pulmicort and Adrenal-Insufficiency

To establish the prevalence of adrenal insufficiency (AI) in children with eosinophilic esophagitis treated with swallowed fluticasone propionate (FP) or budesonide.. Children treated with FP or budesonide for ≥ 6 months underwent a low-dose adrenocorticotropin stimulation test. Patients using systemic, inhaled, intranasal, or topical glucocorticoids were excluded. The primary outcome is AI, defined as peak serum cortisol <18 μg/dL (≤ 495 nmol/L).. Of 58 patients (81% male), 67% were on FP (median age 13.7 years [range 4.3-19.1], dose 1320 μg/d [440-1760], treatment duration 4.0 years [0.6-13.5]). Thirty-three percent were on budesonide (median age 10.7 years [range 3.2-17.2], dose 1000 μg/d [500-2000], treatment duration 3.4 years [0.6-7.7]). The overall prevalence of abnormal peak cortisol response (≤ 20 μg/dL) was 15% (95% CI 6%-25%) (indeterminate [18-20 μg/dL] 5% [n = 3] vs AI [<18 μg/dL] 10% [n = 6]). All patients on budesonide had a normal response vs only 77% of patients on FP (P = .02), all of whom were taking FP at a dose >440 μg/d.. AI was present in 10% of children treated with swallowed glucocorticoids for ≥ 6 months and was found only in those treated with FP >440 μg/d. We recommend low-dose adrenocorticotropin stimulation testing in children treated long term with high dose FP to allow early detection of AI.

Topics: Administration, Oral; Adolescent; Adrenal Insufficiency; Anti-Inflammatory Agents; Budesonide; Child; Child, Preschool; Drug Administration Schedule; Eosinophilic Esophagitis; Female; Fluticasone; Follow-Up Studies; Humans; Male; Prevalence; Prospective Studies; Treatment Outcome; Young Adult

Asthmatic children on long-term treatment with inhaled corticosteroids (ICS) may exhibit mild adrenal suppression. We aimed to test the hypothesis that baseline adrenal function of some asthmatic children might be lower than that of others and that this difference might be accentuated by ICS therapy.. A low-dose Synacthen test was performed in 41 prepubertal asthmatic children placed on long-term inhaled budesonide (400 microg/day) prior to the onset of ICS treatment, 6 and 12 months later. Five children withdrew before the 6- and another 2 before the 12-month follow-up.. Low adrenal function was demonstrated in 4 children (9.8%) upon recruitment and in another 8 at the 6-month evaluation (22.2%). Adrenal function normalized in the aforementioned 4 children at the 6-month evaluation, while 6 (17.6%) exhibited suppressed adrenal function at the 12-month evaluation. Three of these patients had also exhibited adrenal suppression at the 6-month visit. A significant improvement in peak cortisol values from baseline to the 6- and 12-month evaluation (95% confidence intervals: -283.9 to -69.0 and -239.8 to -50.8, respectively) was evident when children with suppressed adrenal response at the second or third evaluation were excluded.. In many asthmatic children, adrenal response improves on long-term ICS. The expected adrenal suppression of certain patients on maintenance ICS appears to constitute a separate phenomenon.

Topics: Administration, Inhalation; Administration, Oral; Adrenal Insufficiency; Adrenocorticotropic Hormone; Asthma; Budesonide; Child; Child, Preschool; Cohort Studies; Female; Growth Hormone; Humans; Hydrocortisone; Hypothalamo-Hypophyseal System; Immunocompromised Host; Immunosuppressive Agents; Longitudinal Studies; Male; Pituitary-Adrenal System; Prospective Studies; Recovery of Function; Remission, Spontaneous; Steroids; Time; Treatment Outcome

A recent case of iatrogenic Cushing's syndrome and complete suppression of the pituitary-adrenal-axis in a patient with cystic fibrosis (CF) and allergic bronchopulmonary aspergillosis treated with itraconazole as an antifungal agent, and budesonide as an anti-inflammatory agent led to a systematic assessment of this axis and gonadal function in all patients treated with itraconazole in the authors' CF centre. Itraconazole can inhibit CYP3A, thus interfering with synthesis of gluco- and mineralocorticoids, androgens and oestradiol as well as the metabolism of budesonide. The aim of this study was to evaluate adrenal and gonadal function in patients treated with itraconazole with or without budesonide. An adrenocorticotrophic hormone (ACTH) test (250 microg tetracosactid) was performed in 25 CF patients treated with both itraconazole and budesonide, and in 12 patients treated with itraconazole alone (six patients with CF and six with chronic granulomateous disease). Mineralocorticoid and gonadal steroid function were evaluated by measurements of plasma-renin, follicle stimulating hormone, luteinising hormone, progesterone, oestradiol, testosterone, serum-inhibin A and B. ACTH tests performed as part of a pretransplantation programme in an additional 30 CF patients were used as controls. Eleven of the 25 patients treated with both itraconazole and budesonide had adrenal insufficiency. None of the patients on itraconazole therapy alone nor the control CF patients had a pathological ACTH test. Mineralocorticoid and gonadal insufficiency was not observed in any of the patients. Only one patient with an initial pathological ACTH-test subsequently normalised, the other 10 patients improved but had not achieved normalised adrenal function 2-10 months after itraconazole treatment had been discontinued. Suppression of the adrenal glucocorticoid synthesis was observed in 11 of 25 cystic fibrosis patients treated with both itraconazole and budesonide. The pathogenesis is most likely an itraconazole caused increase in systemic budesonide concentration through a reduced/inhibited metabolism leading to inhibition of adrenocorticotrophic hormone secretion along with a direct inhibition of steroidogenesis. In patients treated with this combination, screening for adrenal insufficiency at regular intervals is suggested.

Topics: Adolescent; Adrenal Glands; Adrenal Insufficiency; Adult; Antifungal Agents; Budesonide; Child; Cystic Fibrosis; Drug Interactions; Female; Follow-Up Studies; Gonadal Disorders; Gonads; Granulomatous Disease, Chronic; Humans; Itraconazole; Male; Polypharmacy; Prospective Studies; Time Factors

To evaluate the impact of type and dose of swallowed topical steroids (STS) and concurrent steroid therapy on the development and resolution of adrenal insufficiency (AI) in pediatric eosinophilic esophagitis (EoE).. We performed a retrospective case-control study of pediatric EoE subjects in a single tertiary care center, who were treated with STS for at least 3 months and diagnosed with AI based on a peak stimulated cortisol level of <18 µg/dL (500 nmol/L). Steroid forms and doses, and endoscopy data were collected at the time of AI diagnosis and AI resolution or the last known evaluation. Steroid formulations were converted to a fluticasone-equivalent dose for analysis.. Thirty-two EoE subjects with AI were identified, and 20 had AI resolution, including 12 who remained on lower dose STS. Eight of the 32 patients were also treated with extended-release budesonide (ER budesonide), which resulted in a 7-fold higher total daily steroid dose, and thus were analyzed separately. When the 24 cases that were not on ER budesonide were compared to the 81 controls, no difference was found in the STS dose nor total daily steroid dose, although the inhaled steroid dose had marginal significance. Peak eosinophil counts tended to increase when STS doses were decreased, except in subjects on ER budesonide at AI diagnosis.. Altering the total daily steroid regimen can lead to resolution of AI in patients with EoE, though this may come at the expense of disease control.

Topics: Adrenal Insufficiency; Budesonide; Case-Control Studies; Child; Drug Tapering; Eosinophilic Esophagitis; Humans; Retrospective Studies; Steroids

To determine if extremely preterm (EPT) neonates receiving dexamethasone for the prevention of BPD have a higher incidence of presumed adrenal insufficiency (PAI).. Retrospective cohort study of neonates <28 weeks gestation examining PAI after dexamethasone use and PAI after intratracheal budesonide with surfactant administration.. Of 332 neonates, 38% received dexamethasone. The incidence of PAI was higher in neonates who had received dexamethasone (20.8% vs 2.9%, p < 0.001). However, for intubated babies receiving surfactant, dexamethasone was not independently associated with increased PAI after adjusting for gestational age, birthweight, and race (aOR 2.92, 95% CI: 0.79-10.85). Dexamethasone was independently associated with increased PAI in infants previously receiving budesonide/surfactant treatment (aOR 5.38, 95% CI: 1.38-20.90).. The use of dexamethasone alone was not associated with increased PAI, when adjusted for prematurity-related factors. The combination of budesonide with dexamethasone was significantly associated with increased PAI.

Topics: Adrenal Cortex Hormones; Adrenal Insufficiency; Bronchopulmonary Dysplasia; Budesonide; Dexamethasone; Humans; Infant; Infant, Newborn; Pulmonary Surfactants; Respiration, Artificial; Retrospective Studies; Surface-Active Agents

Topics: Administration, Inhalation; Adrenal Insufficiency; Budesonide; Glucocorticoids; Humans; Hydrocortisone; Hypothalamo-Hypophyseal System; Male; Middle Aged; Pituitary-Adrenal System; Postoperative Complications; Pulmonary Disease, Chronic Obstructive; Vascular Surgical Procedures

Topics: Administration, Inhalation; Adrenal Insufficiency; Aged; Asthma; Bronchodilator Agents; Budesonide; HIV Infections; HIV Protease Inhibitors; Humans; Male; Ritonavir; Withholding Treatment

Topics: Adrenal Insufficiency; Androstadienes; Anti-Inflammatory Agents; Budesonide; Deglutition; Eosinophilic Esophagitis; Fluticasone; Humans

We sought to determine the prevalence of adrenal suppression (AS) in children with eosinophilic esophagitis treated with oral viscous budesonide (OVB). This was a retrospective review of a quality assurance initiative, whereby all children in our center treated with OVB for ≥3 months were referred over an 18-month time frame for endocrine assessment including 1 μg adrenocorticotropic hormone stimulation test. Fourteen of 19 children complied with the referral; of these 14 children, 6 (43%) had suboptimal stimulated cortisol (range 343-497 nmol/L, mean [±SD] 424.7 nmol/L [±52.4], normal ≥500 nmol/L). There was no significant association to treatment duration, dose, or concomitant use of inhaled/nasal corticosteroids. This study suggests that children treated with OVB may be at risk for AS.

Topics: Adolescent; Adrenal Insufficiency; Adrenocorticotropic Hormone; Asthma; Budesonide; Child; Child, Preschool; Eosinophilic Esophagitis; Female; Glucocorticoids; Humans; Hydrocortisone; Male; Retrospective Studies

Topics: Adrenal Insufficiency; Budesonide; Eosinophilic Esophagitis; Female; Glucocorticoids; Humans; Male

Iatrogenic adrenal insufficiency is a potential harmful side effect of treatment with corticosteroids. It manifests itself when an insufficient cortisol response to biological stress leads to an Addisonian crisis: a life-threatening situation. We describe a case of a patient who developed an Addisonian crisis after inappropriate discontinuation of budesonide (a topical steroid used in Crohn's disease) treatment. Iatrogenic adrenal insufficiency due to budesonide use has been rarely reported. Prescribers should be aware of the resulting risk for an Addisonian crisis.

Topics: Adrenal Insufficiency; Budesonide; Crohn Disease; Glucocorticoids; Humans; Iatrogenic Disease; Male; Middle Aged; Withholding Treatment

Topics: Adrenal Cortex Hormones; Adrenal Insufficiency; Asthma; Budesonide; Female; Humans; Hypothalamo-Hypophyseal System; Male; Pituitary-Adrenal System

Topics: Adrenal Insufficiency; Aged; Anti-Inflammatory Agents; Budesonide; Crohn Disease; Humans; Male

Hypothalamic pituitary adrenal axis suppression (HPAS) when treating asthmatic children with inhaled corticosteroids (ICS) is thought to be rare.. To determine the prevalence of HPAS in asthmatic children treated with ICS and nasal steroids (NS).. Twenty-six asthmatic children were recruited. Clinical features of HPAS, height, weight, height and weight velocity, steroid dose, adherence, symptom control and lung functions were documented. Metyrapone test was performed if the serum cortisol was > 83 nmol/L (> 3 microg/dL).. No child had a serum cortisol < 83 nmol/L (< 3 microg/dL). Prevalence of HPAS was 35 (CI = 17%-56%). Daily NS dose/ m2 and cumulative NS dose/m2 were significantly (p = 0.03) inversely correlated with the post-metyrapone ACTH (r = -0.42 for both). Current ICS dose was not associated with the post-metyrapone ACTH (r = 0). There was a weak correlation with the daily ICS dose/m2 (r = -0.12) and cumulative ICS dose/m2 (r = -0.26).. A third of asthmatic children on ICS and NS develop HPAS. Contributing factors are the use of NS, body size and cumulative dose of ICS.

Topics: Administration, Inhalation; Administration, Intranasal; Adolescent; Adrenal Cortex Hormones; Adrenal Insufficiency; Adrenocorticotropic Hormone; Asthma; Budesonide; Child; Child, Preschool; Enzyme Inhibitors; Female; Humans; Hydrocortisone; Hypothalamo-Hypophyseal System; Male; Metyrapone; Pituitary-Adrenal System; Prevalence; Risk Factors; Steroid 11-beta-Hydroxylase; Turkey

Topics: Adrenal Insufficiency; Bronchiolitis Obliterans; Bronchodilator Agents; Budesonide; Child; Child, Preschool; Cushing Syndrome; Drug Interactions; Female; HIV Infections; HIV Protease Inhibitors; Humans; Male; Pulmonary Disease, Chronic Obstructive; Rhinitis, Allergic, Perennial; Ritonavir

We report a 12 year-old asthmatic girl with adrenal insufficiency during inhaled corticosteroid treatment. Symptoms, investigations and treatment are discussed.

Topics: Administration, Inhalation; Adrenal Insufficiency; Adrenergic beta-Agonists; Androstadienes; Anti-Asthmatic Agents; Asthma; Bronchodilator Agents; Budesonide; Child; Ethanolamines; Female; Fluticasone; Formoterol Fumarate; Glucocorticoids; Humans

Adrenal insufficiency (AI) is a potentially life-threatening condition. It is known that high doses of inhaled corticosteroids (ICS) can induce systemic adverse effects. Currently, there are no data on the prevalence of AI associated with the use of ICS. This study aimed to investigate the prevalence and clinical presentation of AI (associated or not associated with exogenous Cushing's syndrome) in patients who were prescribed ICS by French physicians during the period 2000-5.. All metropolitan French paediatricians, endocrinologists, pulmonologists and intensive care physicians (n = 11 783) were mailed questionnaires requesting information regarding cases of AI associated or not associated with exogenous Cushing's syndrome between 2000 and 2005. Data collected included patient demographics, oral corticosteroid or ICS used during the year preceding the diagnosis of AI, underlying condition(s), concomitant treatment(s), presenting clinical signs and symptoms, results of laboratory investigations and outcome. The French pharmacovigilance database was screened for spontaneous reports to determine the frequency of AI associated with the use of ICS, using the capture-recapture method.. Forty-six cases of AI were identified. Twenty-three cases presented with clinical symptoms of AI alone and 23 with exogenous Cushing's syndrome. ICS prescribed were fluticasone propionate (n = 24), budesonide (n = 12) and beclometasone dipropionate (n = 5). In 82% (n = 32) of cases for which data were available, ICS were prescribed at high doses. A potential drug interaction was found in 12 cases. Thirteen cases of AI were identified in the French pharmacovigilance database, one of which was common with the questionnaire survey. The capture-recapture method provided an estimation of 598 (95% CI 551, 648) cases of AI associated with the use of ICS for the 2000-5 period in France.. The results of this study confirm the occurrence of adrenal insufficiency in patients treated with ICS. Although the prevalence of ICS-induced AI reported in this study is low, the likelihood of under-diagnosis underlines the need to consider this risk in patients when prescribing these drugs.

Topics: Administration, Inhalation; Adolescent; Adrenal Insufficiency; Adult; Adverse Drug Reaction Reporting Systems; Aged; Aged, 80 and over; Androstadienes; Beclomethasone; Budesonide; Child; Child, Preschool; Cushing Syndrome; Data Collection; Databases, Factual; Drug Interactions; Female; Fluticasone; France; Glucocorticoids; Humans; Infant; Male; Middle Aged; Prevalence; Young Adult

Topics: Acute Disease; Administration, Inhalation; Adrenal Insufficiency; Androstadienes; Beclomethasone; Budesonide; France; Humans; Retrospective Studies; Steroids

A number of previous studies have suggested that adrenal suppression occurs in asthmatic children treated with high-doses of inhaled glucocorticoids (IGC). This study was designed to determine the frequency of adrenal suppression in children with severe asthma treated with recommended doses of IGC: namely 500-1,000 microg/day of fluticasone propionate or the equivalent of budesonide (1,000-2,000 microg/day) for a period of at least 12 months.. Early morning cortisol (F) and ACTH serum levels were measured in 27 severe asthmatics aged 6-16 years old. The children underwent a low dose ACTH test (1 microg/1.73 m2) with a parallel glucose measurement. Twenty-four hour urine collection was performed before examination for free F (UfF) and creatinine levels. There were no clinical manifestations of adrenal hypofunction in the analyzed children.. Of the 27 patients, 22 had normal basal and post-stimulatory levels of F and normal UfF, and the other five (18.5%) had basal serum F levels of <400 nmol/l. Four of the five also had normal post-stimulatory levels of F and normal UfF. One child had a subnormal peak F value of 484 nmol/l during the ACTH test. None of the patients had a suppressed serum ACTH level, but an elevated ACTH level was found in four children. This study provided biochemical evidence of suboptimal adrenal function in one child in the examined group (3.7%) and a good response to stimulation in all the others, even in those with slightly reduced basal cortisol levels.. This study showed that the use of fluticasone in doses of up to 1,000 microg/day (or the equivalent of budesonide) as long-term treatment of children with severe asthma did not substantially affect their adrenal function.

Topics: Adolescent; Adrenal Cortex Function Tests; Adrenal Insufficiency; Adrenocorticotropic Hormone; Androstadienes; Anti-Asthmatic Agents; Asthma; Blood Glucose; Budesonide; Child; Female; Fluticasone; Humans; Hydrocortisone; Male

Topics: Adolescent; Adrenal Insufficiency; Adrenocorticotropic Hormone; Adult; Anti-Inflammatory Agents; Antifungal Agents; Aspergillosis, Allergic Bronchopulmonary; Bronchodilator Agents; Budesonide; Child; Cystic Fibrosis; Drug Therapy, Combination; Female; Follow-Up Studies; Granulomatous Disease, Chronic; Humans; Itraconazole; Male; Pituitary-Adrenal System

Symptomatic adrenal insufficiency, presenting as hypoglycaemia or poor weight gain, may occur on withdrawal of corticosteroid treatment but has not previously been reported during inhaled corticosteroid treatment. This case series illustrates the occurrence of clinically significant adrenal insufficiency in asthmatic children while patients were on inhaled corticosteroid treatment and the unexpected modes of presentation. General practitioners and paediatricians need to be aware that this unusual but acute serious complication may occur in patients treated with inhaled corticosteroids.

Topics: Administration, Inhalation; Administration, Topical; Adrenal Insufficiency; Adrenocorticotropic Hormone; Androstadienes; Anti-Inflammatory Agents; Asthma; Beclomethasone; Budesonide; Child; Child, Preschool; Female; Fluticasone; Humans; Hydrocortisone; Male

Topics: Acute Disease; Adrenal Insufficiency; Androstadienes; Anti-Allergic Agents; Anti-Inflammatory Agents, Non-Steroidal; Asthma; Budesonide; Child; Female; Fluticasone; Humans; Nebulizers and Vaporizers

Topics: Administration, Topical; Adolescent; Adrenal Insufficiency; Adult; Anti-Inflammatory Agents; Budesonide; Child; Child, Preschool; Female; Glucocorticoids; Growth; Humans; Infant; Male; Pregnenediones

The Netherlands Centre for Monitoring of Adverse Reactions to Drugs received two reports of adrenal suppression, attributed to inhaled budesonide. In the first patient, a 7-year-old girl, there were growth retardation, centripetal weight gain and a Cushingoid moonface with unmeasurable serum levels of cortisol after long-term treatment with 600, and later 1000 micrograms daily. In the second patient, an 8-year-old boy, there was malaise with onset a few months after start of treatment with 400 micrograms budesonide daily. There was a lowered serum level of cortisol which returned to normal after discontinuation of budesonide. Although inhaled corticosteroids cause systemic adverse effects less frequently than orally administered corticosteroids, such effects may occur occasionally.

Topics: Administration, Topical; Adrenal Cortex; Adrenal Insufficiency; Aerosols; Anti-Inflammatory Agents; Asthma; Bronchodilator Agents; Budesonide; Child; Cushing Syndrome; Female; Glucocorticoids; Humans; Male; Pregnenediones

Topics: Acute Disease; Adrenal Insufficiency; Adult; Aerosols; Bronchodilator Agents; Budesonide; Humans; Male; Pregnenediones

Increasing dose of budesonide, each dose given for a minimum of 1 month, were administered via a Nebuhaler to 14 patients. Two consecutive abnormally low fasting morning plasma cortisol values, taken 2 weeks apart, were accepted as evidence of hypothalamo-pituitary-adrenal (HPA) hypofunction. Data from nine of the 14 patients entering the study were available for analysis. One patient developed HPA hypofunction while inhaling 2.4 mg budesonide per day and another retained normal HPA function on a dose of 12 mg. In the remaining patients, intermediate doses resulted in suppression, or the patients were withdrawn unsuppressed for other reasons (n = 3). The results in this small patient sample suggest that budesonide administered via the Nebuhaler in doses up to 1.6 mg daily does not significantly affect plasma cortisol.

Topics: Administration, Inhalation; Adolescent; Adrenal Insufficiency; Adult; Aged; Asthma; Budesonide; Female; Humans; Hydrocortisone; Hypothalamo-Hypophyseal System; Male; Middle Aged; Nebulizers and Vaporizers; Pituitary-Adrenal System; Pregnenediones