Screening for Adrenal Insufficiency in Children With Eosinophilic Esophagitis

Gastroenterologists who are members of an eosinophilic esophagitis (EoE) consortia are much more likely to routinely screen for adrenal insufficiency (AI) in children with EoE who are being treated with topical corticosteroids, according to a study recently published in the Journal of Pediatric Gastroenterology and Nutrition. 

This 3-part study was structured as follows. In part 1, a survey was sent to gastroenterologists (completed by n=238) regarding screening for AI among children with EoE being treated with topical corticosteroids. In part 2, children with EoE who had been treated for at least 6 months with topical corticosteroids (n=37) received prospective screening for AI using morning serum cortisol (MSC) levels; a repeat screening and/or further adrenocorticotropic hormone (ACTH) testing was performed on any patient with an MSC level <10 mcg/dL. Peak serum cortisol <18 mcg/dL was set as the threshold for AI. In part 3, serum that was drawn in part 2 was analyzed (n=26) for correlations between dehydroepiandrosterone sulfate (DHEA-S) and MSC levels to determine potential utility of DHEA-S level as a marker for adrenal function.

One-way analysis of variance was employed to examine clinical variations between children with and without AI. The association between MSC and DHEA-S levels was analyzed using Spearman’s rank-order correlation, while potential predictors for DHEA-S levels were evaluated using a multiple regression analysis.

Among the physicians who completed the survey, 7% (n=16) reported screening for AI when treating children with topical corticosteroids. Gastroenterologists practicing in an EoE consortia group were significantly more likely to screen for AI than those who were not (43% vs 3%, respectively; P =.0001). Among the 37 children screened for AI, 51% (n=19) were identified as having AI, and 10 were given low-dose ACTH stimulation testing following ≥1 abnormal MSC testing results. An AI diagnosis was confirmed among 5% (n=2) of these children. A moderate association was observed between MSC and DHEA-S (rₛ=0.44; P =.025). 

Limitations to this study include potential for recall bias, limited sample size, and lack of data on AI diagnosis requirements, abnormal cortisol level criteria, or systemic corticosteroid use prior to an AI-related clinical visit, or use of multiple corticosteroids.

The study researchers concluded that “[only] 7% of providers currently screen for AI, but a higher percentage of gastroenterologists who are members of an EoE consortia routinely screen.” The researchers also indicated that this study’s cohort of individuals with EoE receiving treatment with topical corticosteroids “showed a 5% prevalence of AI…” Furthermore, the study researchers “propose a diagnostic algorithm…to detect asymptomatic AI in EoE patients treated with chronic [topical corticosteroids].”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Bose P, Kumar S, Nebesio TD, et al. Adrenal insufficiency in children with eosinophilic esophagitis treated with topical corticosteroids [published online October 29, 2019]. J Pediatr Gastroenterol Nutr. doi: 10.1097/MPG.0000000000002537