scholarly journals Adrenal suppression from exogenous glucocorticoids: Recognizing risk factors and preventing morbidity

2021 ◽  
Vol 26 (4) ◽  
pp. 242-247
Author(s):  
Alexandra Ahmet ◽  
Anne Rowan-Legg ◽  
Larry Pancer
Keyword(s):  
Risk Factors ◽  
Side Effect ◽  
Inhaled Corticosteroids ◽  
Glucocorticoid Therapy ◽  
Adrenal Suppression ◽  
Adrenal Crisis ◽  
Significant Morbidity ◽  
Potential Side Effect

Abstract Adrenal suppression (AS), a potential side effect of glucocorticoid therapy (including inhaled corticosteroids), can be associated with significant morbidity and even death. In Canada, adrenal crisis secondary to AS continues to be reported in children. Being aware of symptoms associated with AS, understanding the risk factors for developing this condition, and familiarity with potential strategies to reduce risks associated with AS, are essential starting points for any clinician prescribing glucocorticoids.

scholarly journals Adrenal suppression from glucocorticoids: preventing an iatrogenic cause of morbidity and mortality in children

2019 ◽  
Vol 3 (1) ◽  
pp. e000569 ◽  
Author(s):  
Alexandra Ahmet ◽  
Arati Mokashi ◽  
Ellen B Goldbloom ◽  
Celine Huot ◽  
Roman Jurencak ◽  
...  
Keyword(s):  
Risk Factors ◽  
Side Effect ◽  
Healthcare Professionals ◽  
Inhaled Corticosteroids ◽  
Physiological Stress ◽  
Current Knowledge ◽  
Adrenal Suppression ◽  
Adrenal Crisis ◽  
Children At Risk ◽  
Specific Symptoms

Adrenal suppression (AS) is an important side effect of glucocorticoids (GCs) including inhaled corticosteroids (ICS). AS can often be asymptomatic or associated with non-specific symptoms until a physiological stress such as an illness precipitates an adrenal crisis. Morbidity and death associated with adrenal crisis is preventable but continues to be reported in children. There is a lack of consensus about the management of children at risk of AS. However, healthcare professionals need to develop an awareness and approach to keep these children safe. In this article, current knowledge of the risk factors, diagnosis and management of AS are reviewed while drawing attention to knowledge gaps and areas of controversy. Possible strategies to reduce the morbidity associated with this iatrogenic condition are provided for healthcare professionals.

scholarly journals Adrenal Suppression in Pediatric Patients during Treatment for Acute Lymphoblastic Leukemia

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 4863-4863
Author(s):  
Mary-Pat Schlosser ◽  
Daniel Burd ◽  
Alexandra Ahmet ◽  
Sarah Lawrence ◽  
Mylene Bassal
Keyword(s):  
Acute Lymphoblastic Leukemia ◽  
Adrenal Insufficiency ◽  
Hpa Axis ◽  
Lymphoblastic Leukemia ◽  
Maintenance Phase ◽  
Adrenal Suppression ◽  
Adrenal Crisis ◽  
Significant Morbidity ◽  
Steroid Use ◽  
Testing Protocol

Abstract Background: Hypothalamic-pituitary-adrenal (HPA) axis suppression is a form of adrenal insufficiency that can be found following the use of corticosteroids. Individuals with adrenal insufficiency may have non-specific symptoms or even no regular symptoms, however if presented with a physiologic stress such as infection, injury, or surgery, they are at risk of adrenal crisis. Adrenal crisis typically manifests with hypoglycemia, hypotension and critical illness; this condition is associated with significant morbidity and even mortality. Children being treated for leukemia are at increased risk of infection and may require surgical procedures, thus putting them at risk of adrenal crisis in the context of adrenal suppression. It is known that adrenal suppression exists in the short term after the induction phase of treatment in patients with acute lymphoblastic leukemia (ALL), but the prevalence and duration of suppression is still not fully understood. In addition, adrenal suppression has not been specifically evaluated during the maintenance phase of therapy. During maintenance there may be ongoing adrenal suppression from steroid use in induction, or new suppression from steroid use for maintenance therapy itself. There does not yet exist an accepted protocol to monitor for adrenal insufficiency in ALL. Knowing the prevalence and duration of adrenal suppression in maintenance will enable care teams to better recognize and manage the condition, potentially preventing significant morbidity and mortality. Methods: All cases of ALL treated at the Children's Hospital of Eastern Ontario from 2000 to 2014 were retrospectively reviewed for adrenal suppression. Patient characteristics, clinical features, laboratory data, treatment protocol utilized, adverse events and outcomes were examined. Results: 176 patients were diagnosed with new ALL at The Children's Hospital of Eastern Ontario between 2000 and 2014. Prompted by clinical suspicion, 24 had testing done to investigate for adrenal suppression during this time period. 9 of those patients had cortisol levels indicative of adrenal suppression and required further management for the same. Adrenal suppression was identified in early phases of treatment for ALL. Adrenal suppression was also identified in patients during the maintenance phase of treatment. Many more patients had symptoms that could be attributed to adrenal suppression, but never had cortisol levels tested. Conclusion: Adrenal suppression is found in children being treated for ALL, including during the maintenance phase of therapy. Adrenal suppression may have been present in greater numbers of children, but no routine testing protocol exists to identify these patients. Identifying and reviewing cases of adrenal suppression in children during treatment for ALL, including the maintenance phase, gives a better understanding of the risk of HPA axis suppression in this population. This study also provides background data for the development of a prospective study to further look at adrenal suppression in the maintenance phase of ALL. These studies will guide development of a testing protocol to better identify and manage adrenal suppression, thereby reducing its morbidity and mortality, in children being treated for ALL. Disclosures No relevant conflicts of interest to declare.

scholarly journals Screening practices for paediatric asymptomatic adrenal suppression in Canada: Are we addressing this important risk?

2019 ◽  
Vol 25 (6) ◽  
pp. 389-393
Author(s):  
Ellen B Goldbloom ◽  
Alexandra Ahmet
Keyword(s):  
Signs And Symptoms ◽  
Adrenal Suppression ◽  
Adrenal Crisis ◽  
Surveillance Program ◽  
Educational Impact ◽  
Potential Side Effect ◽  
Screening Guidelines ◽  
Screening Practices ◽  
Asymptomatic Patients ◽  
Before And After

Abstract Background Children with adrenal suppression (AS), a potential side effect of glucocorticoids (GCs) may be asymptomatic, present with nonspecific signs and symptoms or with adrenal crisis. Asymptomatic AS (AAS) can only be diagnosed through screening. Identifying and treating asymptomatic patients before symptoms develop may reduce morbidity. Screening guidelines for AS are lacking. Consequently, screening practices are highly variable. Objective To assess (1) the screening practices for and recognition of paediatric AAS among clinicians in Canada and (2) the educational impact of a 2-year surveillance program of symptomatic AS cases. Methods Before and after a 2-year Canadian Paediatric Surveillance Program (CPSP) study of symptomatic AS, participants were surveyed through the CPSP. The prestudy survey was sent to 2,548 participants in March 2010 and the poststudy survey was sent to 2,465 participants in April 2013. Results Response rates were 32% for the prestudy survey and 21% for the poststudy survey. Between the pre- and poststudy surveys, the percentage of physicians who reported routinely screening patients on GCs for AS increased from 10% to 21% and the percentage who reported having a screening policy in their office/centre increased from 6% to 11%. There was no significant change in the percentage of physicians who had diagnosed a child/youth with AAS in the preceding year. Conclusion Frequency of screening for AAS increased following the 2-year study but remains low. Development of a clinical practice guideline should increase both awareness of asymptomatic AS among Canadian paediatricians and the identification of AAS, before symptoms develop.

Partial Adrenal Suppression with Prolonged Use of Depo-Provera

2019 ◽  
Vol 4 (1) ◽  
pp. 64
Author(s):  
Nur Aisyah Zainordin ◽  
Fatimah Zaherah Mohamed Shah ◽  
Rohana Abdul Ghani
Keyword(s):  
Weight Gain ◽  
Medroxyprogesterone Acetate ◽  
Side Effect ◽  
Case Reports ◽  
Adrenal Incidentaloma ◽  
Adrenal Suppression ◽  
Private Pharmacy ◽  
Significant Weight Gain ◽  
The Past ◽  
Depo Provera

A 49-year old patient presented with symptoms of adrenal suppression following an attempt to withdraw Depo-Provera or Depot Medroxyprogesterone Acetate (DMPA) injection. She had been receiving DMPA injections for the past 16 years for contraception. She was initially prescribed DMPA by her gynaecologist but later on began obtaining the medication directly from a private pharmacy without prior consultation from her gynaecologist. Clinically, she had been experiencing significant weight gain and appeared cushingoid. Blood investigations confirmed partial adrenal suppression with presence of an adrenal incidentaloma. This case reports a known side effect of DMPA but occurring at a much lower dose than previously described. It also highlights the need to increase the awareness of the insidious side effect of DMPA and to avoid unsupervised use of the drug.

scholarly journals Clozapine-induced stuttering in the absence of known risk factors: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Florence Jaguga
Keyword(s):  
Risk Factors ◽  
Family History ◽  
Side Effect ◽  
Case Reports ◽  
Extrapyramidal Symptoms ◽  
Prior History ◽  
Case Presentation ◽  
Rare Side Effect ◽  
History Of ◽  
Electrophysiological Findings

Abstract Background Stuttering is a rare side effect of clozapine. It has been shown to occur in the presence of one or more factors such as abnormal electrophysiological findings and seizures, extrapyramidal symptoms, brain pathology, and a family history of stuttering. Few case reports have documented the occurrence of clozapine-induced stuttering in the absence of these risk factors. Case presentation A 29-year-old African male on clozapine for treatment-resistant schizophrenia presented with stuttering at a dosage of 400 mg/day that resolved with dose reduction. Electroencephalogram findings were normal, and there was no clinical evidence of seizures. The patient had no prior history or family history of stuttering, had a normal neurological examination, and showed no signs of extrapyramidal symptoms. Conclusion Clinicians ought to be aware of stuttering as a side effect of clozapine, even in the absence of known risk factors. Further research should investigate the pathophysiology of clozapine-induced stuttering.

Cascade targeting tumor mitochondria with CuS nanoparticles for enhanced photothermal therapy in the second near-infrared window

2021 ◽  
Author(s):  
Haiyan Wu ◽  
Pengpeng Jia ◽  
Yu Zou ◽  
Jiang Jiang
Keyword(s):  
Treatment Outcome ◽  
Heat Generation ◽  
Side Effect ◽  
Photothermal Therapy ◽  
Near Infrared ◽  
Local Heat ◽  
Potential Side Effect ◽  
Improve Treatment ◽  
Improve Treatment Outcome ◽  
Local Heat Generation

Photothermal therapy, assisted by local heat generation using photothermal nanoparticles (NPs), is an emerging strategy to treat tumors noninvasively. To improve treatment outcome and to alleviate potential side effect on...

scholarly journals Pustular Rash in Crohn’s Patient on Ustekinumab Raises Concern for Drug-Induced Paradoxical Psoriasis

2021 ◽  
pp. 662-666
Author(s):  
Mitra Barahimi ◽  
Scott Lee ◽  
Kindra Clark-Snustad
Keyword(s):  
Side Effect ◽  
De Novo ◽  
Pustular Psoriasis ◽  
Initial Weight ◽  
Drug Induced ◽  
Clinical Recurrence ◽  
Potential Side Effect ◽  
First Case ◽  
Tnf Antagonist ◽  
Subcorneal Pustular Dermatosis

We report the case of a 51-year-old male with Crohn’s disease (CD) who developed a reproducible pustular rash after ustekinumab (UST) administration. The patient first presented with a pustular rash on his hands, body, extremities, and scalp starting 5 weeks after his initial weight-based UST induction. The rash resolved spontaneously, then recurred 4 weeks after his first subcutaneous maintenance dose of UST 90 mg. Biopsy of the affected area demonstrated subcorneal pustular dermatosis (SPD). UST was discontinued and the rash resolved. Unfortunately, the patient experienced clinical recurrence of CD, and given prior failure of multiple CD medications, UST was restarted with premedication. Two weeks after UST re-induction, the rash recurred, though less severe. Given improvement in CD symptoms, UST was continued and the rash managed with topical corticosteroids. This is the first case of drug-induced SPD associated with UST. One case report has previously described de novo pustular psoriasis associated with UST in a patient with CD and enteropathic arthritis. Notably, SPD and pustular psoriasis can be histologically indistinguishable. The development of a paradoxical psoriasiform rash is thought to be one of the few dose and duration dependent side effects of TNF-antagonist therapy but has not previously been established as a side effect of UST. This case demonstrates a new potential side effect of UST.

scholarly journals Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies

2010 ◽  
Vol 162 (3) ◽  
pp. 597-602 ◽  
Author(s):  
Stefanie Hahner ◽  
Melanie Loeffler ◽  
Benjamin Bleicken ◽  
Christiane Drechsler ◽  
Danijela Milovanovic ◽  
...  
Keyword(s):  
Risk Factors ◽  
Adrenal Insufficiency ◽  
Educational Status ◽  
Cross Sectional Study ◽  
Sudden Onset ◽  
Stressful Events ◽  
Adrenal Crisis ◽  
Cross Sectional ◽  
Crisis Prevention ◽  
Dhea Treatment

ObjectiveAdrenal crisis (AC) is a life-threatening complication of adrenal insufficiency (AI). Here, we evaluated frequency, causes and risk factors of AC in patients with chronic AI.MethodsIn a cross-sectional study, 883 patients with AI were contacted by mail. Five-hundred and twenty-six patients agreed to participate and received a disease-specific questionnaire.ResultsFour-hundred and forty-four datasets were available for analysis (primary AI (PAI), n=254; secondary AI (SAI), n=190). Forty-two percent (PAI 47% and SAI 35%) reported at least one crisis. Three hundred and eighty-four AC in 6092 patient years were documented (frequency of 6.3 crises/100 patient years). Precipitating causes were mainly gastrointestinal infection and fever (45%) but also other stressful events (e.g. major pain, surgery, psychic distress, heat and pregnancy). Sudden onset of apparently unexplained AC was also reported (PAI 6.6% and SAI 12.7%). Patients with PAI reported more frequent emergency glucocorticoid administration (42.5 vs 28.4%, P=0.003). Crisis incidence was not influenced by educational status, body mass index, glucocorticoid dose, DHEA treatment, age at diagnosis, hypogonadism, hypothyroidism or GH deficiency. In PAI, patients with concomitant non-endocrine disease were at higher risk of crisis (odds ratio (OR)=2.02, 95% confidence interval (CI) 1.05–3.89, P=0.036). In SAI, female sex (OR=2.18, 95% CI 1.06–4.5, P=0.035) and diabetes insipidus (OR=2.71, 95% CI 1.22–5.99, P=0.014) were associated with higher crisis incidence.ConclusionAC occurs in a substantial proportion of patients with chronic AI, mainly triggered by infectious disease. Only a limited number of risk factors suitable for targeting prevention of AC were identified. These findings indicate the need for new concepts of crisis prevention in patients with AI.

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