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Medical Forum / Diseases and Disorders / Sinusitis / August 2006Steroid sprays and adrenal suppression = more sinusitis?
I've been reading a lot on the topic of topical steroids, inhaled steroids and adrenal suppression, which I'm suffering from at present (severe sx of adrenal insufficiency, actually, brought on somehow by my increased dose of metformin for DM). I had a normal serum cortisol a.m./p.m. test last week, despite having all the symptoms of adrenal suppresion, in addition to severe electrolyte depletion, partially due to metformin (potassium) and partially due to not being able to eat much for weeks. Last time I was abruptly told to stop high dose steroid use, I had symptoms of adrenal crisis and the test for that (ACTH stim) failed to show it, because I had some reserve, despite my exceedingly low serum cortisol (ER level). I mention all this because even if those chronically inhaling steroids get tested, even if it's done by an endocrinologist, adrenal suppression is likely to be missed because the tests won't likely find it unless you're in adrenal failure. I also mention it because since I've stopped the metformin, I've been able to fall asleep sleep and eat for the first time in weeks (though not in that order) though I still can't eat more than half normal, like 500 cal per day. My sinuses are better, I expect (and will report back about this) that they will continue to improve as I very slowly wean myself away from the remaining topical steroid in my life and my adrenals rebound (to normal, I hope). In the literature, adrenal suppression typically begins within 2 weeks of onset of use of topical/inhaled steroids. Even very short contact leads to it. Even if doctors are monitoring asthma/sinus/other patients for suppression (and no one I know gets such monitoring), the tests will often/mostly miss it. And adrenal suppression makes allergies and inflammation worse. I guess I don't think that inhaled steroids should be used or so cavalierly recommended for long term use, or that they should be used for only two or three weeks, then a week off before resuming, which is what my dermatologist does. Rhinocort is implicated in adrenal suppression, even though it's a tiny amount. Common tests for growth suppression in peds, for example, did not detect the adrenal suppression despite its presence. :-/ Susan Susan, I have an excellent allergist: his wife got adrenal suppression from standard doses of flovent: which was marketed as being essentially inert and not a systemic risk. He won't use flovent anymore. He prefers budesonide (pulmicort) but remains suspicious of it as well. I agree, we apply steroids to our mucosa or inhale them, and we've been told that they don't reach adrenal suppresive levels, but they can. Inhaled insulin was just approved, so obviously inhaled subtances can reach systemically effective levels. Just an observation: I recently saw someone with low potassium and we discovered SIADH (inappropriate secretion of antidiuretic hormone), it appears to be precipitated by Lyme disease. I hope you're feeling better. Judy > x-no-archive: yes > [quoted text clipped - 47 lines] > > Susan > Susan, > I have an excellent allergist: his wife got adrenal suppression from [quoted text clipped - 6 lines] > Inhaled insulin was just approved, so obviously inhaled subtances can > reach systemically effective levels. Yeah, and especially efficiently through mucosa, right? > Just an observation: I recently saw someone with low potassium and we > discovered SIADH (inappropriate secretion of antidiuretic hormone), it > appears to be precipitated by Lyme disease. > I hope you're feeling better. Thanks, Judy, I'll keep that in mind. I don't feel severely dehydrated anymore, though being so ketogenic and low calories means I've excreted a LOT of fluid and electrolytes. What's bugging me is that I've been taking lots of high dose replacements and still getting vicious, viselike nighttime cramps. I am better, though. Appetite is returning, no longer have pains in my muscles and joints, shortness of breath, etc, I'm less severely fatigued. I walked around for weeks feeling like I might vomit, also some trots. :-/ Still lightheaded and a little jittery, but that can be from extreme low carbs, too. I've decided to change primary docs as a result of his dismissal of my report and reliance exclusively on the test. I think he's burnt out on all that's wrong with me and on my insistence on being the decision maker and having my experience count as evidence. He was the best doc I ever had. I hope to keep him as my inf. diseases doc. I've actually made an appt. with an integrative M.D., Fam. Med. doc. They're FOS about some stuff, too, but at least it'll be new sh*t. ;-) Susan Susan, It's so tough to find someone who works with you. I have to admit that even my beloved ENT once dropped out of the picture when my daughter was in the ER. It was a miscommunication, but he was really busy and they reported to him that the CT was "negative"--the same CT that Peter Catalano at Lahey saw a couple of weeks later and wanted to schedule surgery. And her potassium was 3 (due to overuse of albuterol.) Once the sun went down (it was a Saturday), my allergist called and straightened everything out. Her fiance, who was a fourth year med student at Mt. Sinai at the time and I had to essentially run her case--check the labs, suggest the imaging, get her a nebulizer, and at the end, the ER doc slumped in the chair--he'd done a double shift, and asked us what we thought we should do about her. If I knew, I wouldn't have been in the ER in the first place: she had a high fever--likely flu--although rapid flu negative (it's a lousy test), she'd been on levaquin and prednisone for a 4 month sinusitis, she has an immunodeficiency--IgA deficiency, and her asthma kicked into high gear. She'd seen a prominent pulmonologist in Boston who had done an inadequate methacholine challenge test and told her she didn't have asthma. In the end, we put her on high dose zithromax and prednisone, repeated the pulmonary function tests a few weeks later--they were strongly positive--and complained about the ER experience (got a good response) and the Boston doc (got an angry defensive response). A colleague has told me repeatedly: "Whenever I need the healthcare system, it never fails to dissapoint me." There actually was a good article in Time a few months ago about how physicians are terrified to be patients, or have their family members be patients: one doctor talked about staying in the hospital around the clock "to protect his wife from the care." So, it's a flawed system, and if he is the best doctor youve had, I wouldn't sever all ties, but you need someone who will work with you as well. Seriously, whenever we have a positive interaction with the healthcare system, it's a pleasant surprise. Good luck with the holistic FP's. Judy > x-no-archive: yes > [quoted text clipped - 37 lines] > > Susan > Susan, > It's so tough to find someone who works with you. I have to admit [quoted text clipped - 20 lines] > strongly positive--and complained about the ER experience (got a good > response) and the Boston doc (got an angry defensive response). What a nightmare. And it's not malpractice because it *is* the community standard. > A colleague has told me repeatedly: "Whenever I need the healthcare > system, it never fails to dissapoint me." nod nod nod. > There actually was a good article in Time a few months ago about how > physicians are terrified to be patients, or have their family members > be patients: one doctor talked about staying in the hospital around the > clock "to protect his wife from the care." Ever doctor and nurse I know feels this way with a relative in need of medical intervention in a hospital. > So, it's a flawed system, and if he is the best doctor youve had, I > wouldn't sever all ties, but you need someone who will work with you as > well. He'd originally been my specialist, then I asked him to be my PCP a few years ago. We need to stop going steady. :-) > Seriously, whenever we have a positive interaction with the > healthcare system, it's a pleasant surprise. And a very unexpected one! > Good luck with the holistic FP's. I've already been told not to wear any fragrances or lotions, she's highly allergic. :-) Also, she offers EDTA chelation in her practice, Reiki circles, meditation nights... What the hay: I've really decided that the only difference between the two schools of quacks is that too many in the conventional one have an unearned veneer of respectability, and are just as disreputable (and profit driven) as those with alternative practices. She actually is in my HMO, so no big investment, other than my hopes and my time. Susan Susan, You're right about the malpractice. I actually talked to an attorney I know who sues doctors, and he felt it was a matter for the board of discipline: I just got so angry--I showed the Boston doc that he didn't follow national protocols from the American Thoracic Society with his lung testing, nor did he follow national protocols for his skin testing, and his practice of not informing patients of abnormal labs was not the community standard. His response was to say that not only did he do nothing wrong, he would not change his practices. That's what got to me. My daughter is would have had to file an official complaint with board, and she didn't want to go there. I do worry about chelation with EDTA, there was a recent JAMA about some harm to children with chelation therapy. So, nothing wrong with meditation and no fragrances, but I worry when they embrace potentially harmful practices. I just got a recommendation to read a book: "Screaming to be Heard" by Dr. Elizabeth Vliet. I'm not sure what it addresses, but I like the title. I completely agree with you about experts who believe their own press. I have run into the occasional exception: the former head of head and neck surgery at Mass Eye and Ear was amazing: Richard Fabian--incredibly talented, a nice/decent person and he listened and truly collaborated. Of course, he retired to Florida.... Judy > x-no-archive: yes > [quoted text clipped - 63 lines] > > Susan > Susan, > You're right about the malpractice. I actually talked to an attorney [quoted text clipped - 7 lines] > got to me. My daughter is would have had to file an official complaint > with board, and she didn't want to go there. Most of us just want to put those awful clinical experiences behind us. The bad docs just get a steady stream of victims behind us that way, but it's so emotionally exhausting to relive it for lawyers, etc., I would imagine. > I do worry about chelation with EDTA, there was a recent JAMA about > some harm to children with chelation therapy. So, nothing wrong with > meditation and no fragrances, but I worry when they embrace potentially > harmful practices. Same here. But many folks claim to have been helped by it. Who's to say. I doubt I'll be convinced to try it. Even the Toronto naturopathic medical college, in a review study, found no evidence for its benefits, recently. I've been actually harmed (in life altering and/or threatening ways) by virtually every M.D. I've been under care of for any length of time in the past and none of them were alternative. Reasons were either treatments or neglect. I guess I've decided to practice caveat emptor with the alt. med. doc the same way I always have. These docs are at least, reputedly, much more "customer" oriented, and, frankly, I'm buying a service about which I will be the decision maker, same as I do in any doc's practice. Trust, but verify. ;-) > I just got a recommendation to read a book: "Screaming to be Heard" > by Dr. Elizabeth Vliet. I'm not sure what it addresses, but I like the > title. What's ironic about my current PCP is that early in our relationship he noted to me that I read and know more about my various medical conditions than most doctors, and that they were typically going to be intimidated and made uncomfortable by that, while assuring me that he had no problem with it. Yet, a few years later, he's so busy batting away my reports of my experiences (including refusing to acknowledge my DM because I found it first by buying a glucose meter) and of what I've found in the literature, that that's all we have going on between us. Except in the case of TBDs, we're still on board together with that; he's familiar with and comfortable with the territory, and understands and believes the severity of the impact on my life. For now. > I completely agree with you about experts who believe their own > press. I have run into the occasional exception: the former head of > head and neck surgery at Mass Eye and Ear was amazing: Richard > Fabian--incredibly talented, a nice/decent person and he listened and > truly collaborated. > Of course, he retired to Florida.... I HATE when they retire! If my allergist ever does, I'm going to slit my wrists! Susan Note also that there is an order of magnitude or more difference between systemic absorption of different sprays. Some are far far higher than others. As I recall, Flonase and Nasonex are extremely low. Others are higher... The papers are out there but I do not have the references any more - I have posted them in the past. > Note also that there is an order of magnitude or more difference between > systemic absorption of different sprays. > > Some are far far higher than others. > > As I recall, Flonase and Nasonex are extremely low. Others are higher... All of them are very efficiently absorbed, and any steroid absorbed has HPA axis effects, the endocrine system is exquisitely fine tuned to react to changes in the feedback loop. Susan Nasonex has a systemic bioavailability that is one one-hundredth that of Rhinocort Aqua and one twentieth that of Flonase. http://www.clevelandclinicmeded.com/ccjm/december2005/table1.htm > Nasonex has a systemic bioavailability that is one one-hundredth that of > Rhinocort Aqua and one twentieth that of Flonase. That's good to know, but here's the thing; any systemic absorption (and mucosa are an extremely efficient vehicle for meds) will alter HPA axis functioning. In addition, there's the problem of reduced host immunity/defenses against pathogens by the use of steroids. There is nothing but good to come of limiting use to 2 consecutive weeks with a week off before resuming steroid use, and everything to gain, in my now very well read but admittedly lay opinion. Susan Oh the full article is here: http://www.clevelandclinicmeded.com/ccjm/december2005/pien.htm >Nasonex has a systemic bioavailability that is one one-hundredth that of >Rhinocort Aqua and one twentieth that of Flonase. > >http://www.clevelandclinicmeded.com/ccjm/december2005/table1.htm > Oh the full article is here: > http://www.clevelandclinicmeded.com/ccjm/december2005/pien.htm [quoted text clipped - 3 lines] >> >>http://www.clevelandclinicmeded.com/ccjm/december2005/table1.htm "Triamcinolone acetonide, budesonide, fluticasone propionate, and mometasone tend not to cause any significant side effects, presumably because they have lower systemic bioavailability (particularly fluticasone and mometasone) and are used in low dosages." This quote from the article you cite is completely contradicted by the available research on Medline wrt both children and adults, especially in the case of fluticasone! Everything I've read calls for HPA axis monitoring with use of inhaled steroids. How many folks here are getting that with each rx of such drugs or even quarterly? Susan I read an article in Medscape about a new nasal steroid being developed, that is supposed to not affect systemic levels at all. > x-no-archive: yes > [quoted text clipped - 20 lines] > > Susan > Everything I've read calls for HPA axis monitoring with use of inhaled > steroids. How many folks here are getting that with each rx of such drugs > or even quarterly? > > Susan By "inhaled steroids" I think they are referring to asthma inhalers, not nasal sprays. > By "inhaled steroids" I think they are referring to asthma inhalers, not > nasal sprays. Adrenal suppression is associated with both. Susan Newer sprays especially, Nasonex being the lowest absorption of all, do not have this effect. From the package insert: http://www.spfiles.com/pinasonex.pdf Pharmacodynamics: Four clinical pharmacology studies have been conducted in humans to assess the effect of NASONEX Nasal Spray, 50 mcg at various doses on adrenal function. In one study, daily doses of 200 and 400 mcg of NASONEX Nasal Spray, 50 mcg and 10 mg of prednisone were compared to placebo in 64 patients with allergic rhinitis. Adrenal function before and after 36 consecutive days of treatment was assessed by measuring plasma cortisol levels following a 6-hour Cortrosyn (ACTH) infusion and by measuring 24-hour urinary-free cortisol levels. NASONEX Nasal Spray, 50 mcg, at both the 200- and 400-mcg dose, was not associated with a statistically significant decrease in mean plasma cortisol levels post- Cortrosyn infusion or a statistically significant decrease in the 24-hour urinary-free cortisol levels compared to placebo. A statistically significant decrease in the mean plasma cortisol levels post-Cortrosyn infusion and 24-hour urinary-free cortisol levels was detected in the prednisone treatment group compared to placebo. A second study assessed adrenal response to NASONEX Nasal Spray, 50 mcg (400 and 1600 mcg/day), prednisone (10 mg/day), and placebo, administered for 29 days in 48 male volunteers. The 24-hour plasma cortisol area under the curve (AUC0-24), during and after an 8-hour Cortrosyn infusion and 24-hour urinary-free cortisol levels were determined at baseline and after 29 days of treatment. No statistically significant differences of adrenal function were observed with NASONEX Nasal Spray, 50 mcg compared to placebo. A third study evaluated single, rising doses of NASONEX Nasal Spray, 50 mcg (1000, 2000, and 4000 mcg/day), orally administered mometasone furoate (2000, 4000, and 8000 mcg/day), orally administered dexamethasone (200, 400, and 800 mcg/day), and placebo (administered at the end of each series of doses) in 24 male volunteers. Dose administrations were separated by at least 72 hours. Determination of serial plasma cortisol levels at 8 AM and for the 24-hour period following each treatment were used to calculate the plasma cortisol area under the curve (AUC0-24). In addition, 24-hour urinaryfree cortisol levels were collected prior to initial treatment administration and during the period immediately following each dose. No statistically significant decreases in the plasma cortisol AUC, 8 AM cortisol levels, or 24-hour urinaryfree cortisol levels were observed in volunteers treated with either NASONEX Nasal Spray, 50 mcg or oral mometasone, as compared with placebo treatment. Conversely, nearly all volunteers treated with the three doses of dexamethasone demonstrated abnormal 8 AM cortisol levels (defined as a cortisol level <10 mcg/dL), reduced 24-hour plasma AUC values, and decreased 24-hour urinary-free cortisol levels, as compared to placebo treatment. In a fourth study, adrenal function was assessed in 213 patients with nasal polyps before and after 4 months of treatment with either NASONEX Nasal Spray, 50 mcg, (200 mcg once or twice daily) or placebo by measuring 24-hour urinary-free cortisol levels. NASONEX Nasal Spray, 50 mcg, at both doses (200 and 400 mcg/day), was not associated with statistically significant decreases in the 24-hour urinary-free cortisol levels compared to placebo. Three clinical pharmacology studies have been conducted in pediatric patients to assess the effect of mometasone furoate nasal spray on the adrenal function at daily doses of 50, 100, and 200 mcg vs placebo. In one study, adrenal function before and after 7 consecutive days of treatment was assessed in 48 pediatric patients with allergic rhinitis (ages 6 to 11 years) by measuring morning plasma cortisol and 24-hour urinary-free cortisol levels. Mometasone furoate nasal spray, at all three doses, was not associated with a statistically significant decrease in mean plasma cortisol levels or a statistically significant decrease in the 24-hour urinary-free cortisol levels compared to placebo. In the second study, adrenal function before and after 14 consecutive days of treatment was assessed in 48 pediatric patients (ages 3 to 5 years) with allergic rhinitis by measuring plasma cortisol levels following a 30-minute Cortrosyn infusion. Mometasone furoate nasal spray, 50 mcg, at all three doses (50, 100, and 200 mcg/day), was not associated with a statistically significant decrease in mean plasma cortisol levels post-Cortrosyn infusion compared to placebo. All patients had a normal response to Cortrosyn. In the third study, adrenal function before and after up to 42 consecutive days of once-daily treatment was assessed in 52 patients with allergic rhinitis (ages 2 to 5 years), 28 of whom received mometasone furoate nasal spray, 50 mcg per nostril (total daily dose 100 mcg), by measuring morning plasma cortisol and 24-hour urinary-free cortisol levels. Mometasone furoate nasal spray was not associated with a statistically significant decrease in mean plasma cortisol levels or a statistically significant decrease in the 24-hour urinary-free cortisol levels compared to placebo. > Newer sprays especially, Nasonex being the lowest absorption of all, do not > have this effect. That depends upon what you (or I) consider "statistically significant." And ignores the fact that the effect acrrues over longer periods of time. There is no way you spray something into your mucosa and don't get systemic absorption and effects. Susan > From the package insert: > http://www.spfiles.com/pinasonex.pdf [quoted text clipped - 78 lines] > decrease in mean plasma cortisol levels or a statistically significant > decrease in the 24-hour urinary-free cortisol levels compared to placebo. The new nasal steroid, ciclesonide, which supposedly will be available next year, is supposed to have no systemic absorption at all, and I think is also supposed to be more effective than others. One article that mentions it: http://www.medscape.com/viewarticle/525684 You can find other articles about it on Medscape as well. There will probably be a new antihistamine nasal spray out in the next year or so. (The only current one is Astelin.) This new one is the same med as in Patanol eye drops, formulated in a nasal spray. I wonder how its efficacy will compare with Astelin. > The new nasal steroid, ciclesonide, which supposedly will be available next > year, is supposed to have no systemic absorption at all, and I think is also > supposed to be more effective than others. No absorption at all would render it completely ineffective. You probably mean no systemic affects after it passes through the metabolism. It's probably BS, kind of like the crap you hear about there being SSRIs with no sexual side effects. I've never known anyone on them who didn't experience them. > One article that mentions it: > [quoted text clipped - 6 lines] > Patanol eye drops, formulated in a nasal spray. I wonder how its efficacy > will compare with Astelin. That I'd be interested in. Astelin is wonderful for me, and allows me to avoid taking Zyrtec (now that I'm desensitized) a lot of the time. Susan Just an FYI: 1: Arch Dis Child. 2002 Jul;87(1):45-8.Click here to read Links Cushing's syndrome, growth impairment, and occult adrenal suppression associated with intranasal steroids. * Perry RJ, * Findlay CA, * Donaldson MD. Department of Child Health, Royal Hospital for Sick Children, Yorkhill, Glasgow, UK. We have previously described iatrogenic Cushing's syndrome secondary to intranasal steroids. This report further highlights the potential deleterious effects of intranasal steroids. Nine cases (including the original two cases) are reviewed to show the varied clinical manifestations of adrenal suppression caused by intranasal steroids. Four presented with Cushing's syndrome, three with growth failure, while two asymptomatic patients were discovered in the course of pituitary function testing. Four children had dysmorphic syndromes--Down's, Treacher-Collins, CHARGE association, and campomelic dysplasia--reflecting the vulnerability of such children to ENT problems, together with the difficulty of interpreting steroid induced growth failure in this context. Adrenal suppression was seen not only with betamethasone but also with budesonide, beclomethasone and flunisolide nasal preparations. A careful enquiry as to the use of intranasal steroids should be routine in children presenting with unexplained growth failure or Cushing's syndrome. Particular vigilance/awareness is required in children with dysmorphic syndromes. PMID: 12089123 [PubMed - indexed for MEDLINE] So, who do you believe, a drug company package insert, or a paper that is not a trial, but a report of serious adrenal suppresion in children who used intranasal steroids? My allergist has seen adrenal suppression at moderate doses of fluticasone for inhalation. Although the steroid in nasonex is considered less biologically active, I have no doubt it also could cause adrenal suppression: and it has just been released as an inhaled steroid for asthma. Judy > x-no-archive: yes > [quoted text clipped - 30 lines] > > PMID: 12089123 [PubMed - indexed for MEDLINE] >So, who do you believe, a drug company package insert, or a paper that >is not a trial, but a report of serious adrenal suppresion in children [quoted text clipped - 3 lines] >considered less biologically active, I have no doubt it also could >cause adrenal suppression Well the FDA has approved Nasonex ecen for young children after reviewing all evidence, with no such cautions...... : and it has just been released as an inhaled >steroid for asthma. [quoted text clipped - 33 lines] >> >> PMID: 12089123 [PubMed - indexed for MEDLINE] > Well the FDA has approved Nasonex ecen for young children after reviewing all > evidence, with no such cautions...... Yabbut, they approved Rezulin, LymeRix and HRT for menopause for CVD prevention, too. They are completely in bed with drug manufacturers. > : and it has just been released as an inhaled > >>steroid for asthma. That doesn't mean it doesn't adrenally suppress. It means they decided that it was useful anyway. Susan >> Well the FDA has approved Nasonex ecen for young children after reviewing all >> evidence, with no such cautions...... > >Yabbut, they approved Rezulin, LymeRix and HRT for menopause for CVD >prevention, too. They are completely in bed with drug manufacturers> There is some validity to that. >> : and it has just been released as an inhaled >> >>>steroid for asthma. > >That doesn't mean it doesn't adrenally suppress. It means they decided >that it was useful anyway. Oh that was quoted text in the post I was responding to, not my words..... |
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