Recovery of hypothalamo–pituitary–adrenal axis suppression during treatment with inhaled corticosteroids for childhood asthma

Objective: To describe recovery of adrenal insufficiency in asthmatic children treated with inhaled corticosteroids (ICS) and cortisol replacement therapy. Design: Retrospective, observational study. Patients: A total of 113 patients, 74 male; age 10.4 (3.3–16.5) years; beclomethasone-­equivalent ICS dose, 800 µg, (100–1,000), tested by low dose short Synacthen (tetracosactide) test (LDSST), were studied. Test results were classified by basal and peak cortisol concentration: “normal” (basal >100 nmol/L, peak >500 nmol/L), “suboptimal” (basal >100 nmol/L, peak 350–499 nmol/L), “abnormal” (basal 15% [2× the inter-assay coefficient of variation]), change in BMI and height standard deviation score (SDS). Results: Baseline test results were abnormal in 17 patients (15%) and all of them had repeat tests. In 13 patients (76%), test results improved (normal in six, suboptimal in seven) and four (24%) remained abnormal. Baseline tests results were suboptimal in 54 patients (48%), of whom 50 (93%) were retested. Repeat tests were normal in 36 patients (72%), remained suboptimal in 11 (22%), and were abnormal in three (6%). Baseline tests results were normal in 42 patients, of whom six patients (14%) were retested. Results remained normal in three (50%), were suboptimal in two (33%), and abnormal in one (17%). Basal and peak cortisol levels increased by >15% in 33/73 (45%) and 42/73 (57%) patients, respectively, and decreased by >15% in 14/73 (19%) and 7/73 (10%), respectively. There was no significant change in height or BMI SDS. Conclusion: Recovery of adrenal function is common and occurs during continued ICS and cortisol replacement therapy

The Use of Iodine as First Line Therapy in Graves' Disease Complicated with Neutropenia at First Presentation in a Paediatric Patient

Aims: Graves' disease is a common cause of hyperthyroidism in the paediatric population. An association between neutropenia and untreated Graves' disease has been described although the aetiology is unknown. Presentation of Case: A 13 year old boy presented with a 3 month history of weight loss, insomnia, fatigue, palpitations and anxiety. On examination, he had tachycardia of 140 beats/minute, sweating, tremors and brisk deep tendon reflexes. The clinical and laboratory results were consistent with Graves' hyperthyroidism. He was treated with Lugol`s iodine and Propanolol in view of his low neutropenia count at diagnosis. Discussion: Thionamide drugs remain the initial treatment of choice in children and adolescents presenting with Graves' disease, however adverse effects such as agranulocytosis remains a concern. Conclusion: In cases where anti-thyroid thionamides are contraindicated due to the risk of side effects such as agranulocytosis or neutropenia, Lugol's iodine may be an alternative temporary form of first line therapy