scholarly journals Glucocorticoid induced adrenal insufficiency

BMJ ◽  
2021 ◽  
pp. n1380
Author(s):  
Alessandro Prete ◽  
Irina Bancos
Keyword(s):  
Adrenal Insufficiency ◽  
Withdrawal Syndrome ◽  
Adrenal Function ◽  
Glucocorticoid Therapy ◽  
Patient Counseling ◽  
Glucocorticoid Treatment ◽  
Factors Affecting ◽  
Function Recovery ◽  
Underlying Disorder ◽  
Glucocorticoid Metabolism

ABSTRACTSynthetic glucocorticoids are widely used for their anti-inflammatory and immunosuppressive actions. A possible unwanted effect of glucocorticoid treatment is suppression of the hypothalamic-pituitary-adrenal axis, which can lead to adrenal insufficiency. Factors affecting the risk of glucocorticoid induced adrenal insufficiency (GI-AI) include the duration of glucocorticoid therapy, mode of administration, glucocorticoid dose and potency, concomitant drugs that interfere with glucocorticoid metabolism, and individual susceptibility. Patients with exogenous glucocorticoid use may develop features of Cushing’s syndrome and, subsequently, glucocorticoid withdrawal syndrome when the treatment is tapered down. Symptoms of glucocorticoid withdrawal can overlap with those of the underlying disorder, as well as of GI-AI. A careful approach to the glucocorticoid taper and appropriate patient counseling are needed to assure a successful taper. Glucocorticoid therapy should not be completely stopped until recovery of adrenal function is achieved. In this review, we discuss the factors affecting the risk of GI-AI, propose a regimen for the glucocorticoid taper, and make suggestions for assessment of adrenal function recovery. We also describe current gaps in the management of patients with GI-AI and make suggestions for an approach to the glucocorticoid withdrawal syndrome, chronic management of glucocorticoid therapy, and education on GI-AI for patients and providers.

scholarly journals AB0353 ADRENAL INSUFFICIENCY AFTER GLUCOCORTICOID TREATMENT OF GIANT CELL ARTERITIS

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 1201.2-1201
Author(s):  
A. Hočevar ◽  
R. Jese ◽  
J. Kramarič ◽  
M. Tomsic ◽  
Z. Rotar
Keyword(s):  
Adrenal Insufficiency ◽  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Cortisol Level ◽  
Adrenal Function ◽  
Glucocorticoid Therapy ◽  
Glucocorticoid Treatment ◽  
Systemic Glucocorticoid ◽  
The Mean ◽  
Corticotropin Stimulation

Background:Adrenal insufficiency is frequently neglected and underappreciated, potentially severe complication of systemic glucocorticoid therapy.Objectives:We aimed to evaluate the prevalence of glucocorticoid induced adrenal insufficiency in giant cell arteritis (GCA).Methods:We analysed adrenal function data in a cohort of GCA patients diagnosed between July 2014 and July 2019, in whom discontinuation of methylprednisolone therapy was planned. Adrenal function was tested by Corticotropin stimulation test (CST). To perform the CST, methylprednisolone was substituted with hydrocortisone (20mg qd in three divided doses) for one to four weeks before the test. Adrenal insufficiency was defined as cortisol level <450 nmol/l measured 30 minutes after the corticotropin injection; additionally, the result of the CST was defined as borderline when the cortisol level 30 minutes after corticotropin injection was between 450 nmol/l and 500 nmol/l.Results:Adrenal function was tested in 74/215 GCA patients before definite methylprednisolone withdrawal (after a median 13.5 (12.9 – 22.4) months of glucocorticoid therapy). The mean (SD) methylprednisolone dose, prior to substitution with hydrocortisone and subsequent CST, was 3.1 (1.6) mg. Adrenal insufficiency was detected in 36/74 patients (48.6%); additionally, 10/74 patients (13.5%) had a borderline CST result. Seventeen patients with either adrenal insufficiency or borderline CST result, had a repeated CST after median (IQR) 11.6 (8.9; 12.6) months. Adrenal insufficiency persisted in 11/17 (64.7%) patients, and 1/17 patients had a borderline CST. A third CST was performed in 4/12 patients with abnormal second CST after median (IQR) 8.3 (6.9; 10.6) months. Adrenal function recovered in one patient, while the adrenal insufficiency persisted in the remaining 3 patients.Conclusion:Adrenal insufficiency is a common and potentially long-lasting glucocorticoid induced adverse event in GCA patients.Disclosure of Interests:None declared

scholarly journals P.089 Recovery from chronic secondary adrenal insufficiency in patients with pituitary disorders

2016 ◽  
Vol 43 (S2) ◽  
pp. S41-S41
Author(s):  
V Munro ◽  
B Tugwell ◽  
S Doucette ◽  
DB Clarke ◽  
A Lacroix ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Tumour Size ◽  
Pituitary Surgery ◽  
Complete Recovery ◽  
Glucocorticoid Therapy ◽  
Hormone Deficiency ◽  
Secondary Adrenal Insufficiency ◽  
Glucocorticoid Treatment ◽  
Acth Secreting

Background: Patients with pituitary disorders may be placed on steroid replacement for secondary adrenal insufficiency (SAI), generally after pituitary surgery; however, data regarding recovery of long-term SAI are lacking. We conducted a study to assess the longer term recovery rate of SAI in patients with pituitary disorders. Methods: We identified all SAI patients from prospectively entered data in the Halifax Neuropituitary Database from November 1, 2005 to September 30, 2014, who had required glucocorticoid therapy for >3 months, and a minimum follow-up of 6 months. Exclusion: ACTH-secreting adenomas; peri-operative glucocorticoid treatment only; glucocorticoids for non-pituitary conditions. Results: 55 patients fulfilled the criteria, 41 (75%) of which had transsphenoidal surgery. Nine (16.4%) patients had complete recovery of SAI over a median of 20 months (range: 8–51). Smaller tumour size and initial cortisol >175 nmol/L had increased likelihood of recovery; those with secondary hypogonadism or growth hormone deficiency were less likely to recover. Conclusions: This is the first study to examine long-term recover of SAI in patients with pituitary disorders: approximately 1 in 6 patients recover adrenal function, up to 5 years after diagnosis. Consequently, patients with SAI should undergo regular testing to prevent unnecessary chronic glucocorticoid therapy.

Swallowed glucocorticoid therapy for eosinophilic esophagitis in children does not suppress adrenal function

2015 ◽  
Vol 28 (9-10) ◽  
Author(s):  
Katherine Q. Philla ◽  
Steve B. Min ◽  
Jody N. Hefner ◽  
Robin S. Howard ◽  
Brian J. Reinhardt ◽  
...  
Keyword(s):  
Eosinophilic Esophagitis ◽  
Serum Cortisol ◽  
Post Treatment ◽  
Adrenal Function ◽  
Glucocorticoid Therapy ◽  
Current Standard ◽  
Glucocorticoid Treatment ◽  
Daily Range ◽  
Significant Difference ◽  
Cortisol Levels

AbstractThe purpose of this study was to examine the effect of chronic swallowed glucocorticoids on adrenal function during the treatment of eosinophilic esophagitis (EoE) in children.Serum cortisol levels were obtained in children with EoE pre- and post-treatment with swallowed glucocorticoids. Exclusion criteria included those on any additional steroid therapy. Once diagnosed with EoE by esophageal biopsy, subjects were treated based on current standard of care with either swallowed fluticasone or budesonide. At the time of follow-up, esophagogastroduodenoscopy and blood sampling was repeated. Both pre- and post-treatment serum cortisol samples were collected fasting, between 07:00 and 10:00, and determined using a competitive binding method assay. The distribution of differences in cortisol levels between the pre- and post-treatment samples satisfied the assumption for normality and were subsequently analyzed using the paired t-test.Pre- and post-treatment serum cortisol levels were examined in 14 children who met clinical and histological diagnostic criteria for EoE. Mean age was 10.1 years (range 2–17 years) with 71% male and 29% female subjects. Swallowed glucocorticoid treatment included fluticasone in 79% and budesonide in 21% of subjects. Mean dosage of fluticasone was 704 μg daily (range 220–880 μg daily) and budesonide 0.8 mg daily (range 0.5–1 mg daily), along with a mean treatment length of 17 weeks (range 8–43 weeks). No significant difference in serum cortisol was found following treatment with swallowed fluticasone or budesonide (mean change 1.9 μg/dL, p=0.75, SD of the change=21.2).Swallowed glucocorticoid therapy does not appear to significantly affect the adrenal axis in children, and therefore, may represent a safe therapy for EoE.

scholarly journals Adrenal insufficiency is seen in more than one-third of patients during ongoing low-dose prednisolone treatment for rheumatoid arthritis

2017 ◽  
Vol 177 (4) ◽  
pp. 287-295 ◽  
Author(s):  
Stina Willemoes Borresen ◽  
Marianne Klose ◽  
Bo Baslund ◽  
Åse Krogh Rasmussen ◽  
Linda Hilsted ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Adrenal Insufficiency ◽  
Low Dose ◽  
Adrenal Function ◽  
Function Evaluation ◽  
Concomitant Treatment ◽  
Glucocorticoid Treatment ◽  
Cross Sectional ◽  
Prednisolone Treatment ◽  
Synacthen Test

Objective Patients receiving long-term glucocorticoid treatment are at risk of developing adrenal insufficiency during treatment. We investigated the prevalence of prednisolone-induced adrenal insufficiency in the particular clinical situation where patients receive ongoing low-dose (5 mg/day) prednisolone treatment, a dose by itself too low to cover glucocorticoid needs during stress. Design and methods Cross-sectional study in 42 patients with rheumatoid arthritis (29 women, aged 36–86 years) treated with 5 mg prednisolone/day, who had received prednisolone for ≥6 months (median: 66, range: 6–444 months). Adrenal function was evaluated by a 250 μg Synacthen test performed after mean 48.7 h prednisolone pause. Local assay-specific cut-off for normal adrenal function was P-cortisol ≥420 nmol/L 30 min after Synacthen injection. Results Overall, 20 of the 42 patients (48%, 95% CI: 33–62%) had an insufficient adrenal response to the Synacthen test. Including only patients who had not received concomitant treatment with any other glucocorticoid formulas within the last 3 months, 13 of 33 patients (39%, 95% CI: 25–56%) had an insufficient response. Adrenocorticotrophic hormone (ACTH) concentrations were generally low and anti-adrenal antibodies were negative indicating secondary adrenal insufficiency as the most likely diagnosis. There was no correlation between duration of treatment and 30 min P-cortisol (P = 0.62). Adrenal function did not depend on sex or seropositivity of rheumatoid arthritis. Conclusion We demonstrate a high prevalence of adrenal insufficiency during ongoing low-dose prednisolone treatment. The results urge to increase focus on the condition to ensure identification and correct management of insufficient patients during stress and withdrawal. Strategies for adrenal function evaluation during ongoing low-dose glucocorticoid treatment need to be established.

Adrenal insufficiency in prednisolone-treated patients with polymyalgia rheumatica or giant cell arteritis—prevalence and clinical approach

Rheumatology ◽  
2020 ◽  
Vol 59 (10) ◽  
pp. 2764-2773 ◽  
Author(s):  
Stina W Borresen ◽  
Toke B Thorgrimsen ◽  
Bente Jensen ◽  
Linda Hilsted ◽  
Else M Bartels ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Polymyalgia Rheumatica ◽  
Hospital Admissions ◽  
Adrenal Function ◽  
Clinical Approach ◽  
Glucocorticoid Treatment ◽  
Prednisolone Dose ◽  
Appropriate Treatment

Abstract Objectives Glucocorticoid treatment is fundamental in polymyalgia rheumatica (PMR) and giant cell arteritis (GCA), but carries a risk of glucocorticoid-induced adrenal insufficiency. Adrenal insufficiency can cause reluctance to stop glucocorticoid treatment after disease remission as symptoms can resemble PMR/GCA flare. We aimed to determine the prevalence of adrenal insufficiency in prednisolone-treated patients with PMR/GCA. Methods We included 47 patients with PMR (n = 37), GCA (n = 1) or both (n = 9), treated with prednisolone for ≥5.4 months, current dose 2.5–10 mg/day. Adrenal function was evaluated using a corticotropin (Synacthen®) stimulation test following 48 h prednisolone pause. Two years’ clinical follow-up data are provided. Results Seven patients (15%) had adrenal insufficiency, 4 (11%) of the 37 patients with PMR alone, and 3 (30%) of the 10 patients with GCA. Corticotropin-stimulated P-cortisol was significantly associated with current prednisolone dose, mean daily dose the last 3 and 6 months before testing, and basal P-cortisol, but not with total dose or treatment duration. Adrenal insufficiency occurred with all current prednisolone doses (2.5–10 mg/day). Five (71%) of the glucocorticoid-insufficient patients could discontinue prednisolone treatment; two of them recovered glucocorticoid function, whereas three still needed hydrocortisone replacement 2 years later. Two patients experienced in total four acute hospital admissions with symptoms of adrenal crises. Conclusion Glucocorticoid-induced adrenal insufficiency occurred in 15% of patients with PMR/GCA. Mean prednisolone dose the last 3 months and basal P-cortisol were the best and simplest predictors of adrenal function. Most of the glucocorticoid-insufficient patients could discontinue prednisolone with appropriate treatment for adrenal insufficiency.

scholarly journals Clinical course of pituitary function and image in IgG4-related hypophysitis

2017 ◽  
Vol 2017 ◽  
Author(s):  
Takatoshi Anno ◽  
Fumiko Kawasaki ◽  
Maiko Takai ◽  
Ryo Shigemoto ◽  
Yuki Kan ◽  
...  
Keyword(s):  
Pituitary Gland ◽  
Adrenal Insufficiency ◽  
Clinical Course ◽  
Laboratory Data ◽  
Glucocorticoid Therapy ◽  
High Dose ◽  
Glucocorticoid Treatment ◽  
Serum Igg4 ◽  
Physiological Dose ◽  
Igg4 Level

Summary A 76-year-old man had a hypopituitarism including adrenal insufficiency, hypogonadism and hypothyroidism. Based on various findings including the swelling of the pituitary gland, increase of serum IgG4 level and abundant IgG4-positive plasma cell infiltration in immunostaining of the pituitary gland, we diagnosed this subject as IgG4-related hypophysitis. In general, a high-dose glucocorticoid treatment is effective for IgG4-related disease. His clinical symptom, laboratory data and adrenal insufficiency were almost improved without any therapy. The serum IgG4 level was decreased and pituitary size was normalized with hydrocortisone as physiological replacement. This case report provides the possibility that IgG4 level is decreased spontaneously or with physiological dose of glucocorticoid therapy. Learning points: We performed the pituitary gland biopsy and histochemical examination glucocorticoid therapy in a subject with IgG4-related hypophysitis. This case report provides the possibility that IgG4 level is decreased spontaneously or with a physiological dose of glucocorticoid therapy. We reported the clinical course of IgG4-related hypophysitis without a high-dose glucocorticoid treatment, although there were a few reports about the retrospective examination. Although the patient had still higher IgG4 level compared to normal range, his clinical symptom disappeared and his laboratory data were improved. We should keep in mind the possibility of IgG4-related hypophysitis when we examine one of the uncertain causes of a hypopituitarism including adrenal insufficiency, hypogonadism and hypothyroidism.

scholarly journals Adrenal Insufficiency Secondary to Septic Shock in a Male Patient with Iatrogenic Cushing’s Syndrome: 2 sides of the Same Coin?

2021 ◽  
Vol 14 ◽  
pp. 117955142110266
Author(s):  
Luca Foppiani
Keyword(s):  
Septic Shock ◽  
Adrenal Insufficiency ◽  
Cushing’S Syndrome ◽  
Cushing's Syndrome ◽  
Stressful Events ◽  
Glucocorticoid Therapy ◽  
Relative Adrenal Insufficiency ◽  
Glucocorticoid Treatment ◽  
Life Saving ◽  
Severe Infections

Cushing’s syndrome causes increased morbidity and mortality due to cardiovascular and infectious diseases. Exogenous Cushing’s syndrome can render the adrenal glands unable to cope with severe infections and may result in Addisonian crisis, which can be fatal if not properly diagnosed and treated. During hospitalization for disease exacerbation, a man on chronic glucocorticoid therapy for Crohn’s disease and Cushingoid features developed polymicrobial septic shock together with hypotension that was unresponsive to fluids. On suspicion of relative adrenal insufficiency (cortisol levels were “inadequately” normal), intravenous hydrocortisone was started; norepinephrine was also required to normalize blood pressure. Following clinical improvement, oral cortisone acetate was started. On discharge, he was instructed on how to manage stressful events by increasing oral glucocorticoid treatment or starting a parenteral formulation, if required. Chronic glucocorticoid therapy can cause severe side-effects; in addition, hypoadrenalism can occur in critical illnesses (eg, severe infections). Prompt recognition and proper therapy of this condition can be life-saving.

scholarly journals Serum IgG4 Concentration is a Potential Predictive Biomarker in Glucocorticoid Treatment for Idiopathic Retroperitoneal Fibrosis

2022 ◽  
Author(s):  
Shoichiro Mukai ◽  
Naotaka Sakamoto ◽  
Hiroaki Kakinoki ◽  
Tadamasa Shibuya ◽  
Ryosuke Moriya ◽  
...  
Keyword(s):  
Retroperitoneal Fibrosis ◽  
Predictive Marker ◽  
Predictive Biomarker ◽  
Complete Response ◽  
Glucocorticoid Therapy ◽  
Smoking History ◽  
Idiopathic Retroperitoneal Fibrosis ◽  
Glucocorticoid Treatment ◽  
Female Ratio ◽  
Serum Igg4

Abstract Objectives: To evaluate the management and outcome of idiopathic retroperitoneal fibrosis (iRPF) in Japan, and identify its clinical biomarker. Methods: We retrospectively analyzed 129 patients with iRPF treated between January 2008 and May 2018 at 12 university and related hospitals. Patients treated with glucocorticoid were analyzed to identify a predictive biomarker. These patients were classified into three groups according to overall effectiveness (no change: NC, complete response: CR and partial response groups: PR), and each parameter was compared statistically.Results: Male-female ratio was 5: 1, and median age at diagnosis was 69 (33-86) years. Smoking history was reported in 59.6% of the patients. As treatment, 95 patients received glucocorticoid therapy with an overall response rate of 84%. As a result, serum concentration of IgG4 was significantly decreased in NC group compared with the other two groups (56.6mg/dL vs 255mg/dL, 206mg/dL, P=0.0059 and 0.0078). ROC analysis was performed between the non-responder (NC) and responder groups (CR+PR) to identify the cut-off value of serum IgG4 as a predictive marker. As a result, AUC was 0.793 and the values of sensitivity and specificity were 0.85 and 0.64, respectively, under the cut-off values of 67.6mg/dL. Conclusions: In the majority of iRPF patients, glucocorticoid therapy resulted in a favorable response. Pre-treatment serum IgG4 concentration may have potential as a predictive biomarker of steroid treatment.

Perioperative Management of Patients on Steroids Requiring Surgery

2017 ◽  
Author(s):  
Alexandra Reiher ◽  
Rebecca S. Sippel ◽  
Dawn M. Elfenbein
Keyword(s):  
Adrenal Insufficiency ◽  
Hpa Axis ◽  
Hormone Secretion ◽  
Perioperative Period ◽  
Solid Organ ◽  
Glucocorticoid Treatment ◽  
Clinical Algorithm ◽  
Susceptibility To Infection ◽  
Inflammatory Bowel ◽  
Endogenous Steroid

Patients with chronic lung disease, inflammatory bowel disease, rheumatoid arthritis, and solid-organ transplantations are often on steroid supplementation either intermittently or chronically. Endogenous steroid use results in decreased adrenocorticotropic hormone secretion by the pituitary gland through negative feedback mechanisms. Over several weeks, this can result in adrenal gland atrophy, eventually leading to secondary adrenal insufficiency. Appropriate management of perioperative glucocorticoid replacement therapy can be challenging, but appropriate replacement is essential to optimize patient outcomes. Insufficient dosing of glucocorticoids during the perioperative period can result in hypotension and even death. Excessive treatment with glucocorticoids decreases wound healing, increases the risk of hyperglycemia, and increases susceptibility to infection. This review covers the historical perspective, the hypothalamic-pituitary-adrenal (HPA) axis, when to suspect an impaired HPA axis, an argument against supraphysiologic glucocorticoid treatment in the perioperative period, the rationale for treating patients with impaired renal function, guidelines for dosing glucocorticoids in the perioperative period, and consulting a specialist. Figures show a clinical algorithm for evaluation and treatment of adrenal insufficiency in the perioperative period and the HPA axis. Tables list steroid conversions and perioperative glucocorticoid treatment recommendations.   This review contains 2 highly rendered figures, 2 tables, and 22 references.

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