Endocrine Abstracts

JOINT340

Background: Glucocorticoids are widely used anti-inflammatory drugs for various pediatric conditions. Adrenal suppression is a rare but serious complication, typically associated with systemic glucocorticoid administration: most commonly, oral, intravenous or intramuscular. While the association between inhaled glucocorticoids and hypothalamic-pituitary-adrenal axis suppression is well-established, the systemic absorption of nasal corticosteroids remains controversial. Current international guidelines for allergic rhinitis suggest that the risk of adrenal insufficiency associated with intranasal glucocorticoid use is minimal.

Case Presentation: A previously healthy 6-year-old girl presented to our pediatric endocrinology clinic for evaluation of Cushing syndrome. She had been referred by her pediatrician following multiple visits to family practice, given the family’s concerns around changes in facial features and increased hair growth. Her medical history was significant for seasonal allergic rhinitis, treated with intranasal beclomethasone for over three months. This had been prescribed by her family physician, at usual doses, and discontinued two weeks prior to her clinic visit. There was no additional exposure to any other medications or supplements. On physical examination, the patient exhibited facial rounding and increased hair growth along the sideburns and back. Laboratory evaluation revealed an undetectable morning cortisol level (<28 nmol/l) and a low ACTH level (2 pmol/l). Further testing confirmed an insufficient cortisol response to ACTH stimulation (peak cortisol 172nmol/l). Other pituitary hormone levels were within reference range. A diagnosis of adrenal suppression secondary to high-dose intranasal steroid use was made. The patient was started on hydrocortisone replacement with gradual tapering. Her family received education on stress dosing during illness to prevent adrenal crisis.

Discussion: This case underscores the possible systemic effects of intranasal corticosteroids. Prolonged use, high doses, concomitant use of CYP3A4 inhibitors, and the presence of genetic variations that affect steroid metabolism, could increase the risk of adverse effects. Early recognition and intervention are critical to prevent life-threatening adrenal crises.

Conclusion: Awareness of adrenal suppression as a potential side effect of intranasal corticosteroids is essential. This case emphasizes the need for judicious use of any type of glucocorticoids. Patient and family education, along with routine monitoring of at-risk patients, are crucial for mitigating risks.