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Screening for adrenal suppression in children lacks standard approach

Posted on March 1, 2012 n/a

Canadian 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 Children’s 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 inhaled corticosteroid therapy.

Alexandra Ahmet, MD, FRCPC
Alexandra Ahmet

Symptoms of adrenal suppression can be highly variable, so there are no tell-tale signs that provide clues for clinicians, Ahmet told Endocrine Today.

“Patients can be asymptomatic, and we don’t 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 don’t 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 said.

Although it is justified to treat children who show symptoms of adrenal suppression, Jonathan Dawrant, MD, FRCPC, a pediatric endocrinologist at Alberta Children’s 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 said.

Jonathan Dawrant, MD, FRCPC
Jonathan Dawrant

Additionally, the standard- or low-dose adrenocorticotropic hormone (ACTH) stimulation test, which is sensitive enough to detect adrenal 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.

“The morning 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 Children’s 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.

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