Adrenal suppression secondary to inhaled fluticasone propionate

Background: Inhaled glucocorticoids are the medical treatment of choice in many of patients with asthma. Fluticasone propionate is an inhaled glucocorticoid with little systemic bioavailability via the oral route and infrequent association with systemic adverse effects at the recommended dosage. Objective: To report a case of adrenal suppression and exogenous glucocorticoid excess from inhaled fluticasone propionate. Methods: A 9-year- old girl with a previous history of episodic asthma was placed on 550 μg of fluticasone propionate daily for severe labile asthma diagnosed by history and methacholine challenge. The patient returned 6 months later with complaints of increased appetite, nausea, and feeling 'hot and flushed.' On physical exam she had stigmata of Cushing's syndrome. The patient subsequently developed orthostatic hypotension and moderate dehydration following a vital illness. After a long taper of fluticasone propionate the patient's adrenal function returned to normal and she had no acute or chronic exacerbations of her asthma. Results: Her 8 AM cortisol was undetectable with an ACTH of 21 pg/mL. The serum prolactin, TSH, free thyroxine, insulin-like growth factor I, and renin activity were all normal. An MRI study of her head was also normal. Repeat methacholine challenges while receiving a much smaller dose fluticasone propionate showed a significant decrease in airway reactivity. Conclusion: Adrenal suppression can occur from inhaled fluticasone propionate at a dosage less than has been previously reported.