Pediatric Endocrine Group
Screening for adrenal suppression in pediatric patients assigned inhaled
corticosteroids for asthma can identify adrenal insufficiency and help prevent
adrenal crises. However, there is no consensus regarding the efficacy and
practicality of various screening tests or the need for oral steroid coverage
to avoid adrenal crises, according to a debate conducted at the Canadian
Pediatric Endocrine Group 2012 Scientific Meeting.
The argument for screening is that there is very good evidence
that children who are receiving greater than or equal to 500 mcg/day of
fluticasone for prolonged periods of time are at very high risk for adrenal
suppression, said Alexandra Ahmet, MD, FRCPC, a pediatric
endocrinologist at the Childrens Hospital of Eastern Ontario; assistant
professor of medicine at the University of Ottawa; and an author of guidelines
published in Allergy, Asthma & Clinical Immunology on the screening
and management of adrenal suppression as a complication of
Symptoms of adrenal suppression can be highly variable, so there are no
tell-tale signs that provide clues for clinicians, Ahmet told Endocrine
Patients can be asymptomatic, and we dont know, of those who
are asymptomatic, who is at risk for adrenal crisis, said Ahmet,
describing adrenal suppression as an under-recognized condition.
If children have adrenal suppression, oral
glucocorticoids should be administered in a stress dose
during illness or surgery, she said.
Although we dont have a perfect screening test, we do have
tests that allow us to identify children who are at highest risk for adrenal
suppression. It is imperative to identify these children, as we have a simple
therapy that can prevent significant morbidity and even mortality, Ahmet
Although it is justified to treat children who show symptoms of adrenal
suppression, Jonathan Dawrant, MD, FRCPC, a pediatric endocrinologist at
Alberta Childrens Hospital, said no studies show decreased morbidity or
mortality with oral steroid coverage in asymptomatic children.
Moreover, elevating daily exposure of exogenous corticosteroids with
oral steroid coverage does not necessarily increase patient safety, Dawrant
Additionally, the standard- or low-dose adrenocorticotropic hormone
(ACTH) stimulation test, which is sensitive enough to detect
suppression, is too resource-intensive.
Most (screening tests for adrenal suppression) are cumbersome and
time-consuming, Dawrant said, adding that many variables can affect the
results of the morning cortisol test, such as stress.
cortisol test is a single blood draw, which is not expensive
and not complicated, but we often get a result that is in a gray
zone, said Dawrant, who is also clinical assistant professor in the
department of pediatrics at the University of Calgary. If you get
in-between results, how will it change your management?
Dawrant and Ahmet said one of the most important solutions to this
problem is education for prescribing physicians about the potential risks of
high-dose inhaled corticosteroids. Although an essential therapy, in many
children a low or moderate dose is sufficient for optimal asthma control.
Jean-Pierre Chanoine, MD, PhD, FRCPC, past president of the
Canadian Pediatric Endocrine Group, and clinical professor and head of the
endocrinology and diabetes unit at British Columbia Childrens Hospital,
University of British Columbia in Vancouver, said adrenal suppression is very
difficult to predict, and there is a lot of individual sensitivity to the
suppressive effects of corticosteroid therapy that are poorly understood.
There is little consensus on a standard way of approaching these
patients, Chanoine said.
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Disclosure: Dr. Ahmet reports receiving speakers fees for
Nycomed. Drs. Dawrant and Chanoine report no relevant financial disclosures.