Getting risks right on inhaled corticosteroids and adrenal insufficiency

Abstract

@ERSpublications Adrenal insufficiency should be considered in patients on inhaled corticosteroids presenting with suggestive symptoms http://ow.ly/kskjU As Thomas Addison observed in his famous monograph written in 1855, the adrenal glands are ''objects of deep interest'' and so they remain [1]. In the monograph he described several patients who presented with generalised weakness and in whom abnormalities of the adrenal glands were found at post mortem. Addison had discovered primary hypoadrenalism, the disease that would later take his name. He observed that ''the disease is by no means of very rare occurrence, and that were we better acquainted with its symptoms and progress, we should probably succeed in detecting many cases'' [1].With Addison's words ringing in our ears we reflect on the paper by LAPI et al. [2] in this issue of the European Respiratory Journal. LAPI et al.[2] describe a nested case-control study examining the association between inhaled corticosteroids and adrenal insufficiency conducted within a cohort of patients treated for respiratory conditions over a 15-year period, starting in 1990, in Quebec, Canada. They identified 392 cases of adrenal insufficiency from 368 238 prevalent users of respiratory medicines from the Régie de l'assurance médicale du Québec database. They did not find, as per their primary objective, an increased risk of adrenal insufficiency among current users of inhaled corticosteroids. However, they did report an increased risk in relation to the use of a current high dose (o52000 mg beclomethasone dipropionate (BDP)-units per day, equivalent to 1000 mg fluticasone per day) of inhaled corticosteroids (OR51.84; 95% CI: 1.16-2.90). They concluded that high doses of inhaled corticosteroids are an independent risk factor for adrenal insufficiency although the risk was much smaller than that seen with oral corticosteroids.This study provides interesting new data, and will add fuel to the debate, about the risk of adrenal insufficiency in patients prescribed inhaled corticosteroids. In our view the conclusion that high doses of inhaled corticosteroids alone increase the risk of adrenal insufficiency is not fully supported by the data presented. Although cases were more likely than controls to be users of high doses of inhaled corticosteroids, the lack of a clear dose-response relationship across the three tertiles of cumulative inhaled corticosteroid dose in the current users and, if anything, the protective effect of recent or past use, as depicted in table 2, casts some doubt on the assertion that there is an independent dose-related impact of inhaled corticosteroids on adrenal insufficiency. A critical issue overall is the overwhelming influence of oral corticosteroid therapy; there was an order of magnitude difference in the cumulative dose of oral corticosteroids in cases versus controls (547.4 mg versus 42.5 mg). Although the authors adjusted for the effect of oral corticosteroids, it is a difficult task to completely adjust for these strong effects. Residual confou...

Commercial Probiotic Products

“…Fewer foods were eliminated when the combination therapy was applied, which may decrease nutritional deficiencies. Although adrenal suppression and growth delay are potential side effects of corticosteroid use in asthmatic patients, these adverse effects have not yet been documented in EoE (23)(24)(25)(26). However, it is unclear if oral treatment shows the same side effect profile in EoE as that of inhaled therapy.…”

Combination Steroid and Test‐based Food Elimination for Eosinophilic Esophagitis

“…There are limited studies regarding the safety of topical corticosteroids in EoE; these studies have been based on <2 years of treatment (19)(20)(21)(22). Although adrenal suppression and growth delay are potential adverse effects of corticosteroid' use in asthmatic patients, these adverse effects have not yet been documented in EoE (23)(24)(25)(26). The effects of the combination therapy on nutrition and on the adverse effects of topical corticosteroids remain unclear and warrant further study.…”