Preliminary results of a pilot study investigating the potential of salivary cortisol measurements to detect occult adrenal suppression secondary to steroid nose drops

[Treatment of chronic eczematous otitis externa]

Otitis externa is a common disease. The article discusses the anatomical and physiological features of the structure of the outer ear, the epidemiology of otitis externa. Acute inflammation is characterized by the presence of significant microflora, and most often it is preceded by the impact of various physical factors. With chronic inflammation, more changes from the skin are recorded, while the microflora is not always isolated. The authors consider the problem of chronic inflammation of the outer ear. They provide their own data on the etiology of inflammation. Particular attention is paid to local treatment, including their own experience of using the combined drug Candiderm. As a result of the treatment, the skin changes of the external auditory canal were completely resolved in all patients by day 28, the itching in the ears completely stopped after 10-14 days of therapy. Stable remission was achieved in 89% of patients.

Hypothalamic-pituitary-adrenal axis suppression and intranasal corticosteroid use: A systematic review and meta-analysis

BACKGROUND

Intranasal corticosteroids (INCS) are used in the management of sinonasal conditions. Use of exogenous steroids can be associated with hypothalamic-pituitary-adrenal axis dysfunction and adrenal insufficiency (AI). We aimed to estimate the rate of AI after INCS use in a meta-analysis, stratified by steroid type and treatment duration.

METHODS

Ovid Medline, Embase Classic, PubMed, Web of Science, and CINAHL databases were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies investigating INCS use and AI. AI was defined as morning serum cortisol <550 nmol/L and <80 nmol/L with and without adrenocorticotropic hormone stimulation. INCS were classified as first (beclomethasone dipropionate, triamcinolone acetonide, beclomethasone, budesonide, dexamethasone) and second (ciclesonide, mometasone furoate, and fluticasone propionate) generation. Duration of treatment was classified as short (<1 month), medium (1-12 months), and long-term (>12 months) time periods.

RESULTS

This search identified 3668 articles. A total of 39 studies (1678 patients) were included in the final analysis. The pooled percentage of AI for routinely utilized first- and second-generation INCS was 0.70% (95% confidence interval [CI], 0.29-1.12%). Stratified by type, AI was observed in 0.78% (95% CI, 0.25-1.30%) of first-generation and 0.58% (95% CI, -0.1% to 1.26%) of second-generation steroids. AI was seen in 0.48% (95% CI, -0.01% to 0.96%) of short-term, 1.13% (95% CI, 0.2-2.1%) of medium-term, and 1.67% (95% CI, 0.37-2.9%) of long-term use of INCS.

CONCLUSION

Overall, the use of INCS carries a low risk for AI. Although modest, this risk may differ depending on the length of duration and type of INCS used. Informing patients of these risks is of importance for the treatment of chronic sinonasal conditions.

[Modern aspects of inflammatory external ear diseases treatment]

The article deals with the problem of inflammatory diseases of the external ear. A review of pruritic dermatoses of the external auditory canal was carried out. It has been shown that in chronic dermatoses, the contamination of the skin with bacterial and fungal pathogens significantly increases, which leads to a high risk of developing secondary infectious pathological processes. Treatment of dermatological inflammatory ear diseases includes careful daily hygiene of the external auditory canal and pharmacotherapy, a key aspect of which is the use of topical etiotropic, anti-inflammatory, and symptomatic drugs. The advantage of the combined drug candiderm is described, which, thanks to the unique combination of beclomethasone, gentamicin and clotrimazole in the composition, effectively relieves the symptoms of external ear dermatoses.

Adrenal Insufficiency in Corticosteroids Use: Systematic Review and Meta-Analysis

OBJECTIVE

We aimed to estimate pooled percentages of patients with adrenal insufficiency after treatment with corticosteroids for various conditions in a meta-analysis. Secondly, we aimed to stratify the results by route of administration, disease, treatment dose, and duration.

METHODS

We searched seven electronic databases (PubMed, MEDLINE, EMBASE, COCHRANE, CENTRAL, Web of Science, and CINAHL/Academic Search Premier) in February 2014 to identify potentially relevant studies. Original articles testing adult corticosteroid users for adrenal insufficiency were eligible.

RESULTS

We included 74 articles with a total of 3753 participants. Stratified by administration form, percentages of patients with adrenal insufficiency ranged from 4.2% for nasal administration (95% confidence interval [CI], 0.5-28.9) to 52.2% for intra-articular administration (95% CI, 40.5-63.6). Stratified by disease, percentages ranged from 6.8% for asthma with inhalation corticosteroids only (95% CI, 3.8-12.0) to 60.0% for hematological malignancies (95% CI, 38.0-78.6). The risk also varied according to dose from 2.4% (95% CI, 0.6-9.3) (low dose) to 21.5% (95% CI, 12.0-35.5) (high dose), and according to treatment duration from 1.4% (95% CI, 0.3-7.4) (<28 d) to 27.4% (95% CI, 17.7-39.8) (>1 year) in asthma patients.

CONCLUSIONS

1) Adrenal insufficiency after discontinuation of glucocorticoid occurs frequently; 2) there is no administration form, dosing, treatment duration, or underlying disease for which adrenal insufficiency can be excluded with certainty, although higher dose and longer use give the highest risk; 3) the threshold to test corticosteroid users for adrenal insufficiency should be low in clinical practice, especially for those patients with nonspecific symptoms after cessation.

Salivary cortisol levels in prepubertal children using inhaled corticosteroids with or without concurrent intranasal corticosteroids

BACKGROUND

Inhaled corticosteroids (ICS) and intranasal steroids (INS) are frequently co-administered in children with asthma and rhinitis. In contrast to monotherapy with ICS or INS, little is known about the safety of concurrent use of topical steroids on hypothalamic-pituitary-adrenal (HPA) axis function in prepubertal children.

OBJECTIVE

Comparison of morning salivary cortisol levels in prepubertal children using maintenance treatment with ICS with and without concurrent use of INS to steroid naïve control groups (healthy children, and children with constipation who are under pediatric care).

METHODS

Cross-sectional observational study in prepubertal children (6-12 years) using ICS alone (n = 41) or in combination with INS (n = 22), compared to different control groups with no steroid treatment (18 healthy children, and 28 children with constipation). Morning salivary cortisol levels were determined from saliva samples collected at home.

RESULTS

The morning salivary cortisol levels of the healthy children (8.7 nmol/L; 95% CI 5.9-18.8), and the children with constipation (8.9 nmol/L; 8.0-11.3) were comparable. The salivary cortisol levels of prepubertal children using ICS (median 4.7 nmol/L; 95% CI 4.6-6.9) or a combination of ICS and INS (5.1 nmol/L; 4.2-7.6) were comparable, but significantly reduced compared to both control groups. There was no correlation between salivary cortisol level and age, duration of disease, or cumulative daily dose of topical steroids.

CONCLUSION

Salivary cortisol levels in prepubertal children using ICS, with or without concurrent use of INS, were comparable. However, salivary cortisol levels were significantly reduced compared to steroid naïve controls, irrespective of the cumulative daily dose of topical steroids. Pediatr. Pulmonol. 2011; 46:1055-1061. © 2011 Wiley Periodicals, Inc.

Characterising and quantifying outcomes in rhinology out-patients: measurements in the 'real world'

AIMS

We aimed to evaluate a practical, computerised database for collection of patient-reported and clinical outcome data, introduced as a means of characterising our patient population and assessing the effect of our interventions.

METHODS

A prospectively updated, computerised database was used to detail each patient's coded and structured diagnosis and clinical findings. Response to treatment was recorded using the Sino-Nasal Outcome Test 22 and changes in graded clinical examination findings.

RESULTS

Data for 770 patients were prospectively entered into the database. Patients were grouped diagnostically as follows: rhinitis (20.4 per cent), chronic rhinosinusitis (12.2 per cent), chronic rhinosinusitis with polyps (24.7 per cent), anatomical anomaly (22.7 per cent), epistaxis (3.4 per cent) and 'other' (18.4 per cent). Following initial medical intervention, the greatest improvement in the Sino-Nasal Outcome Test 22 score was seen in the chronic rhinosinusitis with polyps group (-11.3), followed by the rhinitis group (-6.1) and the chronic rhinosinusitis group (-5.4).

CONCLUSIONS

The tested rhinology database provides a simple, effective and practical tool for integrating the recording of clinical and patient-reported outcome measures during the out-patient visit. It enables characterisation of the patient population, and accurately monitors and records treatment responses.

[News for adrenal insufficiency]

The congress of the Endocrine Society 2008 approached the diagnostic, etiologic, prognostic and therapeutic novelties of adrenal insufficiency (AI). Diagnosis of AI often requires serum cortisol measurement during dynamic tests. Salivary cortisol measurement was reported to have an equivalent diagnostic performance to serum cortisol and that is even better when CBG levels are altered. Iatrogenic AI is much more frequent than Addison's disease. Two studies have shown that patients with inhaled corticosteroid and opioid treatments should be tested for AI. A Norwegian study reported an increased mortality in the subgroup of young men that presented Addison's disease before the age of 40. Plasma cortisol concentration in patients with current glucocorticoid replacement therapy differs notably from those observed in physiological condition. This imperfect replacement may be responsible for adverse physical condition and impaired quality of life. Two formulations of delayed hydrocortisone tablets with different pharmacokinetics from usual hydrocortisone (DuoCort and Chronocort) are in development. The first study is promising and shows that these formulations better mimick the body's natural cortisol release. Its use in the treatment of AI in patients with congenital adrenal hyperplasia has also been tested.

Diagnostic Value of Salivary Cortisol in Children with Abnormal Adrenal Cortex Functions

AIMS

It has been shown that the free cortisol level in saliva may reflect plasma free cortisol. The measurement of cortisol in saliva is a simple method, and as such it is important in the pediatric age group. In this research, the diagnostic value of measurement of salivary cortisol (SC) measurement was examined in adrenal insufficiency (AI).

METHODS

Fifty-one patients, mean age 10.8 +/- 4.29, who were investigated for possible AI, were included. Basal cortisol levels were below 18 microg/dl. Adrenal function was determined by low-dose ACTH test. During the test, samples for SC were obtained simultaneously with serum samples (at 0-10-20-30-40 min).

RESULTS

Mean basal serum cortisol level was 8.21 +/- 4.10 microg/dl (mean +/- SD). Basal SC was correlated to basal serum cortisol (r = 0.64, p < 0.001). A cut-off of 0.94 microg/dl for SC differentiated adrenal insufficient subjects from normals with a sensitivity and specificity of 80 and 77%, respectively. A peak SC less than 0.62 microg/dl defined AI with a specificity of 100%; however, sensitivity was 44%.

CONCLUSION

Measurement of SC may be used in the evaluation of AI. It is well-correlated to serum cortisol. Peak SC in low-dose ACTH test can be used to differentiate patients with AI in the initial evaluation of individuals with suspected AI.

Basal and dexamethasone suppressed salivary cortisol concentrations in a community sample of patients with posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) has been associated with lower concentrations of cortisol and enhanced suppression of cortisol by dexamethasone, although discrepancies exist among reports. The objective of the study was to determine the pattern of cortisol responses in patients seeking treatment for PTSD resulting from a variety of traumatic experiences and to test whether cortisol responses are significantly related to childhood trauma, severity of symptoms, or length of time since trauma.

METHODS

Salivary cortisol was measured at 8 AM, 4 PM, and 10 PM on 2 consecutive days before and after a 10 PM dose of .5 mg dexamethasone in 17 psychotropic medication and substance-free subjects with PTSD and 17 matched control subjects.

RESULTS

Repeated-measures analysis of variance (ANOVA) of the baseline salivary cortisol concentrations demonstrated a significant effect for group with higher concentrations in the PTSD group but no significant differences in responses to dexamethasone. The presence of childhood abuse did not significantly affect salivary cortisol concentrations, and there was no correlation between predexamethasone cortisol and either the severity of PTSD symptoms or the time since the index trauma.

CONCLUSIONS

Neither low basal concentrations nor enhanced suppression of cortisol are consistent markers of a PTSD diagnosis.

Production of gender-specific morning salivary cortisol reference intervals using internationally accepted procedures

Background: Salivary cortisol concentrations correlate well with biologically active unbound free plasma cortisol concentrations. Despite its practical and analytical advantages, salivary cortisol measurement has been used mainly as a research tool rather than for the routine evaluation of adrenal function. This may be partly explained by the lack of robust reference data in the literature.

Methods: Using the recommended procedures for the production of reference intervals published by the International Federation of Clinical Chemistry, we aimed to produce morning salivary cortisol reference intervals for males and females. Salivary cortisol was measured in 496 specimens collected from 248 reference individuals (128 males, median age 41years, range 16–86; and 120 females, median age 44years, range 16–98) attending an otorhinolaryngology clinic. Reference individuals mailed saliva specimens sampled on two consecutive mornings to our laboratory, where cortisol concentrations were measured.

Results: Statistical analysis showed no significant correlation with age or body mass index. The following 95% gender-partitioned reference intervals were produced: males 10.9–40.3nmol/l; and females 9.3–40.3nmol/l.

Conclusion: Knowledge of these salivary cortisol reference intervals helps us monitor the adrenal function of outpatients using topical intranasal glucocorticoids for rhinosinusitis.

Are nasal steroids safe?

Nasal steroids have emerged as an integral part of rhinitis management. Most studies have shown no evidence of significant hypothalamic-pituitary-adrenal axis suppression from nasal steroid use, at least based on dynamic testing. Bone mineral density loss, glaucoma, and cataract formation are risks associated with systemic steroids, but reports with nasal steroid use are few. Growth retardation has been seen with some nasal steroids, but not others, based on stadiometric growth studies. Further studies are certainly needed to resolve this issue. Nasal steroids, in general, have an excellent safety record.