A 35-year-old, white female with a 10-year history of mild, persistent asthma was treated with albuterol for eight years. For the past two years, she has achieved excellent control with twice-daily use of a fluticasone/salmeterol 100 µg/50 µg inhaler (Advair). A recent viral upper respiratory tract infection required her to use a larger dose of Advair 500 µg/50 µg twice daily for four weeks, after which she tapered back to her baseline regimen. The patient is a nonsmoker and has no evidence of gastroesophageal reflux disease. At what dose of inhaled fluticasone should I be concerned about systemic absorption? Should this premenopausal, asymptomatic patient (no fractures or loss of height) undergo periodic (every three to four years) dual-energy x-ray absorptiometry to screen for osteoporosis?
—Jeffrey M. Akhtar, DO, Pittsburgh
With the increased use of more potent corticosteroid inhalers, the potential for systemic levels of absorbed corticosteroids is increased. While biochemical suppression of the pituitary-adrenal axis can be shown in patients using high-dose inhaled therapy, the clinical significance of this suppression is less clear. High doses (>800 µg/day) of inhaled corticosteroid have been associated with skin thinning and, in children, mild growth retardation. Short courses of increased inhaler use in response to asthma exacerbations are appropriate and should not spur concerns of adverse corticosteroid effects. Routine bone mineral density screening of patients similar to the one described because of inhaled corticosteroid use is controversial and has not yet been shown to have clinical benefit (J Allergy Clin Immunol. 1994;94:796-803).
—R. Steven Tharratt, MD, professor of clinical internal medicine and anesthesiology, Division of Pulmonary and Critical Care Medicine, University of California, Davis, School of Medicine (102-16)