1. Adrenal Suppression Occurs in Children Treated with Inhaled
Steroids Taken Orally for Eosinophilic Esophagitis Treatment
Mahmuda M. Ahmed MD1, Anastasios Angelides MD2, Meghana Gudala MD1,
Alexander Knee MS3 and Holley Allen MD, MSPH1.
1Endocrinology, Baystate Children's Hospital, Springfield, MA, United States; 2Gastroenterology, Baystate Children's Hospital,
Springfield, MA, United States, 3Division of Academic Affairs, Baystate Medical Center, Springfield, MA, United States.
ABSTRACTBackground:
Eosinophilic esophagitis (EoE), a chronic immune mediated esophageal disease has
been described as “asthma of the esophagus”. Inflammatory changes in the
esophageal mucosa and submucosa are reduced through the use of inhaled
corticosteroids (ICS) that are deliberately swallowed. Very little is known about the
impact of this treatment modality on adrenal function and whether secondary
adrenal suppression occurs.
Objective:
To determine whether adrenal suppression occurs in patients treated with ICS which
are swallowed for treatment of EoE. We hypothesized that adrenal suppression does
occur in patients during and immediately after chronically swallowed ICS treatment.
Design/Methods:
A descriptive study was designed to include both prospective and retrospective data.
Consent and assent were obtained from study subjects < 18 years and only consent
was obtained from those ≥ 18 years. All subjects had histologically confirmed EoE.
Data, compiled via in-person questionnaire and patient charts were incorporated into
a database. Morning ACTH, cortisol and DHEA-S levels were collected. Individuals
with a morning cortisol < 8 mcg/dL were referred for a 1 mcg ACTH stimulation test.
Results:
In our cohort of 46 patients, 23 subjects (17M) with mean age 13.6 years (range 6
to 19) were prescribed chronic ICS taken orally and had morning screening labs.
The median cortisol level was 10.6 mcg/dL (range 4.4 to 24.7). Six subjects
underwent ACTH stimulation tests following low morning cortisols. Two of these
individuals were found to have biochemical adrenal suppression, both of whom were
treated with a moderate dose of 440 mcg of swallowed fluticasone. The first subject
was a 12 year old male who underwent ACTH stimulation testing during the 10th
week of treatment. He had also taken ICS intermittently for asthma. The other was
an 8 year old male who had completed a 10 week course of treatment one week
prior to the ACTH stimulation test.
Conclusions:
Adrenal suppression occurred in 9% of our patients who are prescribed chronically
swallowed ICS. Prospective studies with a larger sample size are needed to
determine the relationship between timing and dosage of steroids and incidence of
adrenal suppression.
INTRODUCTION
HYPOTHESIS
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Eosinophilic esophagitis (EoE) is a
chronic immune -mediated
esophageal disease.
EoE is described as “asthma of the
esophagus”.
Treatment to decrease inflammation
is through the use of inhaled
corticosteroids (ICS) that are
deliberately swallowed.
Currently, there is limited knowledge
on the impact of this treatment on
adrenal function.
Adrenal suppression occurred in 12.5% of our study subjects who were treated
with swallowed ICS for treatment of EoE.
Future prospective studies with larger sample size, are needed to determine the
relationship between timing/dosage of steroids and presence of adrenal
suppression.
Adrenal suppression occurs in patients treated with
chronically swallowed ICS for treatment of EoE.
*No conflict of interest
RESULTS
METHODS
CONCLUSIONS
Demographic Data Study Subjects (n=46)
Mean Age
(years +/- SD)
14.0 +/- 5.0
Male 29 (63%)
Caucasian 24 (52%)
Mean Age at Diagnosis
(years +/- SD)
10.5 +/- 5.4
Steroids Initiated 40 (87%)
Type /Dose of
Swallowed ICS
50% Fluticasone 400 mcg
5% Fluticasone 800 mcg
2.5% Budesonide 1 mg
2.5% Budesonide 2 mg
40% Changed from one type to another
Labs Drawn 24 (60%)
Characteristics of 3 Patients with Evidence of Adrenal Suppression
Patient 1 Patient 2 Patient 3
Age 12.4 years 8.8 years 9.6 years
Sex Male Male Male
Ethnicity Hispanic-White Caucasian Caucasian
Body Surface Area (m2) 1.63 1.16 0.95
BMI Percentile 98.9 95.7 21
Steroid Type/Dose
Fluticasone 400
mcg
Fluticasone 400
mcg
Fluticasone 400
mcg
Number of ICS Courses 1 1 1
Treatment Duration
When Screening Labs
Drawn
2.5 months 1 month 2 weeks
Treatment Duration
When LD ACTH Stim.
Test Performed
3 months
5 days after
completion of 6
week course
2 months
Concomitant Steroid Use
for Asthma
Yes No No
Peak Cortisol (μg/dL)
At 30 min post LD ACTH
7.6 12.7 11.7
IRB approved descriptive study with both prospective and
retrospective data collection
Consented 46 patients from 3 to 20 years of age
Demographic, treatment modality and lab data collected
Screening labs drawn prior to 10 AM
Low dose (LD) ACTH stimulation test performed if morning
cortisol < 8 μg/dL
RESULTS
7 out of 24 subjects had low screening morning cortisol levels
3 out of 7 subjects had biochemical evidence of adrenal suppression