Adrenal Insufficiency in Children With Eosinophilic Esophagitis Treated With Topical Corticosteroids

Abstract

Objectives: The aim of the study was to identify practices of gastroenterologists screening for adrenal insufficiency (AI) and report prevalence of AI in children with eosinophilic esophagitis (EoE) treated with topical corticosteroids (TCS); compare serum dehydroepiandrosterone sulfate (DHEA-S) levels to morning serum cortisol (MSC) levels as screening tool for AI. Methods: A multipart study was conducted. In part 1, a survey about screening practices for AI in children with EoE on TCS was sent to gastroenterologists belonging to a PedsGI listserv and to EoE consortia. In part 2, children with EoE on TCS for ≥6 months were prospectively screened for AI with MSC levels. For subjects with a MSC level of <10 μg/dL, a repeat MSC level and/or confirmatory adrenocorticotropic hormone (ACTH) stimulation testing was offered. AI was defined by peak serum cortisol level <18 μg/dL. In part 3, DHEA-S levels were drawn with MSC levels. Results: Seven percent (16/238) of gastroenterologists screened for AI. Providers in EoE consortia were more likely to screen than nonconsortia providers [9/21(43%) vs 7/217(3%); P = 0.0001]. Thirty-seven children were prospectively screened for AI, and 51% (19/37) had a low MSC level. Ten patients had a low-dose ACTH stimulation test (LDST) after 1 or more low MSC levels. Five percent (2/37) of patients were diagnosed with AI. DHEA-S and MSC levels had a moderate correlation (r s = 0.44, P = 0.03). Conclusions: Gastroenterologists belonging to EoE consortia were more likely to screen for AI. Prevalence of AI in our prospective cohort was 5%. DHEA-S has a moderate correlation with MSC levels, but more data is required to assess utility as a screening tool for AI.

Esophageal polyp in a teenage boy with eosinophilic esophagitis

“…There have been several articles describing adrenal insufficiency after prolonged oral glucocorticoid intake for EoE. [20][21][22][23][24][25] These effects are more pronounced when the patient is on additional steroids for conditions like atopic dermatitis, asthma, or allergic rhinitis. 25 Adrenal insufficiency has been seen with both oral budesonide and fluticasone propionate.…”

Impact of Dose Reduction of Topical Steroids to Manage Adrenal Insufficiency in Pediatric Eosinophilic Esophagitis

“…Generally, STS are well tolerated, but there have been consistent reports of AI. With recent estimates of AI incidence in this population ranging from 5% to 10% (6,7,9) many EoE patients are at risk of significant morbidity, and attempts should be made to avoid AI and address it quickly once it occurs. In this study, we report our experience with 32 STS-treated EoE subjects (obtained from approximately 440 subjects with morning cortisol testing, data not shown) who were diagnosed with AI and compare them to 81 STS-treated EoE controls without AI to investigate factors that increase AI likelihood.…”

“…To date, of the systemic complications, only the development of AI has been demonstrated. A variety of risk factors for AI development have been suggested and a broad range of incidence rates from 0% to 66% have been reported in the setting of variable methodologies used for screening and diagnosis of AI (6)(7)(8)(9)(10).…”

“…Many studies have attempted to determine why some STS-treated EoE patients develop AI while others do not despite treatment with similar topical steroid dosages. Factors associated with an increased likelihood of AI include lower BMI and increased steroid dosage (7,9). Additionally, there is evidence that genetic susceptibility, specifically single nucleotide polymorphisms in the PDGFD gene locus, may increase the likelihood of AI in some patients (19).…”

An Update on Eosinophilic Esophagitis: Etiological Factors, Coexisting Diseases, and Complications

“…It is a condition of inadequate production of steroid hormones by adrenal glands, mainly cortisol; however, the aldosterone production can also be impaired. Recently, a children-based study reported 5% of cases of EoE, who were treated with topical corticosteroids, presented with adrenal insufficiency [126]. However, more data and research work are required to assess the efficacy of screening adrenal insufficiency in patients with EoE.…”