Adrenal suppression: A practical guide to the screening and management of this under-recognized complication of inhaled corticosteroid therapy

Abstract

Inhaled corticosteroids (ICSs) are the most effective anti-inflammatory agents available for the treatment of asthma and represent the mainstay of therapy for most patients with the disease. Although these medications are considered safe at low-to-moderate doses, safety concerns with prolonged use of high ICS doses remain; among these concerns is the risk of adrenal suppression (AS). AS is a condition characterized by the inability to produce adequate amounts of the glucocorticoid, cortisol, which is critical during periods of physiological stress. It is a proven, yet under-recognized, complication of most forms of glucocorticoid therapy that can persist for up to 1 year after cessation of corticosteroid treatment. If left unnoticed, AS can lead to significant morbidity and even mortality. More than 60 recent cases of AS have been described in the literature and almost all cases have involved children being treated with ≥500 μg/day of fluticasone.The risk for AS can be minimized through increased awareness and early recognition of at-risk patients, regular patient follow-up to ensure that the lowest effective ICS doses are being utilized to control asthma symptoms, and by choosing an ICS medication with minimal adrenal effects. Screening for AS should be considered in any child with symptoms of AS, children using high ICS doses, or those with a history of prolonged oral corticosteroid use. Cases of AS should be managed in consultation with a pediatric endocrinologist whenever possible. In patients with proven AS, stress steroid dosing during times of illness or surgery is needed to simulate the protective endogenous elevations in cortisol levels that occur with physiological stress.This article provides an overview of current literature on AS as well as practical recommendations for the prevention, screening and management of this serious complication of ICS therapy.

Para entender la acción de cortisol en inflamación aguda: una mirada desde la glándula suprarrenal hasta la célula blanco

“…Pese a la existencia de función normal del eje HHA, la capacidad de síntesis de cortisol en estrés agudo puede estar disminuida por factores tales como el uso previo de corticoides sistémicos o inhalados 48 . También la exposición a algunos fármacos genera un efecto deletéreo en la síntesis de cortisol y entre ellos es necesario considerar el uso de ketoconazol 49 y etomidato [50][51][52][53][54] , siendo especialmente este último un fármacos de uso frecuente en el ambiente de paciente crítico.…”

Safety of Inhaled Corticosteroids in the Therapy of Bronchial Asthma

“…В результате длительного лечения высокими дозами иГКС могут развиваться системные НЭ: угнетение коры надпочечников [19], снижение минеральной плотности костной ткани [20], замед-ление линейного роста у детей [21][22][23][24], изменение массы тела, катаракта и глаукома, истончение кожи и склонность к образованию синяков [25]. Систем-ные эффекты иГКС определяются фракцией препа-рата, которая всасывается из легких, и ротоглоточ-ной фракцией, и зависят от активности молекулы, дозы иГКС, системы доставки, системной биодо-ступности, метаболизма при первом прохождении через печень, клиренса (см.…”

Neonatal Hypotension, the Role of Hydrocortisone and Other Pharmacological Agents in its Management

“…Prolonged use may be defined as constant administration for 2 weeks or intermittent administration for a total of 3 weeks during a 6 month period or longer [53]. Patients exposed to long-term hydrocortisone therapy are likely to develop adrenal insufficiency secondary to hypothalamic-pituitary-adrenal axis suppression.…”