A low dose of Seretide can go a long way…
S K Thukral, P Valsalakumari, S Akavarapu, J Acharya, J F Todd
Imperial Centre for Endocrinology, Hammersmith Hospital
A 46 year old female (46F) was referred to endocrinology clinic following the discovery of a cortisol <0.02 mcg/dl (NR 2.3-11.9) whilst on holiday in Jordan in 2012. She reported a 6 month history of fatigue, nausea, dizziness, weight loss and poor concentration. Symptoms were worst mid-afternoon. Her past medical history included a right nephrectomy for a congenital abnormality aged 2 years, asthma, idiopathic rhinitis, nasal septum surgery, tonsillectomy and limited pulmonary vasculitis. Her only regular medication was Seretide 250mcg inhaler. Her most recent 10 day course of oral steroids was 2 years prior. Clinical examination was unremarkable with no hyperpigmentation and no postural drop in blood pressure.
46F’s full blood count, haematinics, renal profile, liver and bone profile, HbA1c, TFT and GH were in normal range. FSH and LH indicated perimenopause and vitamin D was 67nmol/L. An immediate short synacthen test showed a 0 minute ACTH of 10.9, 0 minute cortisol 2, 30minute 31 and 60 minute 60. She was commenced on hydrocortisone 20/10/10 and fludrocortisone 50mcg OD immediately. The MRI adrenals showed small adrenal glands that were morphologically normal and an MRI pituitary was unremarkable. Adrenal, ovarian and thyroid peroxidase antibodies were negative.
When re-reviewed one month later, the nausea and fatigue had completed resolved. Hydrocortisone was reduced to a maintenance dose of 10/5/5mg. 4 months later, 46F tried to reduce Seretide to 125mcg OD but developed a cough. A trial off fludrocortisone for 1 week and a subsequent renin 5.1 and aldosterone 1420 ruled out mineralocorticoid deficiency allowing fludrocortisone therapy to be stopped. In 2013 she was diagnosed with mild Churg Strauss Syndrome (rheumatoid factor and lupus anticoagulant positive) and required an intranasal steroid inhaler.
46F was diagnosed with adrenal insufficiency secondary to endogenous glucocorticoid suppression by low dose Seretide. This case highlights the risk of systemic absorption from low dose inhaled steroids in adults. Similar cases have been reported in the paediatric population at similar doses of fluticasone (<500mcg/d). Physicians must have a greater awareness of adrenal insufficiency when prescribing steroids of any dose and route.