What is the treatment for a patient with fluticasone (fluticasone propionate)-induced adrenal suppression?

Treatment of Fluticasone-Induced Adrenal Suppression

Immediate Management: Discontinue Fluticasone and Initiate Glucocorticoid Replacement

The primary treatment for fluticasone-induced adrenal suppression is immediate discontinuation of fluticasone and initiation of physiologic glucocorticoid replacement therapy to prevent adrenal crisis. 1

Step 1: Discontinue Fluticasone Immediately

• Stop all fluticasone propionate therapy as soon as adrenal suppression is confirmed 2, 3, 4
• Switch to alternative asthma controller medications such as salmeterol or other non-corticosteroid options 4
• Critical pitfall: Never abruptly discontinue fluticasone without providing glucocorticoid coverage, as this can precipitate life-threatening adrenal crisis 1, 5

Step 2: Assess Clinical Severity and Initiate Appropriate Glucocorticoid Replacement

The treatment intensity depends entirely on symptom severity:

For Mild/Asymptomatic Patients (Grade 1):

• Initiate hydrocortisone 10-20 mg orally in the morning and 5-10 mg in early afternoon 1
• Alternative: Prednisone 5-10 mg daily 1
• Consider holding further asthma medications until stabilized on replacement hormones 1
• Mandatory endocrine consultation 1

For Moderate Symptoms (Grade 2):

• Start outpatient treatment at 2-3 times maintenance dosing: hydrocortisone 20-30 mg in morning and 10-20 mg in afternoon, OR prednisone 20 mg daily 1, 5
• Taper stress-dose corticosteroids down to maintenance over 5-10 days 1
• Endocrine consultation required 1

For Severe Symptoms or Suspected Adrenal Crisis (Grade 3-4):

• Immediate hospitalization with IV hydrocortisone 100 mg bolus plus 0.9% saline infusion at 1 L/hour (minimum 2L total) 1, 5
• If diagnosis uncertain and ACTH stimulation testing still needed, use dexamethasone 4 mg IV instead (does not interfere with cortisol assays) 1
• Taper stress-dose corticosteroids to maintenance over 7-14 days after discharge 1
• Never delay treatment for diagnostic procedures if adrenal crisis is suspected 1, 5

Step 3: Confirm Diagnosis and Monitor Recovery

• Measure urinary fluticasone propionate 17β-carboxylic acid to confirm systemic absorption (markedly elevated in fluticasone-induced suppression) 4
• Obtain morning cortisol and ACTH levels at baseline 1, 5
• Do not attempt ACTH stimulation testing until fluticasone has been discontinued for adequate washout period 5
• Repeat morning cortisol 2-4 months after fluticasone discontinuation to assess HPA axis recovery 4

Step 4: Transition to Maintenance Therapy

Once stabilized, typical maintenance glucocorticoid dosing:

• Hydrocortisone 15-25 mg daily in divided doses (e.g., 10 mg at 7:00 AM, 5 mg at 12:00 PM, 2.5-5 mg at 4:00 PM) 1
• Alternative: Cortisone acetate 25-37.5 mg daily in divided doses 1
• Alternative: Prednisolone 4-5 mg daily (only if compliance issues or marked energy fluctuations) 1

Fluticasone-induced adrenal suppression is typically secondary (central) adrenal insufficiency, so mineralocorticoid replacement with fludrocortisone is NOT required 1

Step 5: Patient Education and Safety Measures (Mandatory)

• All patients must receive instruction on stress dosing: double or triple the dose during illness, fever, or physical stress 5
• Prescribe emergency injectable hydrocortisone 100 mg IM kit with self-injection training 5
• Medical alert bracelet or necklace indicating adrenal insufficiency is mandatory 1, 5
• Educate on warning signs of adrenal crisis: severe weakness, confusion, vomiting, hypotension 5
• Endocrine consultation prior to any surgery or procedures for stress-dose planning 1

Expected Timeline for HPA Axis Recovery

• Gradual recovery of adrenal axis typically occurs over 2-9 months after fluticasone discontinuation 2, 4
• Morning cortisol should normalize within 4 months in most cases 4
• For long-term fluticasone exposure, consult endocrinology for recovery and weaning protocol 1, 5
• Hydrocortisone can usually be discontinued after 2-3 months if repeat morning cortisol is normal 4

Critical Pitfalls to Avoid

• Never assume "standard doses" of fluticasone are safe: adrenal suppression has been documented with doses as low as 220-460 μg/day 2, 3, 4, 6
• Do not rely on presence of Cushingoid features to diagnose suppression—many patients are asymptomatic or have only mild fatigue 4
• Missing this diagnosis can result in adrenal crisis upon fluticasone discontinuation, particularly during perioperative periods or acute illness 4, 6
• Avoid diagnostic testing while patient is still on fluticasone or immediately after stopping—this yields false results 5