ESPE Abstracts (2016) 86 RFC1.7

The Recovery of Adrenal Function in Children with Chronic Asthma Assessed by Low Dose Short Synacthen Test (LDSST)

Arundoss Gangadharana, Paul McCoyb, Michael McGuiganc, Mohammed Didia, Urmi Dasa, Poonam Dharmaraja, Senthil Senniappana, Renuka Ramakrishnana, Zoe Yunga, Lynn Hatcharda, Pauline Blundella, Kelly Stirrupa & Joanne Blaira

aDepartment of Endocrinology, Alder Hey Children’s Hospital, Liverpool, UK; bDepartment of Respiratory Medicine, Alder Hey Children’s Hospital, Liverpool, UK; cDepartment of Paediatrics,
Mid Cheshire Hospital NHS Foundation trust, Crewe, UK

Background: Hypothalamic-Pituitary–Adrenal (HPA) axis suppression is common during inhaled corticosteroid (ICS) treatment of asthma, and deaths due to adrenal crisis are described. Little is known about the optimal treatment or recovery of ICS induced HPA axis suppression.

Aims: To describe the treatment and outcomes of children with ICS induced HPA suppression diagnosed on the low dose short Synacthen test (LDSST).

Method: The data from ICS treated children between 2008–2014 were studied. Age, ICS dose at the time of LDSST (Beclomethasone equivalent) and the outcome of LDSST (‘Normal’: Peak cortisol ≥500 nmol/l, ‘Suboptimal’: Peak cortisol 350–499 nmol/l and ‘Abnormal’: Peak cortisol <350 nmol/l)) were noted. Abnormal basal cortisol levels at 9 am(0-min) <100 nmol/l were also analysed in detail. Children with ‘suboptimal’ responses were treated with hydrocortisone (20 mg/m2 per day) during illness only; those with ‘abnormal’ responses were treated with hydrocortisone 5–7.5 mg/m2 per day, and 20 mg/m2 per day during illness.

Results: Total of 218 tests were carried out in 113 children (M=74), mean age 10.2±3.3 years, 1.9 LDSSTs/child (range 1–6). Duration of follow up was 1.0±1.5 years. Peak cortisol responses were normal in 42(37%), suboptimal in 58(51%) and abnormal in 13(12%). The 9 am cortisol was <100 nmol/l in 9(8%) children. Two patients in this group recovered, but 4 remained abnormal after 1.8 (0–5.5) years, with failed follow up in 3/9. Adrenal function recovered in 23/38(61%) and 5/7(71%) of patients in suboptimal and abnormal group respectively over 1.38±1.6 years. In suboptimal group, 1/38(3%) worsened and 14/38(37%) still remained suboptimal. Persistent abnormality was also noted in 2/7(29%) patients of abnormal group [Table-1]. Statistical analysis comparing ICS doses in those not recovered (start 693±321 mcgs Vs final 631±424 mcgs) was significant (P=0.027*) after a follow up of 2.2±1.6 years. Two patients with abnormal responses experienced adrenal crises, but none in the normal or suboptimal groups.

Table 1.
CharacteristicsSub optimalAbnormal
Total numbers (113)[M]58 [39]13 [10]
Age in years at first test -mean (SD) 10.5 (3.3)9.8 (3.7)
F/U in Years -mean (SD)1.5 (1.6)1.0 (1.5)
Steroid dose in MCGS Mean (SD)689 (289)754 (260)
Average tests/person2.22.1
Normalisation or improvement (%)23/38 (61%)5/7 (71%)
Worsening or no improvement (%)15/38 (39%)2/7 (29%)
No Follow up test (% of this group)20 (34%)6 (46%)

Conclusion: Treatment with daily hydrocortisone in modest doses is compatible with HPA recovery.