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Russell, in his editorial “Very high-dose corticosteroids: panacea or poison?1”, speculates about the reasons why “the practice of using increasingly high doses of inhaled corticosteroid therapy, particularly of fluticasone, became commonplace in the UK.” He blames doctors: “it appears that better disciplined clinicians elsewhere in the world were less willing to stray beyond licensed dosages” and also the raising of the licensed dose of fluticasone propriate in children, from 200 to 400 μg/day, although this happened in 2001, at least 5 years after this prescribing practice became commonplace.2
The question as to how this situation arose is important, and was discussed by a judge at a fatal accident inquiry3 in 2005 into the death of a 5-year-old girl in 2001 from adrenal crisis due to high-dose inhaled fluticasone propriate. It was this death that prompted the recent investigation of adrenal function in children with asthma, prescribed fluticasone propriate >500 μg/day.4
At the inquiry, evidence was heard from the treating clinicians and others including a pharmacist, paediatricians, a chest physician, representatives of the Medicines and Healthcare Products Regulatory Agency (formerly the Medicines Control Agency) and GlaxoSmithKline (GSK), the manufacturers of fluticasone propriate. Evidence was heard that at the time of the launch of fluticasone propriate, the product monograph claimed “mean plasma cortisol concentrations remained within the normal range for adults and children, demonstrating that even at high doses (2000 micrograms), fluticasone is well tolerated …
Competing interests: None.