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Llahana S, Yuen KCJ. Development and validation of a novel treatment adherence, satisfaction and knowledge questionnaire (TASK-Q) for adult patients with hypothalamic-pituitary disorders. Pituitary 2024:10.1007/s11102-024-01425-9. [PMID: 38976180 DOI: 10.1007/s11102-024-01425-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 07/09/2024]
Abstract
PURPOSE Successful treatment outcomes of adults with hypothalamic-pituitary disorders necessitate the adoption of intricate self-management behaviors, yet current scales for evaluating treatment adherence and satisfaction are inadequate for this patient group. This research introduces a novel treatment adherence, satisfaction and knowledge questionnaire (TASK-Q) developed specifically to identify patients' unmet needs in better assessing and managing these disorders. METHODS The study was conducted in three phases: (1) generating items and testing content validity, (2) refining these items through a pilot study, and (3) a main study evaluating the psychometric properties of the TASK-Q scale among 262 adults in a Pituitary Nurse-led Clinic, with 152 (58%) patients completing the questionnaire. RESULTS Exploratory factor analysis was used to test the factor structure and construct validity of the TASK-Q, revealing a 22-item scale divided into Satisfaction and Knowledge (17 items) and Adherence (5 items) subscales, and exhibiting high internal consistency (Cronbach's α = 0.90). Significant correlations were identified between satisfaction and knowledge (r = 0.67, p < 0.001), satisfaction and adherence (r = 0.23, p = 0.005), and knowledge and adherence (r = 0.43, p < 0.001). Complex treatment regimens, like daily growth hormone injections and adjusting glucocorticoids during illness, negatively affected adherence (p < 0.001). CONCLUSION The TASK-Q is a novel validated scale that can effectively evaluate patients' perspectives on adherence, knowledge and satisfaction. Our findings highlight the significant impact of Advanced Nurse Practitioners in improving patient self-management behaviors, which likely leads to better treatment outcomes for people with hypothalamic-pituitary disorders.
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Affiliation(s)
- Sofia Llahana
- School of Health & Psychological Sciences, City, University of London, London, UK.
- Department of Diabetes and Endocrinology, University College London Hospitals National Health Service (NHS) Foundation Trust, London, UK.
| | - Kevin C J Yuen
- Departments of Neuroendocrinology and Neurosurgery Barrow Pituitary Center, Barrow Neurological Institute, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, AZ, USA
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Hee NKY, Lim QH, Paramasivam S, Lim LL, Vethakkan S, Ganapathy SS, Ratnasingam J. The use of prednisolone during Ramadan fasting in patients with adrenal insufficiency. Clin Endocrinol (Oxf) 2024; 100:221-229. [PMID: 38031259 DOI: 10.1111/cen.14999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/24/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE Once daily prednisolone taken at predawn has been proposed to be the glucocorticoid replacement of choice in patients with adrenal insufficiency (AI) who intend to fast for the month of Ramadan. However, the effects of prednisolone on metabolic parameters and quality of life during fasting for Ramadan are unknown. DESIGN, PATIENTS AND MEASUREMENTS Patients with AI on twice-daily hydrocortisone, who had low or moderate risk and intended to fast, were recruited. Patients were converted to prednisolone 5 mg once daily taken at sahur (predawn) and Ramadan education given. Weight, sleep duration, biochemical parameters and quality of life measures (SF-36 questionnaire) were analysed at the end of Ramadan and compared against baseline. RESULTS Twenty patients (13 men) were recruited, with a mean age of 59.9 ± 15.0 years. All patients were on hydrocortisone 15 mg daily (in divided doses) as pre-Ramadan glucocorticoid replacement. Half had type 2 diabetes with low IDF-DAR risk. Eighty-five percent of patients completed the full 29 days of fasting with no complications. There was a significant reduction in weight (-1.1 ± 1.6 kg, p = .005), with no significant change in blood pressure or sleep duration. There was a significant increase in urea (0.80 ± 1.1 mmol/L, p = .005) and haematocrit, (0.011 ± 0.019 L/L, p = .019) and decrease in serum sodium (-1.6 ± 3.0 mmol/L, p = .028), with no change in serum creatinine or liver function. Quality of life measures were preserved in all domains with significant improvement in role limitation due to physical health (15.3 ± 21.6, p = .005) and bodily pain (8.8 ± 16.3, p = .031). CONCLUSIONS This study has demonstrated that converting patients with AI who are fasting for Ramadan from twice-daily hydrocortisone to prednisolone 5 mg daily at sahur was safe, with no major short-term adverse effects. Despite the higher equivalent glucocorticoid doses, patients experienced weight loss and no clinically significant change in blood pressure, sleep, biochemical parameters or quality of life. This study paves the way to trial even lower doses of prednisolone once daily in patients fasting for Ramadan with AI.
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Affiliation(s)
- Nicholas Ken Yoong Hee
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Quan Hziung Lim
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Sharmila Paramasivam
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Lee Ling Lim
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shireene Vethakkan
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shubash Shander Ganapathy
- Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
| | - Jeyakantha Ratnasingam
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
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Yazidi M, Salem MB, Oueslati I, Khessairi N, Chaker F, Chihaoui M. Adherence to glucocorticoid replacement therapy in Addison's disease: Association with patients' disease knowledge and quality of life. ENDOCRINOL DIAB NUTR 2023; 70:532-539. [PMID: 38783727 DOI: 10.1016/j.endien.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/11/2023] [Indexed: 05/25/2024]
Abstract
Little is known about the quality of adherence to glucocorticoid replacement therapy in patients with Addison disease (AD). The aim of this study was to evaluate the quality of glucocorticoid treatment adherence in patients with AD and to assess its association with patients' disease knowledge and quality of life. METHODS This is a cross-sectional study including 58 patients with AD. The Girerd questionnaire was used to assess the quality of adherence to glucocorticoid replacement therapy. A questionnaire was specially designed to assess patients' disease knowledge. The AddiQol questionnaire, specific to AD, was used to assess the patients' quality of life. Patients were considered non-adherent if they gave three or fewer than three negative answers to the Girerd questionnaire (score≤3/6). RESULTS The mean age of the patients was 48.4±13.3 years (39 women and 19 men). Twenty-seven patients (46%) were non-adherent to glucocorticoid replacement therapy. An age below 48 years, poor adherence to comorbidity treatments, baseline cortisolemia at diagnosis>5μg/dl, history of adrenal crisis, poor knowledge about the disease, BMI<26.7kg/m2, waist circumference<90cm, low systolic blood pressure, fasting blood glucose<0.9g/l, and triglyceride<1g/l were the factors independently associated with non-adherence (respectively ORa [CI 95%]=4.8 [2.8-10.7], 5.0 [3.0-12.2], 2.3 [1.2-6.2], 4.1 [2.0-8.3], 3.9 [1.2-7.2], 3.9 [1.1-6.9], 1.8 [1.1-2.9], 4.8 [2.6-8.2], 2.5 [1.1-5.3], and 2.2 [1.1-5.1]). There was a positive correlation between the disease knowledge questionnaire score and the Girerd score (p=0.02, r=0.31). There was a positive correlation between the AddiQoL score and the Girerd score (p=0.01, r=0.32). CONCLUSION Non-adherence to glucocorticoid replacement therapy was common in patients with AD and was associated with more frequent adrenal crisis and poorer quality of life. The quality of treatment adherence was correlated with patients' disease knowledge. Therapeutic education is essential to reduce the frequency of non-adherence, especially among young patients.
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Affiliation(s)
- Meriem Yazidi
- Department of Endocrinology, University of Tunis el Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunisia.
| | - Maram Ben Salem
- Department of Endocrinology, University of Tunis el Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University of Tunis el Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunisia
| | - Nadia Khessairi
- Department of Endocrinology, University of Tunis el Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University of Tunis el Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunisia
| | - Melika Chihaoui
- Department of Endocrinology, University of Tunis el Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunisia
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Beshyah AS, Elamouri JS, Almagdub I, Abdulrahman H, Hafidh K, Beshyah SA. Burden and Patterns of Medical Emergencies during Ramadan Fasting: A Narrative Review. IBNOSINA JOURNAL OF MEDICINE AND BIOMEDICAL SCIENCES 2023. [DOI: 10.1055/s-0043-1764355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
Abstract
Introduction Acute medical problems may occur more frequently during Ramadan fasting (RF). We aimed to provide a narrative overview of the global literature on medical emergencies during RF.
Methods This is a nonsystematic review of the international literature from one major medical online database (PubMed, National Institutes of Health, United States). The relevant literature was narrated in a concise thematic account.
Results There is a variable impact in the burden and time distribution of emergency services and hospitalization during RF that may require readjustment of resource allocation. Studies of the risk of accidents and injuries may be increased overall or at specified times, around Iftar time. A classical impact of emergencies has been the risk of worsening peptic ulcer disease. RF impacts diabetic emergencies such as severe hypoglycemia, hyperglycemia, and diabetic ketoacidosis, particularly in type 1 diabetes and poorly controlled patients. Glucocorticoid replacement therapy may represent a challenge to patients and physicians that require education and dose adjustment. Acute neurological conditions of interest include the “first day of Ramadan headache,” epilepsy, and strokes. Several studies evaluated the risk of the acute coronary syndrome and heart failure with inconsistent findings. RF may impact the renal and urological systems through stone disease, renal colic, and acute kidney. The impact on hematological conditions was mostly focused on the safety of anticoagulant therapy during Ramadan.
Conclusion The review addresses the emergency medical encounters of the fasting patient during Ramadan to allow a holistic and ethnically sensitive approach to medical care under circumstances where decisions have to be taken with no delay.
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Affiliation(s)
- Anas S. Beshyah
- Department of Gastroenterology, Wythenshawe Hospital, Manchester, United Kingdom
| | - Jamila S. Elamouri
- Nephrology Unit, Department of Internal Medicine, Tripoli Central Hospital, Tripoli, Libya
| | - Ihab Almagdub
- Department of Medicine, Sheikh Khalifa Medical City, SEHA, Abu Dhabi, United Arab Emirates
| | - Husen Abdulrahman
- Department of Medicine, Sheikh Khalifa Medical City, SEHA, Abu Dhabi, United Arab Emirates
| | - Khadija Hafidh
- Department of Medicine, Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates
- Department of Medicine, Dubai Medical College for Girls, Dubai, United Arab Emirates
| | - Salem A. Beshyah
- Department of Medicine, Dubai Medical College for Girls, Dubai, United Arab Emirates
- Department of Medicine, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
- Department of Medicine, Yas Clinic Khalifa City, Abu Dhabi, United Arab Emirates
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Mofokeng TRP, Beshyah SA, Ross IL. Characteristics and Challenges of Primary Adrenal Insufficiency in Africa: A Review of the Literature. Int J Endocrinol 2022; 2022:8907864. [PMID: 36060294 PMCID: PMC9433274 DOI: 10.1155/2022/8907864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/28/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUNDS Africa comprises 54 countries with varying degrees of economic development. As with other healthcare systems, rare diseases such as adrenal insufficiency are neglected and poorly documented. OBJECTIVES We wished to explore primary adrenal insufficiency (PAI) in Africa, its prevalence, aetiology, genetics, presentation, diagnosis, and treatment and to determine the unmet needs in clinical care, education, and research. MATERIALS AND METHODS A narrative nonsystematic review of the literature was undertaken. We searched two online databases (PubMed and Google scholar) using the search terms "Addison's disease/PAI, primary adrenal insufficiency coupled with "Africa," "country names," and "genetic disorders." A total of 184 PAI records were reviewed. The exclusion of abstracts, conference proceedings, single case reports, and duplicate studies covering the same subject matter yielded 124 articles, of which 97 informed the final manuscript. RESULTS A wide range of aetiology of PAI was encountered, but their true prevalence is unknown. Aetiology varied with region and age of presentation as reflected by predominantly TB, HIV, and infective causes occurring in sub-Saharan Africa and more congenital forms described in North Africa associated with consanguinity. In Africa, the diagnostic criteria for PAI do not universally accord with conventional criteria, and there is a heavy reliance on clinical suspicion and biochemistry, including random cortisol of <400 nmol/L, rather than the tetracosactide test where stimulated cortisol <500-550 nmol/L confirms the diagnosis. CONCLUSIONS A high index of suspicion is warranted to diagnose PAI in resource-limited settings, especially where tetracosactide tests are not universally available.
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Affiliation(s)
- Thabiso R. P. Mofokeng
- Division of Endocrinology, Department of Medicine, University of the Free State, Bloemfontein, South Africa
| | - Salem A. Beshyah
- Dubai Medical College for Girls, Dubai, UAE
- Yas Clinic Group Hospital, Khalifa City, Abu Dhabi, UAE
| | - Ian L. Ross
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Chihaoui M, Yazidi M, Oueslati I, Khessairi N, Chaker F. Intermittent fasting in adrenal insufficiency patients: a review and guidelines for practice. Endocrine 2021; 74:11-19. [PMID: 34213700 DOI: 10.1007/s12020-021-02804-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
Ramadan fasting is a religious duty for adult Muslims. Even though sick people are exempted from fasting, numerous are those who insist on fasting, and seek advice from their physicians. The role of the physician is to support his patient and preserve his health. However, little is known about intermittent fasting in adrenal insufficiency. The aim of this review was to determine the risks of fasting in patients with adrenal insufficiency, the subjects at risk of complications, and the measures that can be undertaken for safe fasting. The analysis of the data of the different studies showed that there is a risk of complications during fasting in these patients. Optimal glucocorticoid replacement therapy for safe fasting has not yet been determined. Finally, a risk stratification and the modalities of the pre-Ramadan visit for adrenal insufficiency fasting patients have been suggested.
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Affiliation(s)
- Melika Chihaoui
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Meriem Yazidi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Nadia Khessairi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Chihaoui M, Madhi W, Yazidi M, Hammami B, Oueslati I, Khessairi N, Grira W, Bibi A, Feki M, Chaker F. Salivary cortisol levels during Ramadan fasting in hydrocortisone-treated secondary adrenal insufficiency patients. Endocrine 2020; 70:404-411. [PMID: 32789535 DOI: 10.1007/s12020-020-02452-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Patients with adrenal insufficiency have difficulties in fasting during the month of Ramadan with an increased risk of complications. Cortisol levels are unknown in these patients. The objective of this study was to assess the daily cortisol profile in hydrocortisone-treated patients with secondary adrenal insufficiency (SAI) and healthy controls during a fasting day. METHODS A cross-sectional matched case-control study on 50 hydrocortisone-treated SAI patients and 69 controls who are used to fast. Clinical and therapeutic data were collected. Five salivary samples for cortisol measurement were collected throughout a fasting day of the third week of Ramadan 2019. RESULTS Salivary cortisol levels were significantly higher on awakening, at midnight and before the predawn meal in patients compared with controls. The circadian cortisol rhythm was disrupted in patients. The area under the salivary cortisol level versus time curve (AUC) was lower than the 2.5th percentile of the controls in one patient (2.5%) and higher than the 97.5th percentile in 23 patients (59%) who were considered overtreated. Age ≥ 35 years was independently associated with overtreatment (adjusted odds ratio = 12.0; 95% CI (2.0-70.4); p = 0.006). Seven patients broke their fasting for a complication compared with no one of the controls (p = 0.001). No factor was associated with this risk. CONCLUSIONS Salivary cortisol levels were high in fasting hydrocortisone-treated SAI patients with a disruption of the circadian rhythm.
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Affiliation(s)
- Melika Chihaoui
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Wiem Madhi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Bessem Hammami
- Department of Biochemistry, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Nadia Khessairi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Wafa Grira
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Amina Bibi
- Department of Biochemistry, National Institute of Nutrition, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Moncef Feki
- Department of Biochemistry, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Beshyah SA, Ali KF, Saadi HF. Management of adrenal insufficiency during Ramadan fasting: a survey of physicians. Endocr Connect 2020; 9:804-811. [PMID: 32738124 PMCID: PMC7487190 DOI: 10.1530/ec-20-0314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Appropriate dose adjustments of glucocorticoids replacement therapy for adrenal insufficiency (AI) is vital. OBJECTIVE We sought to scope physicians' perceptions, and practices regarding Ramadan fasting (RF) impact on the management of AI. METHODS A web-based survey of a convenience sample of endocrinologists. RESULTS Nearly two-thirds of 145 respondents (64.1%) were adult endocrinologists and almost half (49%) saw more than 10 hypoadrenal patients per year. Most respondents (78.6%) prescribed hydrocortisone, while the minority prescribed other preparations. The glucocorticoid doses were reportedly divided twice daily by 70.8% and thrice daily by 22.2% of respondents. Respondents recognized RF as having potential consequences in adrenal insufficiency patients included causing hypoglycaemia, undue tiredness, and fatigue, hypotension, feeling dizzy, and light-headedness. Symptoms of under-replacement were thought to happen in the late afternoon by 59.3% of respondents. Almost half (45.5%) of respondents thought that RF has some probable or definite impact on glucocorticoid therapy that certainly warrants specific concern and possible action. Three quarters (76.4%) of respondents confirmed providing specific management recommendations during RF. The most frequently reported recommendation was taking in the usual morning dose of hydrocortisone just before pre-dawn meal (Suhor) (57.8%). A third switch patients from hydrocortisone to prednisolone/prednisone. Half reported providing patients with specific recommendations regarding breaking their fast and/or seeking help if hypoadrenal symptoms occur. CONCLUSIONS There is a remarkable variation in the physicians' perceptions and practices regarding the management of AI during Ramadan. This warrants professional effort to increase the awareness and dissemination of evidence-based guidelines.
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Affiliation(s)
- Salem A Beshyah
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
- Diabetes and Endocrine Clinic, Mediclinic Airport Road Hospital, Abu Dhabi, United Arab Emirates
| | - Khawla F Ali
- Department of Medicine, Royal College of Surgeons in Ireland Medical University of Bahrain, Adliya, Bahrain
- Correspondence should be addressed to K F Ali:
| | - Hussein F Saadi
- Department of Endocrinology, Medical Subspecialties Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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Hussain S, Hussain S, Mohammed R, Meeran K, Ghouri N. Fasting with adrenal insufficiency: Practical guidance for healthcare professionals managing patients on steroids during Ramadan. Clin Endocrinol (Oxf) 2020; 93:87-96. [PMID: 32419166 DOI: 10.1111/cen.14250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/24/2023]
Abstract
There are limited recommendations for fasting in many chronic diseases such as adrenal insufficiency (AI). Research in such situations highlights potential for complications and need for education for patients with AI undertaking fasting during Ramadan. This article aimed to provide up-to-date guidance for healthcare professionals to educate, discuss and manage patients with AI who are considering fasting in Ramadan and is religiously compatible. Latest guidance on this topic and the evidence base for steroid dosing are reviewed and discussed. Risk stratification for patients with AI and optimal strategies for management, including steroid dosing, are detailed. Our review highlights that patients with AI wishing to fast should undergo a thorough risk assessment ideally several months before Ramadan. 'High risk' and 'Very high risk' patients should be encouraged to explore alternative options to fasting discussed below. Prior to the commencement of Ramadan, all patients must receive up-to-date education on sick day rules, instructions on when to terminate their fast or abstain from fasting, carry steroid warning information and must have a valid intramuscular (IM) hydrocortisone pack and know how to administer this. Switching patients with AI desiring to fast from multiple daily hydrocortisone replacement to prednisolone 5 mg once daily at dawn (during Suhoor or Sehri) is recommended and discussed. Patients on fludrocortisone for AI should be advised to take their total dose at dawn. We provide practically relevant case-based scenarios to help with the application of this guidance. Future efforts need to focus on healthcare professional awareness and further research in this setting.
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Affiliation(s)
- Sufyan Hussain
- Department of Diabetes and Endocrinology, Guy's and St Thomas' Hospital NHS Trust, London, UK
- Department of Diabetes and Endocrinology, King's College London, London, UK
| | - Shazia Hussain
- Department of Diabetes and Endocrinology, Barts Health NHS Trust, London, UK
| | | | - Karim Meeran
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Imperial College London, London, UK
- Department of Diabetes and Endocrinology, Imperial College London NHS Trust, London, UK
| | - Nazim Ghouri
- Department of Diabetes and Endocrinology, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Queen Elizabeth University Hospital, Glasgow, UK
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Chihaoui M, Grira W, Chaker F, Oueslati I, Ben Amor Z, Yazidi M, Feki M. Blood pressure evaluated by 24 h ambulatory blood pressure monitoring in Ramadan-fasting patients with corticotrope deficiency. Endocrine 2020; 68:210-214. [PMID: 31997149 DOI: 10.1007/s12020-020-02213-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/18/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE The risks of Ramadan fasting on blood pressure (BP) in patients with adrenal insufficiency are unknown. This study aimed to evaluate the levels of BP and particularly the risk for hypotension during a fasting day compared with a nonfasting day in patients with corticotrope deficiency. METHODS A prospective case-crossover study on 28 patients with known and treated corticotrope deficiency who were fasting the month of Ramadan. Clinical (eating and sleeping habits, abnormal symptoms, weight, height, and BP) and paraclinical (creatinine, sodium, and cortisol) data were collected. Patients had a 24 h ambulatory BP monitoring during a Ramadan fasting day then again during a nonfasting day. RESULTS The data of 25 patients were analyzed; 20 women, median age: 40 years (IQR, 22.5-45.5), median duration of the disease: 6 years (IQR, 2.5-12). The prevalence of hypotension did not differ between the fasting day and the nonfasting day. Hour by hour BP levels comparison showed that both systolic and diastolic BP were significantly lower at 2.00 p.m. during fasting. BP variability was significantly lower during the fasting period compared with the same period during the nonfasting day. CONCLUSIONS Fasting was not associated with an increased risk for hypotension in patients with known and treated corticotrope deficiency.
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Affiliation(s)
- Melika Chihaoui
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Wafa Grira
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Zohra Ben Amor
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Moncef Feki
- Department of Biochemistry, Faculty of Medicine of Tunis, University Hospital La Rabta, University of Tunis El Manar, Tunis, Tunisia.
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Tanaka S, Abe M, Kohno G, Kushimoto M, Ikeda J, Ogawa K, Suzuki Y, Ishihara H, Fujishiro M. A Single Episode of Hypoglycemia as a Possible Early Warning Sign of Adrenal Insufficiency. Ther Clin Risk Manag 2020; 16:147-153. [PMID: 32161465 PMCID: PMC7051808 DOI: 10.2147/tcrm.s238435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 02/11/2020] [Indexed: 01/08/2023] Open
Abstract
A 65-year-old woman without a history of diabetes mellitus was admitted for elective total knee arthroplasty for osteoarthrosis. There were no specific complaints except for knee flexion contractures, and the results of preoperative tests were unremarkable. On the day of surgery, the patient suffered from a hypoglycemic attack (52 mg/dL) after preoperative overnight fasting. A dextrose infusion immediately corrected the hypoglycemia, and a total knee arthroplasty was then performed. Although a hypoglycemic attack did not recur, further evaluation was required because of nausea that persisted after surgery. The morning serum cortisol level was 0.15 µg/dL with undetectable adrenocorticotropic hormone (ACTH), and the insulin-like growth factor-1 level was 9 ng/mL. An empty sella and bilateral adrenal atrophy were evident in imaging studies. ACTH and growth hormone (GH) did not respond to testing with corticotropin-releasing hormone and GH-releasing peptide-2, respectively. While serum cortisol did not increase on a rapid ACTH stimulation test, urinary free cortisol excretion responded to a prolonged ACTH stimulation test. Finally, the patient was diagnosed as having empty sella syndrome with ACTH and GH deficiencies. After the administration of hydrocortisone as maintenance replacement therapy, the patient's prolonged postoperative nausea disappeared. Adrenal insufficiency is latent in patients with hypoglycemia episodes. Because patients with adrenal insufficiency require appropriate perioperative corticosteroid supplementation, clinicians should give priority to identifying the underlying etiology of hypoglycemia over non-urgent elective surgery when these co-occur.
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Affiliation(s)
- Sho Tanaka
- Division of Nephrology, Hypertension, and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan.,Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan
| | - Masanori Abe
- Division of Nephrology, Hypertension, and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Genta Kohno
- Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masaru Kushimoto
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan
| | - Jin Ikeda
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan
| | - Katsuhiko Ogawa
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan.,Division of Neurology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yutaka Suzuki
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan.,Division of Neurology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hisamitsu Ishihara
- Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Midori Fujishiro
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan.,Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
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Chihaoui M, Mimita W, Oueslati I, Rejeb O, Ben Amor Z, Grira W, Yazidi M, Chaker F. Prednisolone or hydrocortisone replacement in patients with corticotrope deficiency fasting during Ramadan result in similar risks of complications and quality of life: a randomized double-blind controlled trial. Endocrine 2020; 67:155-160. [PMID: 31552584 DOI: 10.1007/s12020-019-02082-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 09/03/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The aims of the study were to compare the risk of complications and the quality of life in patients with corticotrope deficiency, who fasted during Ramadan. Both hydrocortisone and prednisolone were compared as treatments. METHODS A randomized double-blind crossover clinical trial conducted in the department of Endocrinology of the University Hospital la Rabta in Tunis, during Ramadan 2018, on 53 patients with known corticotrope deficiency treated with hydrocortisone 20 mg per day and who were willing to fast during Ramadan. Patients were randomized into two groups; AB that received hydrocortisone twice daily for 14 days then prednisolone once daily with a placebo for 14 days and group BA that received the two treatments in the reverse order. Patients had to complete a daily follow-up sheet about their eating and sleeping habits, the occurrence of complications and blood glucose monitoring and also to respond to the AddiQoL questionnaire at the end of each treatment period. RESULTS Fifty patients' data were analyzed; 29 men, mean age: 42.4 ± 13.3 years, mean duration of the disease: 8.1 ± 7.6 years. The frequency of complications, mean blood glucose levels and the quality of life did not differ on hydrocortisone compared to prednisolone after adjustment for the sequence of the treatment. CONCLUSIONS the risks of Ramadan fasting in patients with corticotrope deficiency were the same on hydrocortisone or prednisolone.
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Affiliation(s)
- Melika Chihaoui
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Wafa Mimita
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ons Rejeb
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Zohra Ben Amor
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Wafa Grira
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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13
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Chihaoui M, Grira W, Bettaieb J, Yazidi M, Chaker F, Rejeb O, Oueslati I, Feki M, Kaabachi N, Slimane H. The risk for hypoglycemia during Ramadan fasting in patients with adrenal insufficiency. Nutrition 2017; 45:99-103. [PMID: 29129244 DOI: 10.1016/j.nut.2017.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/03/2017] [Accepted: 07/22/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The risk for hypoglycemia during Ramadan fasting in patients with adrenal insufficiency (AI) is not fully known. The aims of this study were to evaluate this risk objectively and to determine the associated factors. METHODS This prospective case-crossover study included 25 women and 5 men with known and treated AI and a median age of 38.5 y. Patients underwent clinical examination and a fasting blood sample was collected to measure glucose, urea, creatinine, sodium, potassium, cortisol, growth hormone and free thyroxine. A 24-h continuous glucose monitoring system (CGMS) using iPro2 (Medtronic, Parsippany, NJ, USA) with Enlite sensor (Medtronic) was performed for each patient during a Ramadan fasting day then again during a nonfasting day. RESULTS Interstitial glucose levels during the 24-h period, the fasting period, and the fasting period after exclusion of the 5 postprandial hours were significantly lower during the fasting day than on the nonfasting day. Hypoglycemia occurred in three patients (10%) during the fasting day but not during the nonfasting day (P = 0.23). Hypoglycemia was asymptomatic in two cases. Male sex was significantly associated with the occurrence of hypoglycemia. CONCLUSION Interstitial glucose levels were lower during fasting in patients with AI. However, the risk for hypoglycemia was not increased.
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Affiliation(s)
- Melika Chihaoui
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia.
| | - Wafa Grira
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Jihene Bettaieb
- Department of Medical Epidemiology, University of Tunis El Manar, Faculty of Medicine of Tunis, Pasteur Institute of Tunis, Tunis, Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Ons Rejeb
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Moncef Feki
- Department of Biochemistry, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Naziha Kaabachi
- Department of Biochemistry, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Hedia Slimane
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
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14
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Debono M. Fasting during the ramadan: a challenge for patients with adrenal insufficiency. Endocrine 2017; 57:196-198. [PMID: 28528508 DOI: 10.1007/s12020-017-1329-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/12/2017] [Indexed: 01/09/2023]
Affiliation(s)
- Miguel Debono
- Consultant in Endocrinology and Honorary Senior Lecturer, Department of Endocrinology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals/University of Sheffield, Sheffield, UK.
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