—Findlay et al report two paediatric cases of iatrogenic Cushing’s syndrome associated with exogenous administration of intranasal corticosteroids.1-1
These cases clearly show the potential of “locally active” corticosteroids to cause serious systemic effects. This problem is not, however, limited to betamethasone, nor is it solely the consequence of high doses or exceptionally prolonged administration of this particular corticosteroid.
Reports to the adverse event reporting system of the US Food and Drug Administration have shown that intranasal corticosteroids given by metered dose devices are associated with systemic steroid effects, including Cushing’s syndrome and growth suppression. Reports in the peer reviewed literature,1-2
as well as unpublished data,1-3
indicate that intranasal corticosteroids taken without interruption at the currently recommended doses may significantly reduce growth velocity in children. After a review of these and additional data a joint meeting of the pulmonary-allergy drug and endocrine-metabolic drug advisory committees in July 1998 voted to recommend that the precautions section of the label for all intranasal (and oral inhaled) corticosteroids be amended to reflect these products’ potential to inhibit growth in children.
All doctors should be aware of this, particularly as intranasal beclomethasone dipropionate is available without prescription in the United Kingdom. Many patients who are prescribed intranasal corticosteroids for allergic rhinitis also receive orally inhaled corticosteroids for asthma. The additive effects of these drugs1-4
and their potential impact on growth velocity are of particular concern.
Growth retardation could serve as an early warning of the systemic effects of corticosteroids, before Cushing’s syndrome can be diagnosed. Consequently, to reduce the risk of these untoward side effects, the Food and Drug Administration is recommending that the current label be amended to advise health practitioners that height and weight should be measured regularly in children receiving these drugs. Such measurements offer a rapid, sensitive, and inexpensive screen for detecting decreases in growth velocity and thereby may prevent other systemic adverse effects; they may also help in the development of strategies to reduce dosing.
Data regarding the lowest effective dose of any intranasal or inhaled corticosteroid are scarce. Equally rare are well controlled studies comparing the relative growth effects of different corticosteroids.
It is therefore premature to consider one corticosteroid over another as a means of diminishing this potential problem. Corticosteroids are a valuable therapeutic option in both allergic rhinitis and asthma. Intranasal and oral inhaled products provide a breakthrough in minimising the systemic effects of this class of agents, but the benefits that they offer should be balanced against the complications they might induce.