Endocrine Abstracts

Background: Intranasal steroids are commonly used for allergic rhinitis, rhinosinusitis and nasal polyps as they are considered safe in terms of long-term adverse effects profile due to favourable pharmacokinetic characteristics as compared to other oral and inhaled steroids. Some are also available over the counter without prescription.

Case: We report a patient with iatrogenic Cushing”s syndrome and secondary adrenal insufficiency due to chronic intranasal steroid use. A 42-year-old lady was referred to endocrinology with a recent history of tiredness, proximal muscle weakness and low 9 AM morning cortisol levels (7 nmol/l [RR: 172-497 nmol/l]). She was feeling tired and had non-specific pain all over her body. She had a history of chronic allergic rhinitis for which she was prescribed regular intranasal beclomethasone and fluticasone for many years. Further history revealed that she was regularly prescribed fluconazole 50mg OD for 15 days a month for the last 1 year before this presentation. On examination, she had purple abdominal striae, proximal myopathy, supraclavicular and subscapular fat deposition. Further investigations showed 9 am cortisol of 36 nmol/l with no response to Short Synacthen (Post Synacthen cortisol levels: 30 mins - 116 nmol/l, 60 min - 156 nmol/l), and ACTH levels of <3 ng/l. The rest of the Pituitary profile was normal.

Progress: She was started on hydrocortisone 10 mg/5 mg/5 mg and she was referred to the ENT team for assessment and advice regarding suitable non-steroidal treatment for her chronic rhinitis. Despite physiological steroid replacement, she continued to feel pain and myalgia. She was asked to double the dose of hydrocortisone replacement. After this change, she felt much better and remains under follow up with the endocrine team to supervise gradual weaning to a lower physiological replacement dose.

Discussion: This patient demonstrates that though intranasal steroids are considered safe for the treatment of allergic rhinitis, treating physicians and general practitioners should use it with caution especially when using with other medications. The concomitant use of enzyme inhibitors can significantly increase bioavailability of some intranasal steroids especially fluticasone and budesonide which can lead to adverse effects like iatrogenic Cushing”s syndrome and secondary adrenal insufficiency. Moreover, Fluconazole can also downregulate steroidogenesis and its concurrent use with nasal steroids can also precipitate adrenal suppression.

Questions for discussion: 1. Bioavailability of commonly used inhaled/intra-nasal steroids and effect of enzyme inhibitors on it. 2. How to wean these patients off steroids safely and effectively.