https://doi.org/10.4081/monaldi.2026.3521
Balancing control and safety: hypothalamic-pituitary-adrenal axis effects of dual-route fluticasone in unified airway disease
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Published: 10 July 2026
The concurrent presence of allergic rhinitis and bronchial asthma, known as unified airway disease, often requires combined therapeutic approaches. This prospective study investigates the clinical efficacy and safety of combined inhaled and intranasal fluticasone propionate in such patients. A total of 25 adult patients with moderate to severe allergic rhinitis and bronchial asthma were enrolled. After excluding 2 lost-to-follow-up patients, 23 patients completed the study. Participants received combined inhaled and intranasal fluticasone propionate for four weeks. Clinical outcomes were assessed using Total Nasal Symptom Score (TNSS), Asthma Control Test (ACT), spirometry, and 24-hour urinary free cortisol levels pre- and post-treatment. Significant improvements were observed in TNSS (9.09±2.89 to 2.13±1.62; p<0.0001) and ACT scores (20.48±3.07 to 24.09±1.12; p<0.0001). Pulmonary function tests showed significant increases in forced vital capacity from 3.16±0.73 L to 3.75±0.63 L (p=0.0053) and forced expiratory volume in 1 second from 2.18±0.75 L to 2.71±0.80 L (p=0.0252). Mean urinary free cortisol levels decreased from 31.35±9.35 mcg/24 h to 28.02±9.14 mcg/24 h, though the change was not statistically significant (p=0.2295). Combined inhaled and intranasal fluticasone propionate therapy significantly improves symptom control and pulmonary function in patients with allergic rhinitis and bronchial asthma. No significant suppression of the hypothalamic-pituitary-adrenal axis was observed, indicating a favorable safety profile for short-term use.
Downloads
Paiva Ferreira LKD, Paiva Ferreira LAM, Monteiro TM, et al. Combined allergic rhinitis and asthma syndrome (CARAS). Int Immunopharmacol 2019;74:105718. DOI: https://doi.org/10.1016/j.intimp.2019.105718
Chhabra SK, Gupta CK, Chhabra P, et al. Prevalence of bronchial asthma in school children in Delhi. J Asthma 1998;35:291-6. DOI: https://doi.org/10.3109/02770909809068220
Valovirta E. Managing co-morbid asthma with allergic rhinitis: targeting the one-airway with leukotriene receptor antagonists. World Allergy Organ J 2012;5:S210-1. DOI: https://doi.org/10.1186/1939-4551-5-S3-S210
Global Initiative for Asthma. Global strategy for asthma management and prevention, 2023. Available from: https://ginasthma.org
Brożek JL, Bousquet J, Agache I, et al. Allergic rhinitis and its impact on asthma (ARIA) guidelines—2016 revision. J Allergy Clin Immunol 2017;140:950-8. DOI: https://doi.org/10.1016/j.jaci.2017.03.050
Derendorf H, Meltzer EO. Molecular and clinical pharmacology of intranasal corticosteroids: clinical and therapeutic implications. Allergy 2008;63:1292-300. DOI: https://doi.org/10.1111/j.1398-9995.2008.01750.x
Daley-Yates PT. Inhaled corticosteroids: potency, dose equivalence and therapeutic index. Br J Clin Pharmacol 2015;80:372-80. DOI: https://doi.org/10.1111/bcp.12637
Kline GA, Symonds CJ, Holmes DT. Cortisol suppression with low-dose inhaled fluticasone propionate: a randomized controlled trial. CMAJ 2021;193:E426-30. DOI: https://doi.org/10.1503/cmaj.78162
Lipworth BJ. Systemic adverse effects of inhaled corticosteroid therapy: a systematic review and meta-analysis. Arch Intern Med 1999;159:941-55. DOI: https://doi.org/10.1001/archinte.159.9.941
Broersen LH, Pereira AM, Jorgensen JO, Dekkers OM. Adrenal insufficiency in corticosteroids use: systematic review and meta-analysis. J Clin Endocrinol Metab 2015;100:2171-80. DOI: https://doi.org/10.1210/jc.2015-1218
Todd GRG, Acerini CL, Ross-Russell R, et al. Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom. Arch Dis Child 2002;87:457-61. DOI: https://doi.org/10.1136/adc.87.6.457
Stelmach R, do Potrocinio T Nunes M, Ribeiro M, Cukier A. Effect of treating allergic rhinitis with corticosteroids in patients with mild-to-moderate persistent asthma. Chest 2005;128:3140-7. DOI: https://doi.org/10.1378/chest.128.5.3140
Barnes PJ. Inhaled corticosteroids. Pharmaceuticals 2010;3:514-40. DOI: https://doi.org/10.3390/ph3030514
Moghaddam KG, Rashidi N, Meybodi HA, et al. The effect of inhaled corticosteroids on hypothalamic-pituitary-adrenal axis. Indian J Pharmacol 2012;44:314-8. DOI: https://doi.org/10.4103/0253-7613.96300
Derendorf H, Hochhaus G, Meibohm B, et al. Pharmacokinetics and pharmacodynamics of inhaled corticosteroids. J Allergy Clin Immunol 1998;101:S440-6. DOI: https://doi.org/10.1016/S0091-6749(98)70156-3
Attilio L. Boner: effects of intranasal corticosteroids on the hypothalamic-pituitary-adrenal axis in children. J Allergy Clin Immunol 2001;108:S32-9. DOI: https://doi.org/10.1067/mai.2001.115564
Dixit R, Dixit K, Sharma S, Joshi N. Adrenal suppression and its pattern with high dose inhaled budesonide and fluticasone propionate in adult asthmatic patients. Chest Chest 2007;132:505S. DOI: https://doi.org/10.1378/chest.132.4_MeetingAbstracts.505a
Loaiza-Bonilla A, Sullivan T, Harris RK. Lost in the mist: acute adrenal crisis following intranasal fluticasone propionate overuse. Case Rep Med 2010;2010:846534. DOI: https://doi.org/10.1155/2010/846534
Dutta D, Shivaprasad KS, Ghosh S, et al. Iatrogenic cushing's syndrome following short-term intranasal steroid use. J Clin Res Pediatr Endocrinol 2012;4:157-9. DOI: https://doi.org/10.4274/Jcrpe.726
Besemer F, Kramers C, Brinkman K, et al. Hypothalamic-pituitary-adrenal axis suppression by inhaled or nasal corticosteroids in HIV-infected patients. Int J Clin Pharm 2020;42:347-50. DOI: https://doi.org/10.1007/s11096-020-00995-5
Howland WC 3rd. Fluticasone propionate: topical or systemic effects? Clin Exp Allergy 1996;26:18-22. DOI: https://doi.org/10.1111/j.1365-2222.1996.tb00654.x
Treatment of seasonal allergic rhinitis with once-daily intranasal fluticasone propionate therapy in children. Fluticasone Propionate Collaborative Pediatric Working Group. J Pediatr 1994;125:628-34. DOI: https://doi.org/10.1016/S0022-3476(94)70025-7
Ethics Approval
How to Cite
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.