Poster Presentation The Annual Scientific Meeting of the Endocrine Society of Australia and the Society for Reproductive Biology 2014

A case of inhaled corticosteroid induced hypothalamic-pituitary-adrenal axis suppression (#298)

Anna Zheng 1 , Alexia Pape 1
  1. Diabetes and Endocrinology, Wollongong Hospital, Wollongong, NSW, Australia

A 75yo male presented with recurrent syncope for 6 months, on the background of chronic obstructive airway disease. He had been on inhaled corticosteroid therapy (fluticasone 500microgam BD) for over 1 year, without any oral corticosteroids. On presentation, he had asymptomatic postural hypotension of up to 10mmHg, without hypoglycaemia, hyponatraemia or hyperkalaemia.  

He was found to have significant hypothalamic-pituitary-adrenal axis suppression, with low serum ACTH level of <5 pg/ml, and Synacthen stimulation found peak cortisol of 116 nmol/L.  After ceasing inhaled fluticasone for one week, his hypothalamic-pituitary-adrenal axis improved, but remained suboptimal. On repeat testing, his ACTH level normalised to 28 pg/ml, and peak cortisol level was 521 nmol/L on Synacthen. CT-imaging found normal adrenals and pituitary. The patient was commenced on regular steroid supplementation, and the postural hypotension resolved. There were no further syncopal episodes reported.

All forms of corticosteroids can cause hypothalamix-pituitary-adrenal suppression, including topical as well as inhaled preparations. It is important to consider mild pituitary-adrenal suppression in inhaled corticosteroid users. The discussion will include a literature review of inhaled corticosteroid induced secondary hypoadrenalism. 

  1. Lipworth BJ. Systemic adverse effects of inhaled corticosteroid therapy: A systematic review and meta-analysis. Archives of Internal Medicine, 1999. 159(9): p. 941-955.
  2. Mortimer KJ, Tata LJ, Smith CJP, West J, Harrison TW, Tattersfield AE, Hubbard RB. Oral and inhaled corticosteroids and adrenal insufficiency: a case‐control study. Thorax, 2006. 61(5): p. 405-408.
  3. Lapi F, Kezouh A, Suissa S, Ernst P. The use of inhaled corticosteroids and the risk of adrenal insufficiency. Eur Respir J, 2013. 42(1): p. 79-86.
  4. Molimard M, Girodet PO, Pollet C, Fourrier-Réglat A, Daveluy A, Haramburu F, Fayon M, Tabarin A. Inhaled corticosteroids and adrenal insufficiency: prevalence and clinical presentation. Drug Safety, 2008. 31(9): p. 769-774.
  5. Samaras N, Schneider A, Frangos E, Forster A, Samaras D. A rare case of adrenal insufficiency induced by inhaled corticosteroids. Journal of the American Geriatrics Society, 2013. 61(5): p. 841-842.
  6. Schwartz RH, Neacsu O, Ascher DP, Alpan O. Moderate dose inhaled corticosteroid-induced symptomatic adrenal suppression: case report and review of the literature. Clinical Pediatrics, 2012. 51(12): p. 1184-1190.
  7. Johnson SR, Marion AA, Vrchoticky T, Emmanuel PJ, Lujan-Zilbermann J. Cushing syndrome with secondary adrenal insufficiency from concomitant therapy with ritonavir and fluticasone. The Journal of Pediatrics, 2006. 148: p. 386-388.
  8. Fardon TC, Lee DKC, Haggart K, McFarlane LC, Lipworth BJ. Adrenal suppression with dry powder formulations of fluticasone propionate and mometasone furoate. American Journal of Respiratory and Critical Care Medicine, 2004. 170(9): p. 960-966.
  9. Zöllner EW, Lombard C, Galal U, Hough S, Irusen E, Weinberg E. Hypothalamic-pituitary-adrenal axis suppression in asthmatic children on inhaled and nasal corticosteroids—more common than expected. Journal of Pediatric Endocrinology Metabolism, 2011. 24(7-8): p. 529-534.
  10. Zöllner EW, Lombard C, Galal U, Hough S, Irusen E, Weinberg E. Hypothalamic-Pituitary-Adrenal Axis Suppression in Asthmatic School Children. Pediatrics, 2012. 130(6): p. 1512-1519.