Risk factors for glucocorticoid-induced adrenal insufficiency
| Route of administration | Reported risk | Factors that increase the risk | Factors that decrease the risk |
|---|---|---|---|
| Inhaled | Dose- and duration-dependent41 20.3% in patients treated for > 1 year19 | High doses (any glucocorticoid > 0.8 mg/day or fluticasone propionate > 0.75 mg/day)42 Concurrent use of intranasal or oral glucocorticoids43,44 Use of spacer device to deliver more medication to the lower airways45 Higher lung volumes45 | Beclomethasone dipropionate, budesonide, and triamcinolone acetonide are less likely to suppress the HPAA compared with fluticasone propionate42 Ciclesonide has the lowest risk of HPAA suppression46 Lower lung volumes45 |
| Intranasal | Low (≤ 4.2%)19,46,47 | Long-term use (> 12 months)46 | Short-term use46 |
| Intra-articular injections | 52.2%19 GIAI usually occurs 1 to 8 weeks after injection48 After single and repeated injections49 | Higher doses49 Patients with inflammatory disease49 Administration in bilateral joints simultaneously48 | Patients with degenerative disease49 |
| Epidural injections | 52.2%19 | Higher doses50 Longer-acting glucocorticoids (eg, methylprednisolone, triamcinolone)51 | Lower doses50 Shorter-acting glucocorticoids51 |
| Topical | 4.7%19,52 Shampoo formulations are not linked to GIAI53 | Disruption of skin barrier52,54 Long-term use (> 12 months)52,55 Higher-potency topical glucocorticoids (eg, betamethasone dipropionate, clobetasol propionate)52,55,56 Higher doses Application to larger body surface52,54 Use of occlusive bandage52,54 Application on the eyelids, scrotum, and mucosal surfaces52,54 | Lower-potency topical glucocorticoids (eg, dexamethasone cream 0.1%, hydrocortisone 0.5%, hydrocortisone 1%, hydrocortisone 2.5%, methylprednisolone 1%)55 |
GIAI = glucocorticoid-induced adrenal insufficiency; HPAA = hypothalamic-pituitary-adrenal axis
Based on information in references 19 and 41–56.