G27 Screening for adrenal insufficiency in children treated with swallowed topical steroids for eosinophilic oesophagitis: a single center experience. (12th September 2022)

• Record Type: Journal Article
• Authors: Bildstein, Tania; Sonnino, Micol; Puoti, Maria Giovanna; Flynn, Rosalynn; Jackman, Lucy; Goh, Leanne; Gaynor, Edward P
• Is Part Of: Frontline gastroenterology. Volume 13(2022)Supplement 1
• Page Start: A34
• Page End: A35
• Publication Date: 2022-09-12
• Subjects: Gastroenterology -- Periodicals; 616.33005
• DOI: 10.1136/flgastro-2022-bspghan.47
• Languages: English
• ISSNs: 2041-4137

Abstract

Abstract : Background: Few studies report the prevalence of iatrogenic adrenal insufficiency (AI) in children treated with swallowed topical steroids (STS) for eosinophilic oesophagitis (EoE). The reported prevalence of AI based on a morning serum cortisol level followed by confirmatory low-dose adrenocorticotropic hormone (ACTH) stimulation test varies from 5% to 43% in this population. In this study we aimed to identify prevalence of AI among the patients taking STS for EoE in our multidisciplinary clinic. Methods: Clinical and biochemical screening for AI was performed from January 2020 until November 2021. Patients were screened for symptoms of AI and serum morning cortisol and ACTH when assessed in the EoE clinic. If low levels of serum morning cortisol were detected patients were referred for endocrinology evaluation and ACTH stimulation test. Data including gender, age, STS, formulation, duration and indication were collected. See figure 1 for study design. Results: Of the 61 patients followed up in the EoE clinic at the time of the study, 30 (49%) patients were on treatment with STS for a duration >3 months. Of them, 18 (60%) (12 males; median age 12 years, range 3–16) were tested for morning cortisol and ACTH levels. STS in use were oral viscous budesonide (OVB) in 13 (72%) and fluticasone metered dose inhaler (MDI) in 5 (28%). The dose of OVB ranged from 1 to 2 mg/day and fluticasone MDI ranged from 250 to 500 mcg/day. Ten patients (56%) were on concomitant other topical steroids for atopic comorbidities. Median levels of cortisol was 235 mmol/l (range 97–637; normal values 110–560) and ACTH was 18 ng/l (range 8–83; normal values 10–50). No patient reported symptoms suggestive of adrenal suppression. All patients showed normal levels of fasting morning cortisol and 2 patients showed normal cortisol response with altered ACTH levels. Conclusions: Monitoring of patients on STS requires consideration of potential risks such as AI, documented at least 5%-10% (ref JPGN 70 (3) March 2020), similar in Hsu et al and higher in Harel et al. Children with EoE and/or multi-system allergic disease may have red-flag symptoms of loss of appetite, weight loss or abdominal pain; without AI. Our study supports AI being a rare complication of STS such as budesonide or fluticasone, even when on combined swallowed and intranasal steroids. Protocols should include adrenal axis testing for longer term monitoring of children with EoE on STS.