Nguyen Kim-Lien, Lauver David, Kim Isaac, Aresery Matthew
The Reading Hospital and Medical Center, West Reading, Pennsylvania, USA.
Ann Allergy Asthma Immunol. 2003 Jul;91(1):38-43. doi: 10.1016/S1081-1206(10)62056-X.
Although widely used, the effects of steroid "bursts" on the hypothalamic-pituitary-adrenal axis, especially with long-term, concomitant topical steroids use, have not been studied.
To examine the effect of a prednisone burst, long-term intranasal steroids, and inhaled fluticasone propionate on the suppression and recovery of adrenal function.
Adult patients taking long-term intranasal steroids, either moderate-dose (440 microg/d) or high-dose (880 microg/d) inhaled fluticasone propionate, underwent a low-dose cosyntropin stimulation test (LDCST) before and 2 days after a prednisone burst. Suppressed adrenal responses were monitored with a weekly LDCST. Persistent abnormal LDCST results were confirmed by 8-hour cosyntropin infusion. Inhaled fluticasone dosages were decreased; adrenal recovery was evaluated by a monthly LDCST. Adverse effects of steroids were monitored by questionnaires.
Sixty-three patients participated in the study. Three of 31 patients not taking inhaled steroids and 1 of 13 patients taking moderate-dose fluticasone had abnormal LDCST results on day 2 after the prednisone burst, which normalized by the second week. In the high-dose fluticasone group, 14 of 19 patients had suppressed LDCST responses on day 2 and adrenal function recovered in 10 of 19 patients by the fourth week. These patients complained significantly of decreased libido (P = 0.02), listlessness (P = 0.03), and weight loss (P = 0.05). High-dose fluticasone (r = 0.66, P < 0.001) and duration of use (r = 0.32, P = 0.01) were statistically correlated with adrenal impairment. Of the 4 patients with persistent adrenal impairment, 3 patients successfully reduced dosages of inhaled fluticasone and adrenal function recovered in 2 to 10 months.
Prednisone bursts induce brief adrenal impairment. Intranasal steroids and moderate-dose fluticasone had no effect on adrenal function. High-dose, inhaled fluticasone caused mild-to-significant adrenal suppression and delayed the recovery after a steroid burst. Avoiding or limiting the duration of high-dose inhaled steroids would minimize systemic adverse effects.
尽管类固醇“冲击疗法”被广泛使用，但关于其对下丘脑-垂体-肾上腺轴的影响，尤其是长期同时使用局部类固醇时的影响，尚未得到研究。
研究泼尼松冲击疗法、长期鼻用类固醇以及吸入丙酸氟替卡松对肾上腺功能抑制和恢复的影响。
成年患者长期使用中等剂量（440微克/天）或高剂量（880微克/天）吸入丙酸氟替卡松鼻用类固醇，在接受泼尼松冲击疗法前及冲击后2天进行低剂量促肾上腺皮质激素刺激试验（LDCST）。每周进行一次LDCST监测肾上腺反应受抑制情况。持续异常的LDCST结果通过8小时促肾上腺皮质激素输注来确认。减少吸入丙酸氟替卡松剂量；每月进行一次LDCST评估肾上腺恢复情况。通过问卷调查监测类固醇的不良反应。
63名患者参与了研究。31名未使用吸入类固醇的患者中有3名以及13名使用中等剂量氟替卡松的患者中有1名在泼尼松冲击疗法后第2天LDCST结果异常，至第二周恢复正常。在高剂量氟替卡松组中，19名患者中有14名在第2天LDCST反应受抑制，19名患者中有10名在第四周肾上腺功能恢复。这些患者明显抱怨性欲减退（P = 0.02）、无精打采（P = 0.03）和体重减轻（P = 0.05）。高剂量氟替卡松（r = 0.66，P < 0.001）和使用时长（r = 0.32，P = 0.01）与肾上腺损害存在统计学相关性。在4名肾上腺损害持续存在的患者中，3名患者成功减少了吸入丙酸氟替卡松剂量，2至10个月后肾上腺功能恢复。
泼尼松冲击疗法会导致短暂的肾上腺损害。鼻用类固醇和中等剂量氟替卡松对肾上腺功能无影响。高剂量吸入丙酸氟替卡松会引起轻度至显著的肾上腺抑制，并延迟类固醇冲击疗法后的恢复。避免或限制高剂量吸入类固醇的使用时长可将全身不良反应降至最低。
