Second line controller treatment might have been tried

EDITOR—The lesson of the week from Drake et al highlighted iatrogenic adrenal suppression due to high doses of fluticasone in children.1 The real lesson here is not to use drugs off label without having any other alternative or being aware of the potential adverse effects.

It is unclear from the report whether the prescribers told the parents of these children of the potential for developing adverse effects at five to seven times the maximum recommended dose in children (>200 ¼g/day of fluticasone). Presumably the prescribers were aware of the decline in the therapeutic ratio above 200 ¼g/day but had weighed the potential benefits against the risks in each specific case, even though no data indicate any efficacy gain above this dose in children. It is not stated in the report whether any attempt had been made to step down to a lower dose, or whether second line non-steroidal controller treatment had been tried before increasing to such high doses.

It would also be relevant to know about the children's lung function before admission as the lung bioavailability of fluticasone is directly correlated to predicted forced expiratory volume in one second, such that systemic absorption would be reduced in more severe asthma.

This report should not detract from using appropriate low doses of inhaled corticosteroids, including fluticasone, in asthmatic children as they have a high therapeutic ratio at conventional labelled doses.2^–1 Their use above such doses may result in patients falling off the precipice of the systemic dose-response curve.