Hypothalamic-pituitary-adrenal axis suppression in asthmatic children on inhaled and nasal corticosteroids - More common than expected? (original) (raw)
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The Journal of Clinical Endocrinology & Metabolism
Context The low-dose (1 µg) ACTH test (LDT) is widely used to assess central adrenal insufficiency (CAI); however, the serum cortisol cutoff value is controversial. Salivary cortisol (SC) may be a more accurate measurement for CAI. Objective To assess a new maximum cutoff value of serum cortisol after LDT in pediatric patients, taking into account serum and SC measurements. Design and Setting Prospective study in a pediatric tertiary referral center. Working Hypothesis The combined analysis of serum and SC response to LDT might improve LDT for CAI diagnosis. Participant and Outcome Measurement A total of 145 pediatric patients underwent LDT. Serum and SC levels were measured. A central adrenal sufficient (CAS) response was established according to the reference serum cortisol cutoff value of ≥497 nmol/L. Results The LDT study showed central adrenal sufficiency in 72 patients and CAI in 73 patients. Considering the lower quartile of maximum SC value (21 nmol/L) in the CAS group, an i...
BMJ open, 2013
To determine which parameter is the most useful screening test for hypothalamic-pituitary-adrenal suppression in asthmatic children. Cross-sectional study. Paediatric allergy clinics in Cape Town, South Africa. 143 asthmatic children of mostly mixed ancestry, aged 5-12 years. Primary outcome measures included Spearman correlation coefficients (r) calculated between the postmetyrapone (PMTP) serum adrenocorticotropic hormone (ACTH), 11-deoxycortisol (11DOC), 11DOC+ cortisol (C) and height, weight, height velocity, weight velocity, change in systolic blood pressure from supine to standing, early morning urinary free cortisol (UFC), morning C, ACTH and dehydroepiandrosterone sulfate (DHEAS). Secondary outcome measures were the receiver operating characteristics (ROC) curve and the diagnostic statistics for the most promising test. All screening variables were weakly correlated with the three PMTP outcomes. Only DHEAS and UFC (nmol/m(2)) were statistically significant-DHEAS for PMTP ACT...
The Prevalence of Hypothalamic-Pituitary-Adrenal Axis Suppression in Children with Persistent Asthma
Iranian Journal of Pediatrics, 2019
Background: Hypothalamic-pituitary-adrenal (HPA) axis suppression is the most important systemic side effect associated with inhaled corticosteroids (ICS) therapy. Objectives: To evaluate the prevalence and determinants of hypothalamic-pituitary-adrenal (HPA) axis suppression in asthmatic children on ICSs. Methods: A total of 92 children aged 6 to 18 years, diagnosed with persistent asthma, and receiving regular ICS therapy for a minimum of 3 months, without any systemic steroid therapy within the last 3 months, were enrolled in the study. Clinical and demographic variables were recorded. HPA axis suppression was measured by morning cortisol levels and confirmed by low-dose adrenocorticotropic hormone stimulation test. Results: Of 92 enrolled patients, 51 (55.4%) were male. The mean age was 10.1 ± 2.6 years. HPA axis suppression was observed in two (2.1%) patients. The body mass index (BMI) values were significantly lower in the HPA axis suppression group compared to the other enrollees. No relationship was observed between the HPA axis suppression and the ICS dose, duration of therapy or coadministration of long-acting beta-agonists or nasal steroids. Conclusions: In our study, the prevalence of HPA axis suppression was 2.1%. Children with persistent asthma who has been treated with regular ICS should be screened for HPA axis suppression.
Thorax, 2003
Background: A study was undertaken to assess the function of the hypothalamic-pituitary-adrenal axis (HPA) in a group of asthmatic children before and after treatment with inhaled corticosteroids. Methods: Thirty prepubertal patients of mean (SD) age 6.7 (1.8) years were treated with inhaled corticosteroids. All children underwent a corticotrophin releasing hormone (CRH) test with evaluation of serum cortisol and adrenocorticotrophin hormone (ACTH) levels before and after 3 months of treatment. Twenty four hour urine samples were also collected to measure free cortisol (UFC) excretion. Results: Subjects showed no difference between basal serum cortisol levels (mean change-18; 95% CI-41 to 5; p=0.118) and delta (peak minus basal) levels (mean change-13; 95% CI-38 to 12; p=0.308) before and after treatment, whereas the peak cortisol level (mean change-31; 95% CI-55 to-7; p=0.013) and area under the curve (AUC) (mean change-175; 95% CI-288 to-63; p=0.003) after CRH were significantly lower following treatment. Basal, peak and AUC ACTH were significantly lower after treatment (p<0.05, p=0.004 and p=0.003, respectively), while delta ACTH was similar before and after treatment ((mean change-12; 95% CI-31 to-7; p=0.199). No significant reduction in 24 hour UFC was observed after the treatment period (before 14.9 (7.1), after 15.0 (11.6); mean change 0.1, 95% CI-5.2 to 5.4; p=0.967). No correlation was found between UFC and any of the parameters of cortisol excretion following the CRH test, either before or after treatment. Conclusions: These data suggest that, at the dosage and for the treatment period used, inhaled steroids do not seem to suppress the HPA axis in the majority of patients. The CRH test may be more sensitive than 24 hour UFC and morning plasma cortisol levels in evaluating systemic activity of inhaled corticosteroid treatment.
Cortisol: ACTH ratio to test for primary hypoadrenalism: a pilot study
Postgraduate Medical Journal, 2013
Introduction A standard short Synacthen test (SST) is the conventional diagnostic test for primary hypoadrenalism. Measuring simultaneous plasma cortisol and adrenocorticotrophin hormone (ACTH) and using the cortisol: ACTH ratio as a first-line test may be safer and more convenient than performing a SST. Methods A retrospective study of 349 patients who had a SST with simultaneous baseline plasma cortisol and ACTH performed between 2005 and 2010 in two separate Australian health centres. The plasma cortisol: ACTH ratio was calculated for each patient and their final diagnosis was determined based on their SST result and a review of their clinical notes. Results Eighteen patients had primary hypoadrenalism, 46 patients had secondary hypoadrenalism and 285 patients had normal adrenal function. All the patients with primary hypoadrenalism had a plasma cortisol: ACTH ratio <3, while none of the patients with normal adrenal function or secondary hypoadrenalism had a cortisol: ACTH ratio <3. Therefore, a cortisol: ACTH ratio <3 had a 100% sensitivity and specificity for the diagnosis of primary hypoadrenalism. Patients with secondary hypoadrenalism had a cortisol: ACTH ratio >3, while subjects with normal adrenal function had a cortisol: ACTH ratio >15. There was overlap in cortisol: ACTH ratios of patients with secondary hypoadrenalism and normal adrenal function. Conclusions Although the cortisol: ACTH ratio predicts primary hypoadrenalism, its value is limited to diagnosing primary hypoadrenalism as it does not distinguish secondary hypoadrenalism from normal adrenal function. Larger prospective studies that include patients with early primary hypoadrenalism are needed to confirm the reliability of plasma cortisol: ACTH ratio as a diagnostic test for primary hypoadrenalism.