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J R Soc Med. 2001 July; 94(7): 350–351.
PMCID: PMC1281603

Severe adrenal suppression by steroid nasal drops

Geoffrey Gill, MD FRCP, Andrew Swift, MB FRCP,1 Alan Jones, MB MRCP, David Strain, MB MRCP, and Philip Weston, MD MRCP

Systemic absorption of corticosteroids from inhaled and topical preparations can result in adrenal underactivity1. When systemic effects from nasal steroid drops have been reported2,3,4,5,6,7, the features were usually cushingoid rather than addisonian.

CASE HISTORY

A woman aged 71 had suffered from chronic sinusitis and recurrent nasal polyps for many years. She had been treated with various intranasal corticosteroids including betamethasone nasal drops, beclomethasone nasal spray, mometasone nasal spray and fluticasone nasal spray. No other topical or systemic corticosteroid treatment had been prescribed. At presentation she reported having been unwell and tired for about twelve months; at this time she had been using betamethasone 0.1% drops for eight months, 1-2 drops in each nostril once daily. Clinically she was not cushingoid. A short tetracosactrin (Synacthen) test was arranged, and she was asked to stop the steroid drops a few days beforehand. After stopping treatment she became unwell and experienced weakness, fatigue, nausea and headache, and was almost unable to get out of bed. The short Synacthen test (250 μg tetracosactrin intramuscularly) showed severe adrenal impairment. The basal cortisol was only 10 nmol/L, rising to 312 nmol/L after 30 minutes. After completing the test she was restarted on the betamethasone drops and felt much better.

Over the next two months she was weaned off the betamethasone drops and a repeat short Synacthen test four months later showed a much improved response with basal plasma cortisol 180 nmol/L, rising to 593 nmol/L at 30 minutes. She felt very well, with only minor return of nasal symptoms.

COMMENT

This case illustrates the ability of intranasal corticosteroid treatment to cause symptomatic adrenal suppression without cushingoid features. There may be a tendency for patients inadvertently to administer too many drops. In a study by Gallagher and Mackay, doctors were shown how to administer drops correctly but even in this group over a 14-day period overuse was the rule8. Excess steroid nasal drops probably trickle down the nasopharynx and are swallowed. The patient is thus effectively on systemic as well as local steroids.

Drops do seem more likely than sprays to result in systemic steroid absorption2,3,4,5,6,7. Thus Synacthen tests have given normal results in patients on beclomethasone spray10 but subnormal results after 6 weeks of betamethasone drops11. Long-term use of nasal steroid drops is probably inadvisable. With nasal steroid sprays more accurate doses can be delivered.

References

1. Wilson AM, Sims EJ, Lipworth BJ. Dose response with fluticasone propionate on adrenocortical activity and recovery of basal and stimulated responses after stopping treatment. Clin Endocrinol 1999;50: 329-34 [PubMed]
2. Findaly CA, Macdonald JF, Wallace AM, Geddes N, Donaldson MDC. Childhood Cushing's syndrome induced by betamethasone nose drops and repeat prescriptions. BMJ 1998;317: 739-40 [PMC free article] [PubMed]
3. Daman Willems CE, Dinwiddie R, Grant DB, Rivers RP, Kahir M. Temporary inhibition of growth and adrenal suppression associated with the use of steroid nose drops. Eur J Pediatr 1994;153: 632-4 [PubMed]
4. Heroman WM, Bybee DE, Cardin MJ, Bass JW, Johnsonbaugh RE. Adrenal suppression and Cushingoid changes secondary to dexamethasone nose drops. J Pediatr 1980;96: 500-1 [PubMed]
5. Nutting CM, Page SR. Iatrogenic Cushing's syndrome due to nasal betamethasone: a problem not to be sniffed at! Postgrad Med J 1995;71: 231-2 [PMC free article] [PubMed]
6. Stevens DJ. Cushing's syndrome due to the abuse of betamethasone nasal drops. J Laryngol Otol 1988;102: 219-21 [PubMed]
7. Kimmerle R, Rolla AR. Iatrogenic Cushing's syndrome due to dexamethasone nasal drops. Am J Med 1985;79: 535-7 [PubMed]
8. Gallagher G, Mackay I. Doctors and drops. BMJ 1991;303: 761. [PMC free article] [PubMed]
9. Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ 1998;317: 6124-9 [PMC free article] [PubMed]
10. Brannan MD, Herron JM, Reidenberg P, Affrime MB. Lack of hypothalamic-pituitary-adrenal axis suppression with once-daily or twice-daily beclomethasone dipropionate aqueous nasal spray administered to patients with allergic rhinitis. Clin Ther 1995;17: 637-47 [PubMed]
11. Gaziz AG, Homer JJ, Page S, Jones NS. The effect of topical nasal betamethasone drops for nasal polyposis on adrenal function. Clin Otol 1998;23: 280

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press