Secondary Adrenal Insufficiency: Recent Updates and New Directions for Diagnosis and Management

Optimal functioning of hypothalamic-pituitary-adrenal axis after cessation of prednisolone therapy: a cross-sectional study in children with nephrotic syndrome

BACKGROUND

Hypothalamic-pituitary-adrenal (HPA) axis recovery after cessation of steroid therapy in children with nephrotic syndrome (NS) has hardly been studied in the literature.

METHODS

This 22-month cross-sectional study recruited children (2-14 years) with NS, having received a minimum 3 months of prednisolone, now in remission, and off steroids for 1, 3, or 6 months. Serum cortisol-basal and stimulated (with long-acting intramuscular adrenocorticotropic hormone), and factors affecting them, were assessed. Low basal and stimulated cortisol were taken as < 138 nmol/L and < 500 nmol/L, respectively.

RESULTS

Of 80 (60 males) children, median (IQR) age 64 (43, 91.7) months, most were infrequently relapsing (34; 42.5%) or had a single episode of NS (35; 43.8%). As per duration since discontinuation, 23 (28.8%), 35 (43.8%), and 22 (27.4%) children were off steroids for 1, 3, and 6 months, respectively. Overall, 8 (10%) and 26 (32.5%) had low basal and stimulated cortisol levels, respectively. Proportions of children with HPA axis suppression (low peak cortisol) were 9/23 (39%), 12/35 (34%), and 5/22 (23%) in the groups off steroids for 1, 3, and 6 months, respectively. Optimal peak cortisol level, indicating adrenal recovery, was independently associated with duration since cessation of prednisolone [odds ratio (6 months vs. 1 month) was 10.07 (95%CI 1.46 to 69.51); P = 0.019] and basal cortisol levels > 138 nmol/L (odds ratio 25.0 (95%CI 2.94 to 200); P = 0.03).

CONCLUSIONS

Nearly two-thirds of children with mild courses of NS demonstrate optimal HPA axis function between 1 and 6 months post cessation of steroids. Duration since cessation and basal cortisol independently predict optimal adrenal response.

Diagnosis and management of immune checkpoint inhibitor-associated adrenal insufficiency: A single-institution experience

BackgroundImmune checkpoint inhibitor (ICI) therapy has revolutionized the treatment of various malignancies. Unfortunately, ICI therapy has been associated with multiple immune related adverse events (irAEs) resulting in organ damage. One rare, but potentially devastating side effect, is adrenal insufficiency.MethodsA retrospective analysis of all patients receiving anti-PD-1/PD-L1 or anti-CTLA-4 therapy at Gundersen Health System from 2011 to 2023 was conducted.ResultsPatients (n = 684) receiving anti-PD-1/anti-PD-L1/anti-CTLA-4 therapy at Gundersen Health System were included in our retrospective analysis. There were eleven (1.6%) patients that were diagnosed with an adrenal irAE after beginning immunotherapy. The median days from first treatment to diagnosis of irAE was 304 days. Most common symptoms at the time of onset included fatigue (82%) and syncope (36%). Five patients (45%) required treatment delay or cessation and eight (73%) patients were referred to endocrinology after original diagnosis.DiscussionDetection of adrenal insufficiency secondary to immunotherapy requires a degree of high suspicion. Given the potential significant morbidity and mortality associated with adrenalitis/adrenal insufficiency, prompt diagnosis is of the utmost importance. Liberal use of early morning/8 am cortisol screening should be implemented as a standard part of clinical work up in acute onset of fatigue, hypotension, fever, weakness, weight loss, dehydration, oral intolerance, gastrointestinal upset, hyponatremia, and hyperkalemia. Immunotherapy related adrenal insufficiency is a rare complication, with most cases being secondary adrenal insufficiency. Multidisciplinary care with oncology and endocrinology is an important aspect of comprehensive management.

Reassessing the Role of Morning Cortisol in Adrenal Insufficiency Diagnosis: Insights from a Multicentric Cohort

The diagnosis of adrenal insufficiency (AI) is challenging due to nonspecific symptoms. Measuring 8 AM serum cortisol levels is a common screening test, but its accuracy in predicting AI remains uncertain. This study aimed to evaluate the predictive diagnostic value of basal morning cortisol levels in suspected AI cases and compare them with levels in healthy individuals. We have conducted a retrospective multicentric cohort study. The study included an epidemiological cohort (patients with AI suspicion) and a control cohort (healthy volunteers). In the epidemiological cohort an ACTH-stimulation test was performed to confirm (AI group) or exclude (non-AI group) the disease. We have included 273 individuals (168 suspected AI cases and 105 controls). Basal cortisol levels were higher in the control group compared to the AI-suspected group (9.9±3.2 μg/dl vs. 7.7±3.3 μg/dl, p<0.001), though both were below the 15 μg/dl recommended threshold for excluding AI. Within the epidemiological cohort, even after a propensity score matching, taking into consideration sex, age and AI symptoms complaints, no significant difference in basal cortisol levels was found between patients with and without AI [6.10 (4.43; 8.45) vs. 7.14 (4.68; 12.15), p=0.128]. Logistic regression and ROC curve analyses showed a low predictive value for basal cortisol, with a positive predictive value of 18.9% and low specificity. AI patients more frequently experienced hypotension and nausea, compared with non-AI patients. Morning cortisol levels alone are unreliable for diagnosing AI. Revising cortisol cutoffs and incorporating symptom-based criteria may improve diagnostic accuracy.

Hypopituitarism presenting with cardiovascular manifestations: a case report

Hypopituitarism is a rare condition that can be particularly challenging to diagnose in individuals aged 65 and older. It is characterized by a reduced production of one or more hormones by the pituitary gland, resulting in a deficiency of the hormones that normally regulate various bodily functions. While hypopituitarism can affect multiple systems in the body, it is uncommon for it to present with cardiovascular symptoms. This rarity often leads to the condition being overlooked in clinical practice. Therefore, healthcare professionals must maintain a high level of suspicion for hypopituitarism to ensure timely diagnosis and appropriate management. In this study, we present a case of hypopituitarism caused by a tumor in the sellar region, which uniquely manifested with cardiovascular symptoms.

An Update on Advances in Hypopituitarism: Etiology, Diagnosis, and Current Management

This article provides an updated review of hypopituitarism (HP), an endocrine disorder characterized by a deficiency of one or more pituitary hormones. The various etiologies are reviewed, including pituitary neuroendocrine tumors (PitNETs), hypothalamic lesions, genetic mutations, and acquired factors such as head trauma, medications, neoplasms, and infiltrative diseases. It is noted that PitNETs are responsible for approximately half of the cases in adults, whereas in children the causes are predominantly congenital. Diagnosis is based on clinical evaluation and hormonal testing, with identification of the specific hormonal deficiencies essential for effective treatment. Laboratory tests present challenges and limitations that must be understood and addressed. Hormone replacement therapy is the mainstay of treatment, significantly improving patients' quality of life. It is important to know the possible interactions between hormone replacement therapies in HP. Recent advances in understanding the pathophysiology of HP and the importance of a multidisciplinary approach to the management of associated complications are discussed. This article emphasizes the need for comprehensive evaluation and continuous follow-up to optimize outcomes in patients with HP and highlights the importance of ongoing research to improve diagnostic and treatment strategies.

A Retrospective Study on Weaning Glucocorticoids and Recovery of the Hypothalamic-Pituitary-Adrenal Axis

CONTEXT

Glucocorticoids suppress the hypothalamic-pituitary-adrenal (HPA) axis, resulting in tertiary adrenal insufficiency (AI). When weaning patients off glucocorticoids there is no consensus on whether to maintain patients on prednisolone or convert to hydrocortisone.

OBJECTIVE

To investigate HPA axis recovery in patients on long-term prednisolone and assess outcome after hydrocortisone conversion.

METHODS

This was a retrospective cohort study at an outpatient endocrine steroid clinic. Patients were on long-term prednisolone and referred for HPA axis testing between 2015 and 2022. The main outcomes measured were (1) HPA axis recovery rate in patients on prednisolone demonstrated by a normal adrenocorticotrophic hormone (ACTH) stimulation test (AST) and (2) HPA axis recovery rate subanalysis of dose-matched patients with confirmed tertiary AI on prednisolone or hydrocortisone were measured.

RESULTS

In total, 206 patients on prednisolone were tested for tertiary AI. Of these, 176 remained on prednisolone while 30 were converted to hydrocortisone. The overall HPA axis recovery rate for patients on prednisolone after interval testing was 137/206 (66.5%). The HPA axis recovery rate in dose-matched prednisolone and hydrocortisone conversion groups was 7/10 (70%) and 2/13 (15%) (P = .008), respectively. There was no difference in mean (SD) age (67.1 [12.2] vs 63.4 [11.1] years; P = .464) and baseline cortisol (5.3 [4.2] vs 4.6 [3.1] µg/dL; P = .648) and median [interquartile, IQR] glucocorticoid duration (1213 [1114] vs 2316 [4808] days; P = .693) and baseline ACTH (20.5 [29.0] vs 16.3 [14.8] ng/L; P = .905) between dose-matched prednisolone and hydrocortisone groups. Follow-up duration in the prednisolone group was significantly lower (median [IQR] 348 [975] vs 667 [884] days; P = .012).

CONCLUSION

Patients with glucocorticoid-induced AI maintained on once-daily prednisolone can recover HPA axis function when weaning. There is no apparent advantage to recover HPA axis function in converting to multiple-dosing hydrocortisone.

Whole blood transcriptomic signature of Cushing's syndrome

OBJECTIVE

Cushing's syndrome is characterized by high morbidity and mortality with high interindividual variability. Easily measurable biomarkers, in addition to the hormone assays currently used for diagnosis, could reflect the individual biological impact of glucocorticoids. The aim of this study is to identify such biomarkers through the analysis of whole blood transcriptome.

DESIGN

Whole blood transcriptome was evaluated in 57 samples from patients with overt Cushing's syndrome, mild Cushing's syndrome, eucortisolism, and adrenal insufficiency. Samples were randomly split into a training cohort to set up a Cushing's transcriptomic signature and a validation cohort to assess this signature.

METHODS

Total RNA was obtained from whole blood samples and sequenced on a NovaSeq 6000 System (Illumina). Both unsupervised (principal component analysis) and supervised (Limma) methods were used to explore the transcriptome profile. Ridge regression was used to build a Cushing's transcriptome predictor.

RESULTS

The transcriptomic profile discriminated samples with overt Cushing's syndrome. Genes mostly associated with overt Cushing's syndrome were enriched in pathways related to immunity, particularly neutrophil activation. A prediction model of 1500 genes built on the training cohort demonstrated its discriminating value in the validation cohort (accuracy .82) and remained significant in a multivariate model including the neutrophil proportion (P = .002). Expression of FKBP5, a single gene both overexpressed in Cushing's syndrome and implied in the glucocorticoid receptor signaling, could also predict Cushing's syndrome (accuracy .76).

CONCLUSIONS

Whole blood transcriptome reflects the circulating levels of glucocorticoids. FKBP5 expression could be a nonhormonal marker of Cushing's syndrome.

Alkindi Sprinkle for Pediatric Patients With Primary Adrenocortical Insufficiency: A Narrative Review

Adrenocortical insufficiency, also known as adrenal insufficiency (AI), is an endocrine disorder characterized by inadequate production of adrenal hormones, including glucocorticoids and mineralocorticoids (MCs). The condition can be categorized as primary, secondary, or tertiary AI, depending on the location of the defect. Classical symptoms of AI include weakness, fatigue, abdominal pain, tachycardia, hypotension, electrolyte imbalances, and hyperpigmentation. In children, the most common cause of AI is classical congenital adrenal hyperplasia, which results from a deficiency in the 21-hydroxylase enzyme. The 21-hydroxylase enzyme produces all steroids, such as cortisol and aldosterone. AI management primarily involves hormone replacement therapy, typically with oral hydrocortisone and MC supplementation. However, the administration of hydrocortisone to pediatric patients presents challenges related to the lack of available dose-appropriate formulations. Historically, crushed or split adult tablets were used for the pediatric treatment of AI, although this poses an increased risk of under- or overtreatment. Inadequate dosing in the pediatric population can adversely affect growth, development, and metabolic health. Alkindi Sprinkle is a pediatric-specific hydrocortisone oral granule preparation that manages cortisol levels to help facilitate accurate therapeutic dosing. Alkindi offers several advantages, including accurate dosing, taste masking, and ease of administration. The present investigation describes AI, the management of AI, and the treatment of pediatric AI using Alkindi Sprinkle, including clinical efficacy.

Incidence of Fatigue Following Dexamethasone Administration for Supportive Therapy and Efficacy of Tapering in Perioperative Chemotherapy for Breast Cancer: A Retrospective Observational Study

In perioperative chemotherapy for breast cancer, dexamethasone (DEX) is administered at high dose to prevent adverse effects. Abrupt cessation of high-dose DEX treatment induces fatigue, but the incidence of the fatigue is uncertain. In this study, we retrospectively evaluated the incidence of fatigue following DEX administration for supportive therapy and the improvement of fatigue with DEX tapering, a gradual reduction of the daily dose, in breast cancer patients. The subjects were 124 patients with breast cancer receiving epirubicin- or docetaxel-based regimens as perioperative chemotherapy. Of all patients, 16.1% of patients experienced fatigue after cessation of DEX administration. The severity of fatigue was grade 1 in 6.5% of patients, grade 2 in 8.1% of patients, and grade 3 in 1.6% of patients. There were no significant differences in dose and duration of DEX administration between the group with fatigue and the group without fatigue. In almost all patients with fatigue, DEX tapering was performed from the next cycle. The efficacy of DEX tapering was evaluated by comparing the grade and subjective symptoms. Following DEX tapering, the severity of fatigue was significantly reduced (p < 0.05), and the subjective symptom was improved in 94.7% of patients. Therefore, fatigue is occasionally induced after the cessation of DEX administration for supportive therapy in breast cancer patients. The tapering of DEX may be effective for fatigue.

Clinical characteristics and treatment efficacy of immune checkpoint inhibitors (ICIs) in patients with ICIs-induced Adrenal insufficiency

BACKGROUND

Adrenal insufficiency (AI) caused by immune checkpoint inhibitors (ICIs) is an extremely rare immune-related adverse event (irAE). The detailed clinical characteristics and outcomes of patients with ICI-induced AI are unavailable. This study aimed to explore the clinical characteristics and efficacy of treatment in patients with ICI-induced AI.

METHODS

We retrospectively collected information on patients diagnosed with AI caused by ICIs at LiShui Municipal Central Hospital and Zhejiang Cancer Hospital, including baseline characteristics, laboratory results, symptoms, treatment outcomes of AI, and hormone use. Survival outcomes were calculated using the Kaplan-Meier method and stratified according to the different situations.

RESULTS

From December 2020 to February 2023, among 1014 patients treated with ICI therapy, a total of twenty patients were diagnosed with ICI-induced AI. Most of the patients were men (80%, n = 16), with a performance status (PS) of 0 - 1 (95%, n = 19). The median (range) age was 65.9 (49-80) years and 14 patients (70%) were treated with ICIs as first-line therapy. The majority of the patients (70%, n = 14) experienced grade 3 - 4 AI. All patients received corticosteroid replacement therapy, and only 7 patients recovered. The median time to the diagnosis of AI after starting ICI therapy was 5.2 (3.0 - 7.5) months. The objective response rate was 70% and  median progression-free survival in these patients was 16.0 months (95% confidence interval: 11.7 - 20.3 months).

CONCLUSIONS

ICI-induced AI is a rare irAE, and close monitoring of cortisol levels is important. Patients diagnosed with AI after receiving immunotherapy seem to have a favorable outcome.

When Stress Is Not the Only Culprit: A Case of Secondary Adrenal Insufficiency in a Young Patient With Graves' Disease

This case report underscores the significance of maintaining a broad list of differential diagnoses, including adrenal insufficiency, when evaluating patients who present with recurring episodes of hypotension and generalized fatigue. It further underscores that T3 thyrotoxicosis can manifest as the initial and sole presenting feature of Graves' disease. Finally, it emphasizes the critical importance of employing a multidisciplinary approach to discharge high-risk patients from the hospital to minimize the risk of acute decompensation.

Adrenal Failure: An Evidence-Based Diagnostic Approach

The diagnosis of adrenal insufficiency (AI) requires a high index of suspicion, detailed clinical assessment including detailed drug history, and appropriate laboratory evaluation. The clinical characteristics of adrenal insufficiency vary according to the cause, and the presentation may be myriad, e.g. insidious onset to a catastrophic adrenal crisis presenting with circulatory shock and coma. Secondary adrenal insufficiency (SAI) often presents with only glucocorticoid deficiency because aldosterone production, which is controlled by the renin angiotensin system, is usually intact, and rarely presents with an adrenal crisis. Measurements of the basal serum cortisol at 8 am (<140 nmol/L or 5 mcg/dL) coupled with adrenocorticotrophin (ACTH) remain the initial tests of choice. The cosyntropin stimulation (short synacthen) test is used for the confirmation of the diagnosis. Newer highly specific cortisol assays have reduced the cut-off points for cortisol in the diagnosis of AI. The salivary cortisol test is increasingly being used in conditions associated with abnormal cortisol binding globulin (CBG) levels such as pregnancy. Children and infants require lower doses of cosyntropin for testing. 21-hydoxylase antibodies are routinely evaluated to rule out autoimmunity, the absence of which would require secondary causes of adrenal insufficiency to be ruled out. Testing the hypothalamic-pituitary-adrenal (HPA) axis, imaging, and ruling out systemic causes are necessary for the diagnosis of AI. Cancer treatment with immune checkpoint inhibitors (ICI) is an emerging cause of both primary AI and SAI and requires close follow up. Several antibodies are being implicated, but more clarity is required. We update the diagnostic evaluation of AI in this evidence-based review.

Endocrine side effects of immune checkpoint inhibitors

Immune checkpoint inhibitors (ICIs) have increasingly been the mainstay of treatment for numerous malignancies. However, due to their association with autoimmunity, ICIs have resulted in a variety of side effects that involve multiple organs including the endocrine system. In this review article, we describe our current understanding of the autoimmune endocrinopathies as a result of the use of ICIs. We will review the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of the most commonly encountered endocrinopathies, including thyroiditis, hypophysitis, Type 1 diabetes, adrenalitis, and central diabetes insipidus.

A Closer Look at Opioid-Induced Adrenal Insufficiency: A Narrative Review

Among several opioid-associated endocrinopathies, opioid-associated adrenal insufficiency (OIAI) is both common and not well understood by most clinicians, particularly those outside of endocrine specialization. OIAI is secondary to long-term opioid use and differs from primary adrenal insufficiency. Beyond chronic opioid use, risk factors for OIAI are not well known. OIAI can be diagnosed by a variety of tests, such as the morning cortisol test, but cutoff values are not well established and it is estimated that only about 10% of patients with OIAI will ever be properly diagnosed. This may be dangerous, as OIAI can lead to a potentially life-threatening adrenal crisis. OIAI can be treated and for patients who must continue opioid therapy, it can be clinically managed. OIAI resolves with opioid cessation. Better guidance for diagnosis and treatment is urgently needed, particularly in light of the fact that 5% of the United States population has a prescription for chronic opioid therapy.

Development and Resolution of Secondary Adrenal Insufficiency after an Intra-Articular Steroid Injection

Corticosteroid injections are commonly indicated in inflammatory conditions involving the soft tissues, tendon sheaths, bursae, and joints. Local corticosteroids carry a lower risk of complications than systemic corticosteroid but may be systemically absorbed and subsequently suppress the hypothalamic-pituitary-adrenal (HPA) axis. This can cause secondary adrenal insufficiency (SAI) as well as iatrogenic Cushing's syndrome. We report a 78-year-old female who presented with nonspecific gastrointestinal symptoms after a recent intra-articular steroid injection in her shoulder. She had hyponatremia, low morning cortisol, and failed to respond to high-dose cosyntropin. Further workup revealed the underlying cause to be SAI. Follow-up testing revealed a recovery of HPA responsiveness within 2 weeks of her initial diagnosis. Conclusion. Our case highlights how the hypothalamic-pituitary axis (HPA) can be suppressed with intra-articular steroids. The threshold to test corticosteroid users for adrenal insufficiency should be low in clinical practice, especially for those patients with nonspecific symptoms after steroid injections. Once diagnosed, temporary treatment with steroids may be required.

Quality of Life in Patients with Adrenal Insufficiency

Patients with adrenal insufficiency, despite standard glucocorticoid replacement therapy, continue to experience and report impaired self-perceived health status and quality of life. In this review, we will describe quality of life in this patient population, and summarize the determinants of quality of life, based on previous survey-based studies and clinical trials. In addition, some new emerging data during the still ongoing coronavirus disease pandemic are also reviewed in the present article.

New Diagnostic Cutoffs for Adrenal Insufficiency after Cosyntropin Stimulation using Abbott Architect Cortisol Immunoassay

INTRODUCTION

Accurate interpretation of the cosyntropin (ACTH) stimulation test requires method and assay-specific cutoffs of cortisol. Compared with the historical cutoff (18 μg/dL) from polyclonal antibody-based immunoassays, lower thresholds were proposed for the Roche Elecsys II assay that uses a monoclonal antibody. However, cutoffs for other commonly adopted monoclonal antibody-based cortisol assays were not yet available. Here we established the cortisol thresholds specific to the Abbott Architect immunoassay by comparing cortisol measurements on three immunoassays.

METHODS

The ACTH stimulation test was performed in patients with suspected adrenal insufficiency (AI) (n=50). Serum cortisol was measured with Abbott Architect, Roche Elecsys II, and Siemens Centaur assays. Results from Abbott were also compared with those from liquid chromatography-tandem mass spectrometry (LC-MS/MS). Receiver operating characteristic (ROC) analysis was performed to derive new diagnostic thresholds for the Abbott assay using polyclonal antibody-based Siemens assay as the reference method.

RESULTS

Cortisol measurements on Abbott were similar to those from LC-MS/MS and Roche Elecsys II, but significantly lower than Siemens. The optimized cortisol thresholds on Abbott were 14.6 μg/dL at 60 minutes after stimulation (sensitivity 92%; specificity 96%) and 13.2 μg/dL at 30 minutes (sensitivity 100%; specificity 89%).

CONCLUSION

We recommend a cortisol threshold of 14.6 μg/dL at 60 minutes post ACTH stimulation for the Abbott assay. In comparison to the historical threshold of 18 μg/dL, applying the new cutoff may significantly decrease false positive results from ACTH stimulation testing. Using assay-specific cutoffs will be essential to reduce misclassification and overtreatment in patients with suspected AI.