Tag Archives: adrenal insufficiency

Managing Adrenal Insufficiency in Eosinophilic Esophagitis

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M Nistel et al. JGPN 2023; 76: 786-792. Impact of Dose Reduction of Topical Steroids to Manage Adrenal Insufficiency in Pediatric Eosinophilic Esophagitis

In this retrospective study with 32 children with both eosiniphilic esophagitis and adrenal insufficiency (and 81 control subjects), key findings:

  • There was no steroid threshold which corresponded to an increased likelihood of AI
  • 20 of 32 had resolution of AI: 30% discontinued topical steroids, 50% reduced the steroid dose, 20% discontinue ER budesonide. With larger steroid dose reduction, there was an increased likelihood of AI resolution

One of the more useful parts of this publication is the authors provided their standardized approach in identifying AI: “our standard practice is to obtain a morning cortisol level 4-6 months after initiation of STS [swallowed topical steroids]. Subjects with morning cortisol <5 mcg/dL on 2 occasions (due to concerns with assay variation, patient compliance with fasting and holding steroids prior to testing) are then referred to endocrinology for further evaluation.”

My take: This article lays out a good approach for identifying AI in kids with EoE and then provides data on how effective reducing steroids are in resolving AI. It is noted that the peak eosinophil count tended to increase when STS doses were decreased.

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Unrelated article from NPR (not from The Onion): Harvard professor who studies dishonesty is accused of falsifying data (June 26, 2023)

Lego turtle above and polar bear below at Tucson Botanical Gardens

A Better Budesonide for Eosinophilic Esophagitis

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A recent study (S Olivia et al. JPGN 2017; 64: 218-24) examines a preprepared viscous budesonide (PVB) for eosinophilic esophagitis (EoE).

The authors used higher doses than in previous studies: 1 mg twice a day if height <150 cm and 2 mg twice a day if height >150 cm.  Treatment period was 12 weeks.

Key findings:

  • 32 of 36 (89%) showed macroscopic remission at 12 weeks and median eosinophils count in histology dropped from 42.2 to 2.9 cells/hpf.  46.7% maintained remission (off therapy) at 36 weeks.
  • 89% achieved eosinophil count <20 cells/hpf at 12 weeks.
  • In this short study, the authors did not identify any changes in cortisol levels.

My take: A reliable composition from a manufacturer, if not too expensive, would be a big improvement for many kids with EoE. Higher doses of budesonide may be warranted in some cases of EoE.

Related article: “How I Approach the Management of Eosinophilic Esophagitis in Adults” I Hirano. Am J Gastroenterol 2017; 112: 197-99. (Thanks to Seth Marcus for this reference). The author states that he prefers to perform a baseline assessment prior to PPI initiation.  After diagnosis, he will use PPI and if no response, advance to either a dietary approach or topical steroids (he prefers fluticasone using the diskus formulations). His goals for therapy include: elimination of esophageal eosinophilia (<5-15 eos/hpf), resolution of dysphagia, and maintenance of esophageal diameter ≥16 mm. He does advocate annual testing for adrenal insufficiency for those taking long-term topical steroids.

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Adrenal Insufficiency due to Fluticasone in Eosinophilic Esophagitis

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A recent study (MC Golekoh et al. J Pediatr 2016; 170: 240-5) shows that adrenal insufficiency developed in 10% of patients on chronic (>6 months) swallowed corticosteroid therapy for Eosinophilic Esophagitis (EoE).

Background: 58 patients with 67% receiving fluticasone and 33% receiving budesonide.  Median age: 13.7, median fluticasone dose 1320 mcg/day, median treatment duration: 4 yrs.  For budesonide, median dose was 1000 mcg/day and median age 10.7 yrs.

Key findings with low-dose ACTH stimulation:

  • Abnormal peak cortisol (≤ 20 mcg/dL) present in 15% and adrenal insufficiency (< 18 mcg/dL)  (n=6) noted in 10%
  • Only patients receiving >440 mcg/day of fluticasone had adrenal insufficiency
  • No patients taking budesonide had an abnormal cortisol level

Commentary:

  • Higher doses of fluticasone, particularly early in treatment, has been shown to have an improved inflammatory response.  However, as with asthma therapy, higher doses increase the risk of adrenal insufficiency.
  • Adrenal insufficiency can be asymptomatic but pose a risk for life-threatening adrenal crisis.
  • Strengths of study: Fairly large cohort, endoscopic/pathologic reports available, and ACTH stimulation testing which has better sensitivity than random cortisol.
  • Limitations: Lower number of patients receiving budesonide, particularly at a higher dose.  No indication of adherence.

My take: If higher doses of fluticasone are needed for prolonged period, consider screening (endocrinology consultation) for adrenal insufficiency.

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Farjado, Puerto Rico