The possibility of short‐term hypothalamic‐pituitary‐adrenal axis suppression with high‐volume, high‐dose nasal mometasone irrigation in postsurgical patients with chronic rhinosinusitis

• Published in: International forum of allergy & rhinology 2022-03, Vol.12 (3), p.249-256
• Main Authors: Brown, Hannah J., Batra, Pete S., Eggerstedt, Michael, Ganti, Ashwin, Papagiannopoulos, Peter, Tajudeen, Bobby A.
• Format: Article
• Language: English
• Subjects: Adult; Budesonide; Chronic Disease; chronic rhinosinusitis; disease management; Drug dosages; Female; high‐volume irrigation; Hormones; Humans; Hydrocortisone; Hypothalamic-pituitary-adrenal axis; Hypothalamo-Hypophyseal System; Hypothalamus; intranasal steroid irrigation; Lavage; mometasone; Mometasone Furoate - adverse effects; Nasal Lavage; nasal polyps; Patients; Pharmacokinetics; Pituitary; Pituitary-Adrenal System; Prospective Studies; Rhinitis; Rhinitis - drug therapy; Rhinitis - surgery; Rhinosinusitis; Sinusitis; Sinusitis - drug therapy; Sinusitis - surgery; Steroids; Treatment Outcome
• ISSN: 2042-6976; 2042-6984
• DOI: 10.1002/alr.22894

Background Medically refractory chronic rhinosinusitis (CRS) is often treated with functional endoscopic sinus surgery (FESS) and high‐volume steroid nasal irrigation. While budesonide is the most common steroid irrigation for this indication, mometasone has a superior pharmacokinetic profile, which may allow dose escalation. The safety and efficacy of mometasone at higher concentrations than previously used in treating CRS have not been explored. Methods Patients were recruited from a tertiary level clinic between June 2018 and December 2019. Inclusion criteria included adults (>18 years); CRS diagnosis; previous FESS; pre‐treatment morning cortisol within normal range; minimum of twice daily high‐volume sinonasal mometasone irrigations (total dose of 4 mg) for 12 weeks; and post‐treatment morning cortisol measured within 2 weeks following the study period. Patients with potential for endogenous or exogenous disruption of the HPA axis were excluded. Results 14 patients were enrolled in this prospective cohort study. In all but one patient, pre‐ and post‐treatment morning cortisol levels were not significantly different and were within normal limits (6.7‐25.4 μg/dL). Following an uninterrupted 12‐week treatment course, no evidence of HPA axis suppression was found (P = 0.915). The single patient who was found to have a low (1.3 μg/dL) post‐treatment morning serum cortisol level reportedly received an intraarticular steroid shot several days prior to the blood draw. She remained asymptomatic and her rechecked serum cortisol was within normal limits at 12.3 μg/dL. Conclusions High‐volume 2 mg twice daily sinonasal mometasone irrigations did not cause HPA axis suppression in a representative sample of patients with refractory CRS post‐FESS with normal baseline cortisol levels.