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]

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    Iatrogenic adrenal insufficiency as a side-effect of combined
treatment of itraconazole and budesonide.

        * Skov M,
        * Main KM,
        * Sillesen IB,
        * Muller J,
        * Koch C,
        * Lanng S.

    Cystic Fibrosis Centre, National University Hospital,
Rigshospitalet, Copenhagen, Denmark. mskov@dadlnet.dk

    A recent case of iatrogenic Cushing's syndrome and complete
suppression of the pituitary-adrenal-axis in a patient with cystic
fibrosis (CF) and allergic bronchopulmonary aspergillosis treated with
itraconazole as an antifungal agent, and budesonide as an
anti-inflammatory agent led to a systematic assessment of this axis and
gonadal function in all patients treated with itraconazole in the
authors' CF centre. Itraconazole can inhibit CYP3A, thus interfering
with synthesis of gluco- and mineralocorticoids, androgens and
oestradiol as well as the metabolism of budesonide. The aim of this
study was to evaluate adrenal and gonadal function in patients treated
with itraconazole with or without budesonide. An adrenocorticotrophic
hormone (ACTH) test (250 microg tetracosactid) was performed in 25 CF
patients treated with both itraconazole and budesonide, and in 12
patients treated with itraconazole alone (six patients with CF and six
with chronic granulomateous disease). Mineralocorticoid and gonadal
steroid function were evaluated by measurements of plasma-renin,
follicle stimulating hormone, luteinising hormone, progesterone,
oestradiol, testosterone, serum-inhibin A and B. ACTH tests performed as
part of a pretransplantation programme in an additional 30 CF patients
were used as controls. Eleven of the 25 patients treated with both
itraconazole and budesonide had adrenal insufficiency. None of the
patients on itraconazole therapy alone nor the control CF patients had a
pathological ACTH test. Mineralocorticoid and gonadal insufficiency was
not observed in any of the patients. Only one patient with an initial
pathological ACTH-test subsequently normalised, the other 10 patients
improved but had not achieved normalised adrenal function 2-10 months
after itraconazole treatment had been discontinued. Suppression of the
adrenal glucocorticoid synthesis was observed in 11 of 25 cystic
fibrosis patients treated with both itraconazole and budesonide. The
pathogenesis is most likely an itraconazole caused increase in systemic
budesonide concentration through a reduced/inhibited metabolism leading
to inhibition of adrenocorticotrophic hormone secretion along with a
direct inhibition of steroidogenesis. In patients treated with this
combination, screening for adrenal insufficiency at regular intervals is
suggested.

    PMID: 12166560 [PubMed - indexed for MEDLINE]

Susan:

Is there any way I can read the complete article?

I am on Nasonex and I think it is helpful. When I stop it, the sinus
infection/sore throat seems to come back.

So far, I don't think I have any side effects, but I'm sure it can sneak up
on you.

Mel