Childhood Cushing's syndrome induced by betamethasone nose drops, and repeat prescriptions

We welcome Findlay et al's lesson of the week regarding betamethasone
nasal drops in children1 and would agree that the few case reports of
Cushing's Syndrome may represent the "tip of the iceberg". We have
performed a prospective study involving 9 adults with nasal polyposis
treated with six weeks' betamethasone drops, assessing the hypothalamo-
pituitary-adrenal axis using a low dose (1mcg) ACTH stimulation test,
which may detect more subtle impairment of endogenous cortisol production
than the standard test (250mcg)2. We found that all patients had
significantly depressed baseline (9AM) and post-ACTH cortisol after
betamethasone treatment (p<0.001-ANOVA for repeated measures)3.
Furthermore there is reason to believe that in many cases, patients tend
to overcomply with nasal drop medication owing largely to difficulties
administrating the droplet dispenser4. The perceived benefit of
betamethasone over other topical nasal steroids is that its intranasal
distribution may be superior (being in drop form) to that achieved using
aqueous sprays5. We endorse the view that if betamethasone is required
for the treatment of rhinological disease it should be regardede as
systemic corticosteroid administration, and the appropriate coution
exercised.

Jarrod J Homer
Specialist Registrar in Otolaryngology-Head and Neck Surgery
St James's University Hospital
Leeds LS9 7TF

Tasso G Gazis
Specialist Registrar in Endocrinology
Queens Medical Centre University Hospital
Nottingham NG7 2UH

1. Findlay CA, MacDonald JF, Geddes N, Donaldson MDC. Childhood
Cushing's syndrome induced by betamthasone nose drops and repeat
prescriptions. BMJ 1998;317;739-40.

2. Dickstein G, Shechner C, Nicholson WE, Rosner I, Shen-Orr Z,
Adawi F, Lahav M. Adrenocorticotrophin stimulation test:effects of basal
cortisol level, time of day, and suggested new sensitive low dose test. J
Clin Endocrinol Metab 1991;72;773-8.

3. Gazis AG, Homer JJ, Page S, Jones NS. The effect of topical
nasal betamethsone drops for nasal polyposis on adrenal function. Clin
Otolaryngol 1998;23;280.

4. Gallagher G and MacKay I. Doctors and drops. BMJ 1991;303;761.

5. Hardy JG, Lee SW, Wilson cG. Intranasal drug delivery by sprays
and drops. J Pharm Pharmacol 1985;37;294-7.