Corticosteroid Exposure in Chronic Rhinosinusitis and Global Airway Disease: Adrenal and Bone Impact
Abstract
Objective: To investigate cumulative corticosteroid (CC) burden in patients with chronic rhinosinusitis with nasal polyps (CRSwNP), with or without coexisting asthma (global airway disease, GAD), referred for biologic treatment, and to assess the prevalence of CC-related comorbidities, including secondary adrenal insufficiency, osteopenia and/or osteoporosis. Methods: Prospective cohort study of adults with chronic rhinosinusitis with nasal polyps and/or GAD referred to tertiary care for biologic treatment evaluation: Assessments included DXA scan, corticosteroid case history, Synacthen test, and analyses of cumulative CS exposure (systemic [SCS], inhaled [ICS], and nasal [NCS]) using prescription data. Results: Of 90 referred patients, 87 (97%) had complete data set and were included in the final cohort. The prevalence of Type 2 diabetes was significantly higher among patients with CRSwNP only compared with GAD (26% vs. 4%, p = 0.019), whereas subclinical adrenal suppression was detected only in the GAD group (6%, 4/70). Rates of osteopenia or osteoporosis were comparable (47% vs. 43%). Higher CC exposure was associated with lower bone mineral density (BMD) at the lumbar spine, femoral neck, and total hip (all p < 0.02). Notably, these rates are considerably higher than those reported for the general Danish population aged ≥ 50 years, in which approximately 21.1% of women and 6.5% of men are estimated to have osteoporosis. Conclusion: Patients with CRSwNP and GAD had a substantial CC burden from combined systemic, inhaled, and nasal steroid use. This was associated with subclinical adrenal suppression and reduced BMD, while Type 2 diabetes was more prevalent in patients only with CRSwNP.
Plain Language Summary
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a persistent inflammation of the nose and sinuses that often requires repeated treatment with steroid medications — tablets, nasal sprays and inhalers. Many of these patients also have asthma, meaning their total steroid exposure from all sources can be substantial. In this study, we examined the cumulative steroid burden and its effects on bones and hormone function in patients referred for biologic treatment. Of 87 patients we studied, we found that those with both CRSwNP and asthma ("global airway disease") had suppressed adrenal gland function — meaning the body's own stress-hormone production had been partially shut down by prolonged steroid use — in 6% of cases. Rates of reduced bone density (osteopenia and osteoporosis) were high in both groups: around 43-47%. We found that higher total steroid exposure was clearly linked to lower bone density at multiple sites. Our findings — with bone-thinning rates far exceeding those expected for the general population — make a compelling case for minimising cumulative steroid exposure in patients with chronic inflammatory airway diseases, and highlight the urgent need for biologic treatments that can reduce this burden before irreversible harm occurs.