Intravenous pulsed steroids have been studied and shown to be beneficial in children with refractory ABPA exacerbations associated with long-term steroid use.78,79 Although effective, the use of systemic glucocorticoids is limited by significant side effects including obesity, osteopenia, development of type-2 diabetes, insomnia as well as many other effects.80 In addition, long-term glucocorticoid use can cause downregulation of glucocorticoid receptors inducing a steroid-resistant state.80 This evidence concerns the gene NR3C1 and type 2 diabetes mellitus.