Acute Adrenal Crisis in an Asthmatic Child Treated with Inhaled Fluticasone Proprionate

Inhaled corticosteroids (ICSs) are a cornerstone for the treatment of asthma, proven to be very effective in its decades of use. They prevent asthma exacerbations, maximize lung function, and are the only treatment for chronic asthma shown to reduce asthma-related deaths [1]. Inhaled steroids include beclomethasone, budesonide, fluticasone dipropionate, mometasone furoate, and triamcinolone acetate. While all inhaled steroids work by binding to a common glucocorticoid receptor, the potency of each medication differs, as well as the side effect profile. Fluticasone propionate has been in use since the 1990s and is more potent than its predecessors. It has equivalent efficacy when given at half the daily dose of the older medications, beclomethasone diproprionate and budesonide [2]. Its favorable pharmacologic properties include a higher affinity for glucocorticosteroid receptors, higher lipophilicity, and greater lung deposition. Side effects were thought to be lower due to less oral systemic absorption due to an almost complete first pass hepatic clearance (almost 99%) of the swallowed part of the medication (at least 70% of emitted dose) [3, 4]. At the recommended daily dose in children of 100–200？g, there is a good safety profile, with limited effects on the adrenal function or growth. However, such side effects are seen starting at a dose of 400？g/day, particularly when given for a prolonged period [5]. When adrenal suppression is seen in patients, it is usually limited to laboratory abnormalities. Acute adrenal insufficiency is less common but has been reported with increasing frequency over the past decade, especially as fluticasone use has become widespread [4]. We report a case of a 7-year-old asthmatic child who presented with adrenal crisis while on a dose of 220？g/day of fluticasone proprionate, lower than the usual suppressive dose.A 7-year-old asthmatic child presented to the emergency department with a 1 day history of fever, cough, vomiting, and lethar