Here we discuss two cases of adverse systemic effects of inhaled corticosteroids.
A 38-year-old lady presented with lethargy and was noted to be cushingoid, with round face, central adiposity, and bruising. She had history of allergic rhinitis and asthma. She was receiving beclometasone both as nasal spray 100 μg b.d, and as inhaler 400 μg b.d. for the last 10 years. She had only received, a one-week course of oral steroids for acute asthma in the previous 4 years. Her 24-hour urinary free cortisol (UFC) was undetectable. Urinary steroid profile was consistent with exogenous steroid administration. A short synacthen test (SST) showed a flat response with a basal cortisol of 8 nmol/l, rising to 50 at 30 min, and 65 nmol/l at 60 min. Fasting glucose, electrolytes, sex hormones and thyroid function tests (TFT) were normal. A diagnosis of iatrogenic Cushings secondary to inhaled beclometasone with adrenal suppression was made. She was started on replacement hydrocortisone, and her inhaled steroids were tapered with resolution of her cushingoid features.
The second patient with history of asthma was on seretide inhaler (fluticasone 250 μg and salmeterol 25 μg) b.d. and presented with history of tiredness. She had elevated TSH at 4.1 mu/l (0.33.5) with moderately positive microsomal antibodies and was started on Thyroxine. Despite normalisation of her TFT, she complained of exhaustion. A SST showed poor response with basal cortisol of 149 nmol/l rising to 205 at 30 min and to 230 nmol/l at 60 min. She had basal morning ACTH of 24 ng/l (040) and negative adrenal antibodies. A Depot synacthen test showed a peak cortisol of 853 nmol/l at 24 hr. She was started on replacement hydrocortisone and her inhaled steroids were halved with good response.