Adrenal suppression: A practical guide to the screening and management of this under-recognized complication of inhaled corticosteroid therapy

The risk for AS can be minimized through increased awareness and early recognition of at-risk patients, regular patient follow-up to ensure that the lowest effective ICS doses are being utilized to control asthma symptoms, and by choosing an ICS medication with minimal adrenal effects. Screening for AS should be considered in any child with symptoms of AS, children using high ICS doses, or those with a history of prolonged oral corticosteroid use. Cases of AS should be managed in consultation with a pediatric endocrinologist whenever possible. In patients with proven AS, stress steroid dosing during times of illness or surgery is needed to simulate the protective endogenous elevations in cortisol levels that occur with physiological stress.This article provides an overview of current literature on AS as well as practical recommendations for the prevention, screening and management of this serious complication of ICS therapy.Asthma is the most common chronic disease among the young, affecting 10% to 15% of Canadian children and adolescents [1-3]. It is also a major cause of pediatric hospital admissions and emergency department visits [4,5]. Despite significant improvements in the diagnosis and management of asthma over the past decade, as well as the availability of comprehensive and widely-accepted national and international clinical practice guidelines for the disease [6,7], asthma control in Canada remains suboptimal. Approximately 50-60% of Canadian children and adults have uncontrolled disease according to guideline-based asthma control criteria [8,9].Inhaled corticosteroids (ICSs) are the most effective anti-inflammatory medications available for the treatment of asthma and represent the mainstay of therapy for most patients with the disease. The current Canadian standard of care is low-dose ICS monotherapy as first-line maintenance therapy for most children and adults with asthma [7]. Regular ICS use has been shown to reduce symptoms and the need for rescue b