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Feng Y, Chang P, Liu J, Zhang WS. Effects and mechanisms of perioperative medications on the hypothalamic pituitary adrenal response to surgical injury: A narrative review. J Clin Anesth 2024; 94:111367. [PMID: 38232466 DOI: 10.1016/j.jclinane.2023.111367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 11/30/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024]
Abstract
The adrenal gland is a vital endocrine organ, and adrenal steroid synthesis and secretion are closely regulated by the hypothalamic-pituitary-adrenal (HPA) axis in response to various stimuli. Surgery or trauma can activate the HPA axis and induce the secretion of cortisol. Different cortisol responses vary with the grade of surgery. Perioperative medications have the potential to decrease the cortisol level in the body, and both excessive and insufficient cortisol levels after surgery are disadvantageous. The effect of perioperative medications on the HPA response to surgery can be divided into three levels: "adrenal insufficiency (AI)", "stress response inhibition", and "uncertainty". The clinical presentation of AI includes fatigue, nausea, vomiting, abdominal pain, muscle cramps, hypotension, hypovolemic shock and prerenal failure, which may result in fatal consequences. Stress response inhibition can reduce postoperative complications, such as pain and cognitive dysfunction. This is protective to patients during perioperative and postoperative periods. The aim of the present review is to shed light on current evidence regarding the exact effects and mechanisms of perioperative medications on the HPA response to surgical injury and provide the applicable guidance on clinical anesthesia.
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Affiliation(s)
- Yan Feng
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, China; Department of Anesthesiology, West China Hospital, Sichuan University, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, China
| | - Pan Chang
- Department of Anesthesiology, West China Hospital, Sichuan University, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, China
| | - Wen-Sheng Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, China.
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Cushman DM, Kobayashi JK, Wheelwright JC, English J, Monson N, Teramoto M, Dunn R, Lash M, Zarate M. Prospective Evaluation of Pain Flares and Time Until Pain Relief Following Musculoskeletal Corticosteroid Injections. Sports Health 2023; 15:227-233. [PMID: 35331061 PMCID: PMC9950997 DOI: 10.1177/19417381221076470] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Corticosteroid injections are used ubiquitously within musculoskeletal medicine. One of the most common side effects is a postinjection pain flare, though little is known regarding this phenomenon. HYPOTHESIS Some risk factors are related to postinjection pain flare following an ultrasound-guided corticosteroid injection. STUDY DESIGN Prospective clinical research study. LEVEL OF EVIDENCE Level 2. METHODS Patients undergoing ultrasound-guided corticosteroid injections in an academic orthopaedic and sports medicine clinic were approached to participate. Patients completed a survey immediately following their injection and again 2 weeks later, asking them about their pain and side effects. A postinjection pain flare was defined as an increase in pain, as defined by the patient. RESULTS A total of 140 patients completed the entirety of the study, with 29 (20.7%) patients reporting a flare of pain. There was a significant effect of younger age on the development of a pain flare after the injection, estimated as 5.5% decreased odds of developing a flare per year of age (P < 0.01). Gender, injection location, body mass index (BMI), preinjection pain, and corticosteroid type had no contributing effect. When patients obtained relief following the corticosteroid injection, 60.4% had improved pain within 3 days, whereas over 93.7% obtained relief within a week. CONCLUSION Pain flares seem to affect approximately 1 in 5 patients. With increasing age, the likelihood of postinjection pain flare becomes less likely. Sex, injection location, BMI, preinjection pain, and corticosteroid type do not seem to significantly relate to an increase in pain following injection. CLINICAL RELEVANCE Corticosteroid injections are common procedures in the orthopaedic and sports medicine settings. Younger patients can be counseled on the higher likelihood of a pain flare following a corticosteroid injection.
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Affiliation(s)
- Daniel M. Cushman
- Daniel M. Cushman, MD,
University of Utah, 590 Wakara Way, Salt Lake City, UT 84108 (
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Vicentini JRT, Habibollahi S, Staffa SJ, Simeone FJ, Kheterpal AB, Graeber AR, Bredella MA, Chang CY. Relationship of Imaging-guided Corticosteroid Injections to COVID-19 Incidence in the Pandemic Recovery Period. Radiology 2022; 306:237-243. [PMID: 35787202 PMCID: PMC9341274 DOI: 10.1148/radiol.220271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Corticosteroids injected for the treatment of musculoskeletal pain are systemically absorbed and can affect the immune response to viral infections. Purpose To determine the incidence of symptomatic COVID-19 disease in individuals receiving image-guided corticosteroid injections for musculoskeletal pain compared with the general population during the pandemic recovery period. Materials and Methods In this prospective cohort multicenter study, adults with a history of musculoskeletal pain who underwent imaging-guided intra-articular and spine corticosteroid injections from April 2020 to February 2021 were consecutively enrolled. Participants were followed for a minimum of 28 days through their electronic medical record (EMR) or by direct phone communication to screen for COVID-19 test results or symptoms. Clinical data, including body mass index (BMI), were also obtained from the EMR. The incidence of COVID-19 in the state was obtained using the Massachusetts COVID-19 Response Reporting website. The Student t test was used for continuous variable comparisons. Univariable analyses were performed using the Fisher exact test. Results A total of 2714 corticosteroid injections were performed in 2190 adult participants (mean age, 59 years ± 15 [SD]; 1031 women). Follow-up was available for 1960 participants (89%) who received 2484 injections. Follow-up occurred a mean of 97 days ± 33 (range, 28-141 days) after the injection. Of the 1960 participants, 10 had COVID-19 within 28 days from the injection (0.5% [95% CI: 0.24, 0.94]) and 43 had COVID-19 up to 4 months after the injection (2.2% [95% CI: 1.6, 2.9]). These incidence rates were lower than that of the population of Massachusetts during the same period (519 195 of 6 892 503 [7.5%], P < .001 for both 28 days and 4 months). Participants diagnosed with COVID-19 (n = 10) within 28 days from the injection had a higher BMI than the entire cohort (n = 1960) (mean, 32 kg/m2 ± 10 vs 28 kg/m2 ± 6; P = .04). Conclusion Adults who received image-guided corticosteroid injections for pain management during the pandemic recovery period had a lower incidence of symptomatic COVID-19 compared with the general population. © RSNA, 2022 Online supplemental material is available for this article.
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Affiliation(s)
- Joao R. T. Vicentini
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Sina Habibollahi
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Steven J. Staffa
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Frank J. Simeone
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Arvin B. Kheterpal
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Adam R. Graeber
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Miriam A. Bredella
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Connie Y. Chang
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
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Whelan G, Sim J, Smith B, Moffatt M, Littlewood C. Are Corticosteroid Injections Associated With Secondary Adrenal Insufficiency in Adults With Musculoskeletal Pain? A Systematic Review and Meta-analysis of Prospective Studies. Clin Orthop Relat Res 2022; 480:1061-1074. [PMID: 35302533 PMCID: PMC9263464 DOI: 10.1097/corr.0000000000002145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/28/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Corticosteroid injection is a common treatment for individuals experiencing musculoskeletal pain, and it is part of the management of numerous orthopaedic conditions. However, there is concern about offering corticosteroid injections for musculoskeletal pain because of the possibility of secondary adrenal insufficiency. QUESTIONS/PURPOSES In this systematic review and meta-analysis of prospective studies, we asked: (1) Are corticosteroid injections associated with secondary adrenal insufficiency as measured by 7-day morning serum cortisol? (2) Does this association differ depending on whether the shot was administered in the spine or the appendicular skeleton? METHODS We searched the Allied and Complementary Medicine (AMED), Embase, EmCare, MEDLINE, CINAHL, and Web of Science from inception to January 22, 2021. We retrieved 4303 unique records, of which 17 were eventually included. Study appraisal was via the Downs and Black tool, with an average quality rating of fair. A Grading of Recommendations, Assessment, Development, and Evaluations assessment was conducted with the overall certainty of evidence being low to moderate. Reflecting heterogeneity in the study estimates, a pooled random-effects estimate of cortisol levels 7 days after corticosteroid injection was calculated. Fifteen studies or subgroups (254 participants) provided appropriate estimates for statistical pooling. A total of 106 participants received a spine injection, and 148 participants received an appendicular skeleton injection, including the glenohumeral joint, subacromial bursa, trochanteric bursa, and knee. RESULTS Seven days after corticosteroid injection, the mean morning serum cortisol was 212 nmol/L (95% confidence interval 133 to 290), suggesting that secondary adrenal insufficiency was a possible outcome. There is a difference in the secondary adrenal insufficiency risk depending on whether the injection was in the spine or the appendicular skeleton. For spinal injection, the mean cortisol was 98 nmol/L (95% CI 48 to 149), suggesting secondary adrenal insufficiency was likely. For appendicular skeleton injection the mean cortisol was 311 nmol/L (95% CI 213 to 409) suggesting hypothalamic-pituitary-adrenal axis integrity was likely. CONCLUSION Clinicians offering spinal injections should discuss the possibility of short-term secondary adrenal insufficiency with patients, and together, they can decide whether the treatment remains appropriate and whether mitigation strategies are needed. Clinicians offering appendicular skeleton injections should not limit care because of concerns about secondary adrenal insufficiency based on the best available evidence, and clinical guidelines could be reviewed accordingly. Further research is needed to understand whether age and/or sex determine risk of secondary adrenal insufficiency and what clinical impact secondary adrenal insufficiency has on patients undergoing spinal injection. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Gareth Whelan
- Musculoskeletal Department, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Julius Sim
- School of Medicine, Keele University, Keele, UK
| | - Benjamin Smith
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK; Rehabilitation & Ageing Research Group, Injury, Inflammation and Recovery Sciences, School of Medicine, University of Nottingham, UK
| | - Maria Moffatt
- Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
| | - Chris Littlewood
- Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
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Symptomatic COVID-19 infections in outpatient image-guided corticosteroid injection patients during the lockdown phase. Skeletal Radiol 2021; 50:1117-1123. [PMID: 33108512 PMCID: PMC7590247 DOI: 10.1007/s00256-020-03656-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/28/2020] [Accepted: 10/16/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Musculoskeletal pain is a debilitating problem treated with image-guided corticosteroid injections. During the COVID-19 pandemic, multiple societies issued caution statements because of the unknown effect of corticosteroids on the patient's immune system. The purpose is to determine if image-guided corticosteroid injections administered during the COVID-19 lockdown phase were associated with a higher infection rate compared to the general population. MATERIALS AND METHODS In a prospective study, patients undergoing image-guided corticosteroid injections for pain management during the lockdown phase between April 15 and May 22, 2020, were enrolled. One month after the injection, patients were surveyed by telephone for any COVID-19-related symptoms, and the electronic medical record (EMR) was reviewed for symptoms and test results. RESULTS Seventy-one subjects were recruited, 31 (44%) females, 40 (56%) males, ages 58 ± 17 (20-92) years. Follow-up was available in 66 (93%) of subjects, 60 (91%) by phone survey and EMR, 6 (9%) by EMR only, 45 ± 22 (19-83) days after injection. One (1/66, 1.52%; 95% CI 0.04-8.2%) 25-year-old male subject developed symptomatic infection 19 days after a tibiotalar injection. The prevalence of COVID-19 cases in the state of Massachusetts was 0.91% (62,726/6,892,503) during the study period. There was no significant difference in the rate of occurrence of new cases of COVID-19 infection between the corticosteroid injection group and the general population (p = 0.44). CONCLUSION Image-guided corticosteroid injections for pain management performed during the lockdown phase of the COVID-19 pandemic were not associated with a higher infection rate compared to the general population.
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Turmel-Roy J, Bédard MA, Millette M, Simonyan D, Proulx-Gauthier JP, Rousseau-Nepton I. Risk of adrenal insufficiency following intra-articular or periarticular corticosteroid injections among children with chronic arthritis. J Pediatr Endocrinol Metab 2020; 33:1257-1263. [PMID: 32845867 DOI: 10.1515/jpem-2020-0219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 07/13/2020] [Indexed: 11/15/2022]
Abstract
Objectives Intra-articular and/or periarticular corticosteroid injection (IACI) is a common procedure in pediatric rheumatology. Despite many adult studies demonstrating a significant risk of adrenal insufficiency (AI) following the procedure, very little evidence is available in the pediatric literature regarding this risk. The main goal of this study is to evaluate the prevalence of AI in children with chronic arthritis following IACI. Methods This is a retrospective study including children aged 0-18 years who had an IACI from June 2017 to July 2019. An 8:00 morning cortisol (8MC) sample was drawn around two weeks after the injection, and an ACTH 1mcg stimulation test was performed if morning cortisol level was low. AI was defined as an 8MC under 50 nmol/L or an abnormal ACTH stimulation test. Risks factors for AI and its duration were assessed. Results Sixty patients were included in this study. AI prevalence was 30% with 18 of 60 affected patients. The corticosteroid dose injected was statistically associated with the development of AI. Median duration of AI was 181 days for the nine patients who were followed up until resolution of AI. Four patients developed symptoms of AI, namely fatigue (2 of 4), nausea (2 of 4) and abdominal pain (3 of 4). None were hospitalized or died. Conclusions In this cohort of children with chronic arthritis who had an IACI, we found a high prevalence of AI. Monitoring and counseling of such complication is warranted until further evidence is available.
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Affiliation(s)
- Justine Turmel-Roy
- Department of Pediatrics, CHU de Québec - Université Laval, Québec, Canada
| | - Marc-Antoine Bédard
- Department of Pediatrics, Division of Pediatric Immunology, CHU Sainte-Justine, Montréal University, Quebec, Canada
| | - Maude Millette
- Department of Pediatrics, Division of Pediatric Endocrinology, CHU de Québec - Université Laval, Québec, Canada
| | | | | | - Isabelle Rousseau-Nepton
- Department of Pediatrics, Division of Pediatric Endocrinology, CHU de Québec - Université Laval, Québec, Canada
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Hamidi N, Ozturk E, Yikilmaz TN, Atmaca AF, Basar H. The effect of corticosteroid on postoperative early pain, renal colic and total analgesic consumption after uncomplicated and unstented ureteroscopy: a matched-pair analysis. World J Urol 2018; 36:979-984. [PMID: 29396787 DOI: 10.1007/s00345-018-2210-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/24/2018] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To evaluate the effect of corticosteroid (CS) on early postoperative pain, renal colic and total analgesic consumption after uncomplicated and unstented ureteroscopy (URS). METHODS Data of 397 patients who underwent URS and stone fragmentation for symptomatic distal ureteral stone (≤ 15 mm) were retrospectively evaluated. After exclusion, 72 patients who received methylprednisolone (Group I) after non-stenting uncomplicated URS were matched with another 72 patients who did not receive CS (Group II). Cases were matched 1:1 ratio and the matched-pair criteria were age, stone diameter, and duration of surgery. RESULTS Both groups were statistically similar in terms of mean age, operative time, stone size and preoperative pain score. However, the mean postoperative pain score was statistically significantly lower in group I than group II on the day of surgery (3.3 ± 1.7 vs. 3.9 ± 1.3, p = 0.012) and postoperative day 1 (2.8 ± 1.8 vs. 3.4 ± 1.3, p = 0.02), respectively. Renal colic episode development rate (4.2 vs. 13.2%, p = 0.036), parenteral analgesic requirement rate (18.1 vs. 33.3%, p = 0.001) and total parenteral analgesic consumption per patient (18 vs. 36mg, p = 0.009) were statistically lower in group I than group II on the day of surgery; however, there were no statistically significant differences on postoperative day 1. There were no statistically significant differences between groups in terms of ureteral stenting requirement and late unplanned urgent room visit rates. CONCLUSIONS Corticosteroid after uncomplicated URS can be offered to reduce early postoperative pain, renal colic episode and total analgesic consumption.
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Affiliation(s)
- Nurullah Hamidi
- Department of Urology, Atatürk Training and Research Hospital, Ankara, Turkey.
| | - Erdem Ozturk
- Department of Urology, Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
| | - Taha Numan Yikilmaz
- Department of Urology, Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
| | - Ali Fuat Atmaca
- Department of Urology, Atatürk Training and Research Hospital, Ankara Yildirim Beyazit University School of Medicine, Ankara, Turkey
| | - Halil Basar
- Department of Urology, Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
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Borresen SW, Klose M, Baslund B, Rasmussen ÅK, Hilsted L, Friis-Hansen L, Locht H, Hansen A, Hetland ML, Lydolph MC, Feldt-Rasmussen U. Adrenal insufficiency is seen in more than one-third of patients during ongoing low-dose prednisolone treatment for rheumatoid arthritis. Eur J Endocrinol 2017; 177:287-295. [PMID: 28877961 DOI: 10.1530/eje-17-0251] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/16/2017] [Accepted: 07/04/2017] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Stina Willemoes Borresen
- Department of Medical Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Klose
- Department of Medical Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Bo Baslund
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Center of Rheumatology and Joint Diseases
| | - Åse Krogh Rasmussen
- Department of Medical Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Linda Hilsted
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lennart Friis-Hansen
- Department of Clinical Biochemistry, Copenhagen University Hospital, Nordsjællands Hospital, Hillerød, Denmark
| | - Henning Locht
- Center of Rheumatology and Joint Diseases, Copenhagen University Hospital, Frederiksberg Hospital, Frederiksberg, Denmark
| | - Annette Hansen
- Center of Rheumatology and Joint Diseases, Copenhagen University Hospital, Gentofte Hospital, Gentofte, Denmark
| | - Merete Lund Hetland
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Center of Rheumatology and Joint Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | | | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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