Download Adrenal Suppression in Pediatic Asthma

ADRENAL SUPPRESSION IN PEDIATRIC ASTHMA
ADRENAL SUPPRESSION (AS)
SYMPTOMS: ADRENAL SUPPRESSION
(Patient may be asymptomatic)
• Sustained deficiency of HPA axis following
exposure to exogenous glucocorticoids
can last from days to a year
Glucocorticoid Deficiency
• Malaise
• Nausea
• Headache
• Poor growth
• Consider after 2 or more weeks of glucocorticoid
therapy (depends on the type, schedule of
glucocorticoid administration and
individual factors)
• Poor weight gain
• Hypoglycemia*
• Hypotension*
*Symptoms of adrenal crisis
Mineralocorticoid deficiency (causing hypovolemia, hyponatremia and hyperkalemia)
is NOT seen with AS (may be seen with other forms of primary adrenal insuffiency)
COMPARISON OF THE VARIOUS ICS MEDICATIONS
FATE OF INHALED STEROIDS
P0TENTIAL SYSTEMIC SIDE EFFECTS
• Adrenal suppression
• Growth suppression
• Cushingoïd features
• Bone effects
PK/PD CHARACTERISTICS OF ICS MEDICATIONS
Particle size (µm)
Fluticasone
Budesonide
Beclomethasone HFA
Ciclesonide
Lung deposition %
Oral bioavailability %
Protein binding %
Clearance rates (Lh-1)
20
15-30
50-60
52
≤1
11
20/40a
≤ 1/≤ 1a
90
88
87
99/99a
66
84
150/120a
152/228a
2.8
> 2.5
< 2.0
< 2.0
a = Active Metabolite
SCREENING AND DIAGNOSIS OF AS
WHEN TO SCREEN
DIAGNOSIS BEST TEST
• Symptoms (refer to table above)
• Patients receiving high dose ICS (e.g. ≥ 500 mcg fluticasone
≥ 800-1200 mcg beclomethasone/budesonide)
• Cortisol value < lab norm may indicate AS
Consider
endocrine consult
• A normal non-stimulated cortisol does NOT rule out AS
Note: Urinary cortisol is NOT a specific marker of AS
• ACTH stimulation test >500 nmol/L normal in adults, >300
nmol/L normal in infants
HOW TO SCREEN
• Complete 8 am cortisol test
• < lab normal – consider endocrine consult
• within lab normal range – repeat every 6
months
RULES FOR 8 AM TEST:
• Must be done at 8 am or earlier
• No oral steroids 48-72 hours before
• No inhaled steroids the night before
• Fasting not required
PREVENTION AND RECOGNITION OF AS
All PATIENTS ON ICS
• Use lowest possible dose of ICS (regular re-evaluation)
• Consider ICS with minimal systemic effects
• Educate at risk patients and family on potential systemic side effects of ICS
In children on high doses of ICS (e.g. ≥ 500 mcg fluticasone) screen & monitor for adrenal suppression every 6 months.
Consider referral to endocrinologist IF abnormal screening test/growth.
1. Kelly HW. Comparison of inhaled corticosteroids: an update. Ann Pharmacother. 2009 Mar;43(3):519-27.
2. Gulliver T, Eid N. Effects of glucocorticoids on the hypothalamic-pituitary-adrenal axis in children and adults.
Immunol Allergy Clin North Am. 2005;25(3):541-555, vii.
3. Derendorf H. Pharmacokinetic and pharmacodynamic properties of inhaled ciclesonide. J Clin Pharmacol. 2007;47(6):782-789.V
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