Lesson of the week: Symptomatic adrenal insufficiency presenting with hypoglycaemia in children with asthma receiving high dose inhaled fluticasone propionate * Commentary: Exogenous glucocorticoids influence adrenal function, but assessment can be difficult

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Abstract
Children taking high dose fluticasone propionate may present with hypoglycaemia secondary to iatrogenic adrenal suppression # Symptomatic adrenal insufficiency presenting with hypoglycaemia in asthmatic children with asthma receiving high dose inhaled fluticasone propionate {#article-title-2} Children taking high dose fluticasone propionate may present with hypoglycaemia secondary to iatrogenic adrenal suppression Inhaled corticosteroids are central to the successful long term management of asthma and are generally regarded as safe.1 Systemic adverse effects have been described in children but are thought to be rare.2 High dose inhaled corticosteroids are used in the step-up phase of treatment to optimise the control of asthma. Fluticasone propionate may be prescribed at higher doses to relieve respiratory symptoms in the belief that it generates fewer side effects than other inhaled steroids. Some studies have shown that fluticasone is safer than beclomethasone or budesonide, with limited oral absorption and extensive hepatic first pass metabolism leading to a lower systemic bioavailability.3 Others have shown that appreciable amounts of inhaled fluticasone are absorbed from the lung4; fluticasone has also been associated with growth retardation and adrenal suppression in children.5 Reports of adrenal insufficiency in childhood secondary to inhaled steroids have not described hypoglycaemia as a presenting feature.5, 6, 7 We report on four children with asthma presenting with acute hypoglycaemia secondary to adrenal suppression caused by inhaled fluticasone propionate. Case 1 —An 8 year old boy was investigated for a three year history of seizures during intercurrent illnesses, associated with hypoglycaemia (glucose 0.6-1.8 mmol/l; normal range 2.8-6.5 mmol/l). His height was on the second centile, below that predicted from parental heights. He had no cushingoid features. His asthma had been controlled with inhaled fluticasone 1000 µg daily for 5 years. A standard short Synacthen test (Alliance Pharmaceuticals, Wiltshire) showed a peak serum cortisol concentration of less than 20 nmol/l (expected >550 nmol/l). The baseline concentration of adrenocorticotrophic hormone was 6.2 …