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 Health  Vol.8 No.7 , May 2016
The Benefits of Identifying and Treating Adrenal Suppression in Adult Difficult Asthmatics: A Case Series
Abstract: We present 7 adults atopic asthmatics that were referred due to repeatedly relapsing asthma requiring oral courses of prednisolone. All were steroid responsive yet steroid dependant and were screened for adrenal insufficiency after changes to inhaled therapy and other standard anti-asthma treatments failed to improve the situation. All were deemed to be compliant. 4 used long-term intranasal steroids in addition to inhaled corticosteroids. No topical steroid creams were used by these patients. Adrenal suppression was examined via a 9 am cortisol level and a short synacthen test (using intravenous tetracosactide 250 mcg) along with measurement of ACTH (Adreno-Cortico-Trophic Hormone). The tests were performed in periods off prednisolone. We report the observed beneficial effects after treatment of the adrenal insufficiency with hydrocor-tisone acetate replacement therapy in these cases, and the benefit to their exacerbations, hospital admission and the requirement for prednisolone courses. These patients would have been stepped up to yet higher doses of inhaled steroids and even referred for anti-IgE treatment etc. Adrenal suppression is well described in the medical literature for asthmatics, but the beneficial outcomes of treating this are unknown. These 7 cases have been followed for up to 3 years since hydrocorti-sone replacement therapy. Most improved to a stable asthma without frequent exacerbations nor requirement for prednisolone and only 1 had a hospital admission.
Cite this paper: Varney, V. , Parnell, H. and Quirke, G. (2016) The Benefits of Identifying and Treating Adrenal Suppression in Adult Difficult Asthmatics: A Case Series. Health, 8, 642-649. doi: 10.4236/health.2016.87067.
References

[1]   Ahmet, A., Kim, H. and Spier, S. (2011) Adrenal Suppression: A Practical Guide to the Screening and Management of the Under-Recognised Complications of Inhaled Corticosteroids Therapy. Allergy, Asthma & Clinical Immunology, 7, 13-18.
http://dx.doi.org/10.1186/1710-1492-7-13

[2]   Mortimer, K.J., Tata, L.J., Smith, C.J.P., West, J., Harrison, T.W., Tattersfield, A.E. and Hubbard, R.B. (2006) Oral and Inhaled Corticosteroids and Adrenal Insufficiency: A Case-Control Study. Thorax, 61, 405-408.
http://dx.doi.org/10.1136/thx.2005.052456

[3]   Todd, G.R.G., Wright, D. and Ryan, M. (1999) Acute Adrenal Insufficiency in a Patient with Asthma after Changing from Fluticasone Propionate to Budesonide. Journal of Allergy and Clinical Immunology, 103, 956-957.
http://dx.doi.org/10.1016/S0091-6749(99)70447-1

[4]   Sutherland, T.J.T., Hodgekiss, C., Slough, J., Barth, J.H. and Clifton, I.J. (2012) Adrenal Suppression in Difficult Asthma: A Neglected Cause for Concern. Thorax, 67, A67.
http://dx.doi.org/10.1136/thoraxjnl-2012-202678.150

[5]   Taylor, A.V., Laoprasert, N., Zimmerman, D. and Sachs, M.I. (1999) Adrenal Suppression Secondary to Inhaled Fluticasone Propionate. Annals of Allergy, Asthma & Immunology, 83, 68-70.
http://dx.doi.org/10.1016/S1081-1206(10)63515-6

[6]   Havill, S. (2013) Poorly Recognised Adverse Effects of Inhaled Corticosteroids. Prescriber Update, 16, 16-19.

[7]   Zollner, E.W., Lombard, C.J., Galal, U., Hough, S., Irusen, E.M. and Weinberg, E. (2012) Hypothalamic-Pituitary-Adrenal Axis Suppression in Asthmatic School Children. Pediatrics, 130, 1512-1519.
http://dx.doi.org/10.1542/peds.2012-1147

[8]   Sim, D., Griffiths, A., Clarke, C., Rodda, C. and Freezer, N. (2003) Adrenal Suppression from High-Dose Fluticasone Propionate in Children with Asthma. European Respiratory Journal, 21, 633-636.
http://dx.doi.org/10.1183/09031936.03.00306302

[9]   Todd, G., Dunlop, K., McNaboe, J., Ryan, M.F., Carson, D. and Shields, M.D. (1996) Growth and Adrenal Suppression in Asthmatic Children Treated with High-Dose Fluticasone Propionate. Lancet, 348, 27-29.
http://dx.doi.org/10.1016/S0140-6736(96)03339-9

[10]   Kaliner, M.A. (2006) Pharmacologic Characteristics and Adrenal Suppression with Newer Inhaled Corticosteroids: A Comparison of Ciclesonide and Fluticasone Propionate. Clinical Therapeutics, 28, 319-331.
http://dx.doi.org/10.1016/j.clinthera.2006.03.003

[11]   Brown, P.H., Blundell, G., Greening, A.P. and Crompton, G.K. (1990) Do Large Volume Spacer Devices Reduce the Systemic Effects of High Dose Inhaled Corticosteroids? Thorax, 45, 736-739.
http://dx.doi.org/10.1136/thx.45.10.736

[12]   Bruni, F.M., De Luca, G., Venturoli, V. and Boner, A.L. (2009) Intranasal Corticosteroids and Adrenal Suppression. Neuroimmunomodulation, 16, 353-362.
http://dx.doi.org/10.1159/000216193

[13]   Lipworth, B.J. (1999) 24 Hour and Fractionated Profiles of Adrenocortical Activity in Asthmatics Patients Receiving Inhaled and Intranasal Corticosteroids. Thorax, 54, 20-26.
http://dx.doi.org/10.1136/thx.54.1.20

[14]   Gill, G., Swift, A., Jones, A., Strain, D. and Weston, P. (2001) Severe Adrenal Suppression by Steroid Nasal Drops. Journal of the Royal Society of Medicine, 94, 350-351.

[15]   Clark, D.J. and Lip-worth, B.J. (1997) Adrenal Suppression with Chronic Dosing of Fluticasone Propionate Compared with Budesonide in Adult Asthmatic Patients. Thorax, 52, 55-58.
http://dx.doi.org/10.1136/thx.52.1.55

[16]   Clark, D.J., Grove, A., Cargill, R.I. and Lipworth, B.J. (1996) Comparative Adrenal Suppression with Inhaled Budesonide and Fluticasone Propionate in Adult Asthmatic Patients. Thorax, 51, 262-266.
http://dx.doi.org/10.1136/thx.51.3.262

 
 
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