Adrenal responses to a low‐dose short synacthen test in children with asthma

Abstract

SummaryObjectives Corticosteroids are known to cause adrenal suppression. The aim of this study was to assess clinical factors affecting responses to a low dose short synacthen test (LDSST) in asthmatic children using corticosteroids. Design Patients were recruited from secondary care paediatric asthma populations within the UK. Patients Asthmatic children (5-18 years), receiving corticosteroids, underwent a LDSST (n = 525). Measurements Demographics and corticosteroid doses were tested for association with baseline and peak (stimulated) cortisol concentrations. Results Baseline cortisol was significantly associated with age (log baseline increased 0Á04 nM per year of age, P < 0Á0001), but not with gender or corticosteroid dose. Peak cortisol was significantly associated with total corticosteroid cumulative dose (decreased 0Á73 nM per 200 mcg/day, P < 0Á001) but not with age, gender inhaled/intranasal corticosteroid cumulative dose or number of courses of rescue corticosteroids. Biochemically impaired response (peak cortisol ≤500 nM) occurred in 37Á0% (161/435) overall, including children using GINA low (200-500 mcg/day beclomethasone-CFC equivalent 32%, n = 60), medium (501-1000 mcg/day (33%, n = 57) and high (>1000 mcg/day 40%, n = 13) doses of inhaled corticosteroid (ICS) similarly, and 36Á6% of those using fluticasone ICS ≥500 mcg/day (71/194). Impaired response was more frequent in patients on regular oral corticosteroids (66%, n = 27, P < 0Á001). Conclusion Children with asthma can develop biochemical adrenal suppression at similar frequencies for all ICS preparations and doses. The clinical consequence of biochemical suppression needs further study.

The diagnosis and treatment of adrenal insufficiency during childhood and adolescence

“…The SSTs are attractive tests of adrenal reserve in children as the safety profile is excellent and tests are well tolerated 8. Two doses are used most commonly: standard (250 µg, standard dose short Synacthen test (SDSST)) and low (1 µg, low dose short Synacthen test (LDSST)) doses, adjusted variably for body size according to local protocols.…”

“…The LDSST is a safe test, associated with few side effects,8 and it is for this test that normative data in children have been collected. Data from 33 short, normal children report that a peak cortisol value of 500 nmol/L gives a false positive rate as high as 21%, with median cortisol concentrations being 633 nmol/L, range 417–1052 30.…”

Adrenal responses to a low‐dose short synacthen test in children with asthma

“…Following the recent publication of the above article in volume 82, issue 5 of Clinical Endocrinology , the authors have requested the inclusion of the following to the Acknowledgement section “This research was supported by the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London.”…”

Adrenal suppression with glucocorticoid therapy: still a problem after all these years?

“…The risks of adrenal suppression with inhaled GCs have previously been highlighted, for example, a UK survey of adult endocrinologists and paediatricians identified a number of cases of ‘acute adrenal crisis’ in individuals with asthma treated with inhaled GCs, and the relatively low response rate (24%) in this study may have resulted in an underestimation of the true incidence 1. A more recent study reported that 37% of children with asthma had a peak cortisol level below the accepted threshold for biochemical normality following a low dose short synacthen test and suggested that children with asthma taking any preparation of inhaled GCs at any dose may be at risk of adrenal suppression4—that is, it is not only children on ‘excessive’ doses of inhaled GCs who are at risk.…”