Prolonged use of oral corticosteroid treatment is associated with cushingoid side effects and HPA suppression. We are increasingly seeing similar problems associated with nasal steroid therapy.
Case 1: A 41-year-old lady with history of asthma, allergic rhinitis and nasal polyps presented with a clinical appearance of Cushings syndrome. Her medication included Becloforte inhalers 250 mg tds and Betamethasone sodium phosphate nasal drops 0.1% 2 drops bd, both taken for several years.
A short synacthen test (SST) off all treatment confirmed adrenal suppression- basal cortisol- 8 nmol/l, 30 min- 50 nmol/l, 60 min- 65 nmol/l. Other investigations revealed suppressed ACTH (<5 ng/l), negative anti adrenal gland antibodies, unremarkable CT Adrenal glands and normal pituitary function. Hydrocortisone replacement therapy was commenced and the intranasal betamethasone discontinued. She failed two subsequent SSTs and remains on hydrocortisone.
Case 2: A 35-year lady old with a history of asthma and hay fever presented with 10 days of feeling unwell following abrupt discontinuation of her dexamethasone isonicotinate nasal spray. She had taken a range of other steroid nasal sprays and drops for a period of 18 years. She had recently increased the frequency intake- using up to 2 containers (220 metered doses) each week. An SST off treatment revealed a basal cortisol of 132 nmol/l, 30 min 161 nmol/l and at 60 min 179 nmol/l. Serum ACTH was 52 ng/l, Anti adrenal gland antibodies were negative and pituitary function was unremarkable. She continues on hydrocortisone replacement therapy.
Intranasal steroids are in widespread use since and are effective in the treatment of allergic rhinitis and other nasal conditions. Clinicians need to be aware however of potential side effects and should limit their use to the minimum effective dose and shortest possible duration. Patients, who require a prolonged course or who are taking other forms of exogenous steroids should be warned about side effects.