title: Safety analysis of long-term budesonide nasal irrigations in patients with chronic rhinosinusitis post endoscopic sinus surgery.
abstract: Although the safety of topical nasal steroids is well established for nasal spray forms, data regarding the safety of steroid irrigations is limited. We studied the effect of long-term budesonide nasal irrigations (>6 months) on hypothalamic-pituitary-adrenal axis (HPAA) function and intraocular pressure (IOP) in patients post-endoscopic sinus surgery.
  
  
  
  This was retrospective case series. Adrenal function was assessed by using the high-dose cosyntropin stimulation test.
  
  
  
  A total of 48 patients were assessed, with a mean duration of budesonide irrigations of 22 months. Stimulated cortisol levels were abnormally low in 11 patients (23%). None reported to have symptoms of adrenal suppression. Three of 4 patients who repeated the study being off budesonide for at least 1 month returned to near normal levels. Logistic regression analysis revealed that concomitant use of both nasal steroid sprays and pulmonary steroid inhalers was significantly associated with HPAA suppression (p = 0.024). Patients with low stimulated cortisol levels were able to continue budesonide irrigations under the supervision of an endocrinologist without frank clinical manifestations of adrenal insufficiency. IOP was within normal limits in all patients.
  
  
  
  Long-term use of budesonide nasal irrigations is generally safe, but asymptomatic HPAA suppression may occur in selected patients. Concomitant use of both nasal steroid sprays and pulmonary steroid inhalers while using daily budesonide nasal irrigations is associated with an increased risk. Rhinologists should be alerted to the potential risks of long-term use of budesonide nasal irrigations, and monitoring for HPAA suppression may be warranted in patients receiving long-term budesonide irrigation therapy.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA.|Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Ethan
authors.initials: E
authors.lastname: Soudry
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA.
authors.forename: Jane
authors.initials: J
authors.lastname: Wang
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA.
authors.forename: Reza
authors.initials: R
authors.lastname: Vaezeafshar
authors.affiliation: Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA.|Department of Medicine, Stanford University School of Medicine, Stanford, CA.
authors.forename: Laurence
authors.initials: L
authors.lastname: Katznelson
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA.
authors.forename: Peter H
authors.initials: PH
authors.lastname: Hwang
mesh_terms: D000328:Adult; D000368:Aged; D019819:Budesonide / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D002908:Chronic Disease; D003366:Cosyntropin / Q000494:pharmacology; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D007030:Hypothalamo-Hypophyseal System / Q000187:drug effects*; D007429:Intraocular Pressure / Q000187:drug effects; D008297:Male; D008875:Middle Aged; D055556:Nasal Lavage; D010913:Pituitary-Adrenal System / Q000187:drug effects*; D012220:Rhinitis / Q000097:blood / Q000188:drug therapy*; D012709:Serum Albumin / Q000032:analysis; D012852:Sinusitis / Q000097:blood / Q000188:drug therapy*
chemical_list: D005938:Glucocorticoids; D012709:Serum Albumin; D003366:Cosyntropin; D019819:Budesonide; D006854:Hydrocortisone
keywords: HPAA suppression; budesonide; chronic rhinosinusitis; corticosteroid; intraocular pressure; irrigation; safety