Arundoss Gangadharan

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 <100 nmol/L and/or peak <350 nmol/L). Patients with suboptimal results received hydrocortisone during periods of stress only, and those with abnormal responses received daily hydrocortisone, increased during periods of stress. A total of 73 patients (68%) had ≥2 LDSSTs over 2.2 years (0.2–7.7). Measurements Change in cortisol response to repeat LDSST (movement between diagnostic groups, difference in basal and peak cortisol >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.

G442 Are we screening appropriate age group for early diagnosis of CF related diabetes mellitus (CFRD) in UK

Introduction Nutrition plays a pivotal role in long-term survival of Cystic Fibrosis (CF) patients and worsening catabolic state affects the respiratory reserve. Management of glucose intolerance with early insulin treatment promotes anabolism and stabilises lung function. However there is a variation in CFRD screening procedure across various centres (the recommended age at start of diabetes screening varies between 10–12 years as per CF trust, CFF and ISPAD guidelines). Aim To assess if early screening of glycaemic status helps in early identification of glucose intolerance in patients with CF and to evaluate the correlation between OGTT and glycosylated haemoglobin (HbA1c). Methodology Retrospective data on OGTT, HbA1c and patient demographics were collected on all CF patients in a tertiary paediatric hospital (n = 84, 35M). Patients were categorised into 3 age groups [<10, 10 to <12 and ≥12 years]. The data was analysed to assess the incidence of glucose intolerance and to compare OGTT and HbA1c. Results 35 CF patients underwent a total of 127 OGTT with median age of 13 years (range 3–17.3) and median follow up of 4 years (range 0.8–11.1). OGTT: Eleven patients (13%) were diagnosed with CFRD requiring various forms of insulin therapy including insulin pump. This includes 3 patients diagnosed with CFRD as a result of the early OGTT screening between the age of 10 and 12 years (27%). OGTT was undertaken in children less than 10 years of age if they were symptomatic and this has identified one CFRD patient at the age of 9.4 years. Five eligible patients (≥10 years of age) did not undergo OGTT [Table 1]. HbA1c: 89 HbA1c analyses were undertaken along with simultaneous OGTT (Table 2). The HbA1c was ≤42mmol/mol in patients with IGT and >42mmols/mol in patients with postprandial hyperglycaemia.Abstract G442 Table 1 and 2 Conclusions 1. Application of CFF guideline (CFRD screening ≥10 years of age) promotes early diagnosis and management of CFRD. 2. OGTT may not be routinely needed in children <10 years of age unless there are strong clinical indications. 3. A national consensus guideline on CFRD screening would be very useful in early diagnosis and management of CFRD in paediatric population.

G474(P) Role of low dose short synacthen test (LDSST) in the assessment of adrenal reserve in children with chronic Asthma

Background The role of inhaled corticosteroids (ICS) is undisputable in the management of chronic asthma. However, the regular or recurrent use of ICS results in suppression of hypothalamic-pituitary–adrenal (HPA) axis, that could be asymptomatic or results in adrenal crisis. The Low Dose Short Synacthen Test (LDSST) has been shown to be a sensitive test of adrenal function during ICS therapy. Aims To describe recovery of adrenal function in children with abnormal cortisol responses to the LDSST during treatment with ICS for asthma. Methodology The result of LDSST’s performed in children treated with ICS for asthma between 2011–2014 was studied. Results of previous and subsequent LDSST were also collected. Age, gender, cumulative corticosteroid dosage and the outcome of LDSST were analysed. Patients were classified as having normal (>500nmol/L), suboptimal (350–499nmol/L) and abnormal (<350nmol/L) cortisol responses from the results of their first LDSST. Baseline cortisol levels <100nmol/L at 9am were considered abnormal. The repeat LDSST test results were also analysed to assess the movement of patients between the groups and time period for that shift. Results Data are shown as median (range) 184 LDSSTs were carried out in 81 patients (51M), age 10.6 years (0.7–17.1). Duration of follow up was 1.6 years (0–6.3), and the number of LDSST’s was 2.3/patient (1–6). Recovery of adrenal function was observed in 65% and 50% of patients with suboptimal and abnormal group respectively. Test results worsened in 25% of patients including patients in normal group. 13/52 patients with impaired, and 4/14 patients with abnormal tests were not tested further. 10 patients (12%) had basal cortisol levels <100nmol/l, of which 4 became normal and 6 still remained abnormal after 1.9 years (0–6.3) of follow-up. The total daily dose of inhaled corticosteroid (Beclomethasone equivalent) in suboptimal and abnormal group was 780 mcg/day, which was 35% higher than the patients in normal group (p = 0.01). Conclusions 1) Adrenal suppression is common in chronic asthma patients receiving ICS 2) Adrenal function could worsen in patients who were tested normal previously and hence high index of suspicion is required to diagnose this early. 3) Higher dose of inhaled corticosteroid dose is likely to result in suboptimal or abnormal LDSST.