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Author Spotlight: Investigating the Pathophysiology of Eosinophilic Esophagitis
Published on: May 10, 2024
Adrenal Insufficiency after Chronic Swallowed Glucocorticoid Therapy for Eosinophilic Esophagitis
Marjorie C Golekoh1, Lindsey N Hornung2, Vincent A Mukkada3
1Division of Pediatric Endocrinology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
Insights
Children treated with swallowed fluticasone propionate (FP) or budesonide for eosinophilic esophagitis may develop adrenal insufficiency (AI). AI was found in 10% of patients, exclusively those on higher-dose FP, warranting screening.
Area of Science:
- Pediatric Endocrinology
- Gastroenterology
- Pharmacology
Background:
- Eosinophilic esophagitis (EoE) is a chronic inflammatory condition.
- Swallowed glucocorticoids, such as fluticasone propionate (FP) and budesonide, are standard treatments for EoE.
- Long-term use of glucocorticoids raises concerns about potential systemic side effects, including adrenal insufficiency (AI).
Purpose of the Study:
- To determine the prevalence of adrenal insufficiency (AI) in pediatric patients with eosinophilic esophagitis (EoE).
- To investigate the association between AI and the type and dose of swallowed glucocorticoids used (fluticasone propionate vs. budesonide).
Main Methods:
- A cohort of children with EoE treated with swallowed FP or budesonide for at least six months was studied.
- Participants underwent a low-dose adrenocorticotropin stimulation test to assess adrenal function.
- Exclusion criteria included concurrent use of other forms of glucocorticoids (systemic, inhaled, intranasal, topical).
Main Results:
- Out of 58 patients, 10% (n=6) were diagnosed with AI (peak serum cortisol <18 μg/dL).
- Adrenal insufficiency was exclusively observed in patients treated with fluticasone propionate (FP) at doses exceeding 440 μg/d.
- No AI was detected in patients treated with budesonide, and 77% of FP-treated patients had a normal response.
Conclusions:
- AI affects 10% of children with EoE on long-term swallowed glucocorticoids, specifically those on FP at doses >440 μg/d.
- Low-dose adrenocorticotropin stimulation testing is recommended for early AI detection in children on long-term, high-dose FP therapy.
- Budesonide may be a safer alternative regarding adrenal suppression compared to FP in this pediatric population.
Objective:
To establish the prevalence of adrenal insufficiency (AI) in children with eosinophilic esophagitis treated with swallowed fluticasone propionate (FP) or budesonide.
Study Design:
Children treated with FP or budesonide for ≥ 6 months underwent a low-dose adrenocorticotropin stimulation test. Patients using systemic, inhaled, intranasal, or topical glucocorticoids were excluded. The primary outcome is AI, defined as peak serum cortisol <18 μg/dL (≤ 495 nmol/L).
Results:
Of 58 patients (81% male), 67% were on FP (median age 13.7 years [range 4.3-19.1], dose 1320 μg/d [440-1760], treatment duration 4.0 years [0.6-13.5]). Thirty-three percent were on budesonide (median age 10.7 years [range 3.2-17.2], dose 1000 μg/d [500-2000], treatment duration 3.4 years [0.6-7.7]). The overall prevalence of abnormal peak cortisol response (≤ 20 μg/dL) was 15% (95% CI 6%-25%) (indeterminate [18-20 μg/dL] 5% [n = 3] vs AI [<18 μg/dL] 10% [n = 6]). All patients on budesonide had a normal response vs only 77% of patients on FP (P = .02), all of whom were taking FP at a dose >440 μg/d.
Conclusions:
AI was present in 10% of children treated with swallowed glucocorticoids for ≥ 6 months and was found only in those treated with FP >440 μg/d. We recommend low-dose adrenocorticotropin stimulation testing in children treated long term with high dose FP to allow early detection of AI.
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