most effective therapy available for maintenance treatment of childhood asthma. Fear of reduced growth velocity is based on exceptional cases and not on group data. It should, therefore, not be a reason to withhold or withdraw such highly effective treatment in children with asthma.

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Section: Applicability Of the Evidence To The Individual Casementioning

confidence: 99%

Inhaled corticosteroids reduce growth. Or do they?

Brand

2001

Eur Respir J

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“…Multiple studies carried out in approximately 20,00 subjects and summarized previously have shown that these preparations cause few systemic side-effects provided that the dose is kept low [1,2]. The few systemic side-effects demonstrated are more marked in children [3][4][5][6][7][8]. In the case of inhaled beclomethasone in adults, the threshold dose is close to 1 mg daily.…”

mentioning

confidence: 99%

“…Doses of beclomethasone from 1-2 mg daily, and of budesonide from 0.8-1.6 mg daily are now frequently used in treating asthma [10]. Some suppression of the hypothalamo-pituitary-adrenal (HPA) axis has been described when such doses are used [1], but this blockade does not seem to have clinical implications [12] except in rare cases [5,6]. Chronic use of ICS by adults, does not seem to be associated with posterior capsular cataracts, a complication of oral steroids used [13].…”

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confidence: 99%

Skin bruising in asthmatic subjects treated with high doses of inhaled steroids: frequency and association with adrenal function

Roy¹,

LeBlanc²,

Paquette³

et al. 1996

Eur Respir J

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High doses of inhaled corticosteroids (ICS) (budesonide and beclomethasone ≥800 µg·day -1 ) are commonly used in the treatment of asthma. Some investigators have presented evidence for cutaneous effects (bruising), which suggests systemic absorption. This study aimed to assess the prevalence of skin bruising, relate the occurrence of skin bruising to adrenocortical function, and determine the risk factors for skin bruising.One hundred adult asthmatic subjects taking high doses (800-2,000 µg·day -1 ) of ICS for 3 months or more were recruited in an asthma clinic, and 100 control subjects paired for sex and age were recruited from an ophthalmology out-patient clinic. A detailed questionnaire on asthma, general habits and cutaneous lesions was administered. A cutaneous examination was performed. Urine cortisol levels were assessed on two consecutive days. Blood cortisol level and the response to Cortrosyn injection (60 min test) were evaluated.One hundred adult asthmatics (66 females and 34 males), 73 on beclomethasone and 27 on budesonide, were included. The prevalence of skin bruising was 71% based on the questionnaire (32% in controls) and 48% (39 out of 81 subjects) based on direct examination of the skin. We found a satisfactory association between the response to questionnaire and examination of the skin. Adrenocortical function testing showed that a minority of subjects (14 with at least one abnormal test) had lower urinary or blood cortisol levels. These low cortisol levels occurred in subjects who reported skin bruising. By multiple logistic regression, being a female (odds ratio (OR)=20; 95% confidence interval (95% CI)=13-33) and taking ICS for asthma (OR=12; 95% CI=8-18) were significantly (t=5.4) related to the likelihood of developing skin bruising. In addition, among the asthmatic subjects, being older (OR=1.6; 95% CI=1.1-2.4/10 yrs interval) (t=2.3) and being a female (OR=22; 95% CI=7-75) (t=5.0) influenced the occurrence of skin bruising as documented by questionnaire.In asthmatic subjects, taking high doses of ICS is associated with: 1) increased occurrence of skin bruising by comparison with controls, particularly in older subjects; and 2) a generally normal adrenocortical function, although this function is significantly lower in subjects reporting skin bruising.

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“…Los informes disponibles establecen la comparación entre niños asmáticos con y sin tratamiento esteroideo sin hacer referencia a niños sanos. 5,10,21 Los resultados de este estudio sugieren que el asma bronquial per se, o los medicamentos asociados como son los broncodilatadores, podrían favorecer la excreción urinaria de cortisol.…”

Section: Discussionunclassified