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Monge Chacón AG, Wang C, Waqar D, Syeda SA, Kumar R, Meghana DR. Long-Term Usage of Oral Glucocorticoids Leading to Adrenal Insufficiency: A Comprehensive Review of the Literature. Cureus 2023; 15:e38948. [PMID: 37309331 PMCID: PMC10257969 DOI: 10.7759/cureus.38948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/14/2023] Open
Abstract
Systemic glucocorticoid therapy is used worldwide by one to three percent of the general population and 0.5-1.8% on long-term oral glucocorticoid use. It is widely used in conditions such as inflammation, autoimmune diseases, and cancer to inhibit inflammatory responses. One of the possible undesirable side effects of exogenous corticosteroid treatment is adrenal suppression upon discontinuation of the medication and adrenal insufficiency after utilizing the supraphysiologic doses for more than one month. To prevent patients from the unwanted signs and symptoms of adrenal insufficiency, including fatigue, gastrointestinal upset, anorexia/weight loss, etc., better management of the quantity and frequency of exogenous corticosteroid use, as well as better education before starting its use, is needed. For patients actively on exogenous corticosteroids, a close follow-up must be in place to avoid adrenal suppression after the eventual discontinuation of their use. This review article summarizes the important studies to date on this subject, especially oral glucocorticoid use, and analyzes risks such as dose, duration of exposure, and comorbidities of adrenal insufficiency associated with oral glucocorticoid use. We comprehensively include information on those with primary adrenal insufficiency and pediatric patients, hoping to provide better insight and clinical reference.
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Affiliation(s)
| | - Chen Wang
- Medicine, China Medical University, Taichung, TWN
| | - Danish Waqar
- Internal Medicine, Nephrology, Loyola University Medical Center, Chicago, USA
| | | | - Rohan Kumar
- Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
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Prevalence of post-glucose challenge hypoglycemia in adult patients with cystic fibrosis and relevance to the risk of cystic fibrosis-related diabetes. Can J Diabetes 2021; 46:294-301.e2. [DOI: 10.1016/j.jcjd.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/18/2021] [Accepted: 11/09/2021] [Indexed: 11/22/2022]
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Abstract
Synthetic glucocorticoids are widely used for their anti-inflammatory and immunosuppressive actions. A possible unwanted effect of glucocorticoid treatment is suppression of the hypothalamic-pituitary-adrenal axis, which can lead to adrenal insufficiency. Factors affecting the risk of glucocorticoid induced adrenal insufficiency (GI-AI) include the duration of glucocorticoid therapy, mode of administration, glucocorticoid dose and potency, concomitant drugs that interfere with glucocorticoid metabolism, and individual susceptibility. Patients with exogenous glucocorticoid use may develop features of Cushing's syndrome and, subsequently, glucocorticoid withdrawal syndrome when the treatment is tapered down. Symptoms of glucocorticoid withdrawal can overlap with those of the underlying disorder, as well as of GI-AI. A careful approach to the glucocorticoid taper and appropriate patient counseling are needed to assure a successful taper. Glucocorticoid therapy should not be completely stopped until recovery of adrenal function is achieved. In this review, we discuss the factors affecting the risk of GI-AI, propose a regimen for the glucocorticoid taper, and make suggestions for assessment of adrenal function recovery. We also describe current gaps in the management of patients with GI-AI and make suggestions for an approach to the glucocorticoid withdrawal syndrome, chronic management of glucocorticoid therapy, and education on GI-AI for patients and providers.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Darukhanavala A, Kremer T. Automatic referrals within a cystic fibrosis multidisciplinary clinic improve patient evaluation and management. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2021; 24:100259. [PMID: 34195009 PMCID: PMC8237349 DOI: 10.1016/j.jcte.2021.100259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/26/2021] [Accepted: 06/09/2021] [Indexed: 11/23/2022]
Abstract
AUTOMATIC REFERRALS WITHIN A CYSTIC FIBROSIS MULTIDISCIPLINARY CLINIC IMPROVE PATIENT EVALUATION AND MANAGEMENT. Background Cystic fibrosis (CF) affects multiple systems beyond the pulmonary system, including the gastrointestinal and endocrine systems. Many CF clinics focus on pulmonary effects, initiating referrals to other specialties only when a condition has been identified by the primary pulmonary team. Unfortunately, many extrapulmonary manifestations of cystic fibrosis may be overlooked. Thus, implementing a multidisciplinary clinic with automatic referrals to designated subspecialists may improve patient care. Methods This retrospective review of medical records examined the effects of integrating a pediatric endocrinologist into the University of Massachusetts Memorial Medical Center Pediatric CF Clinic in March 2017. In this new CF/Endocrinology clinic, all patients scheduled to see a pulmonologist were automatically referred to pediatric endocrinology. We compared rates of referrals to pediatric endocrinology, oral glucose tolerance tests (OGTTs), and bone density (DEXA) scans before (2013–2016) and after (2017–2020) implementation of this clinic. We also recorded endocrine disorders being evaluated and/or treated after implementation. Results The rate of referral to pediatric endocrinology increased from before (4%) to after (82%) (p < 0.0001) implementation of the CF/Endocrinology Clinic. OGTT and DEXA scan screening rates also increased from 7% to 65% (p < 0.0001) and from 6% to 63% (p = 0.0011), respectively. Before implementation, patients were evaluated by endocrinology primarily for CF-related diabetes. After implementation, the diversity of endocrine conditions under evaluation and/or management increased substantially; the most common were vitamin D insufficiency/deficiency (37.2% of clinic patients), glycemic dysregulation (36.8%), and poor weight gain/failure to thrive (17.5%). Conclusion Implementing a multidisciplinary CF clinic with automatic referrals to pediatric endocrinology improves patient care by promoting early detection and management of endocrine concerns that may have been overlooked and by increasing OGTT and DEXA screening rates.
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Affiliation(s)
- Amy Darukhanavala
- Department of Pediatric Endocrinology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Ted Kremer
- Department of Pediatric Pulmonology, University of Massachusetts Medical Center, Worcester, MA, USA
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Rayas MS, Kelly A, Hughan KS, Daley T, Zangen D. Adrenal function in cystic fibrosis. J Cyst Fibros 2020; 18 Suppl 2:S74-S81. [PMID: 31679732 DOI: 10.1016/j.jcf.2019.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 11/18/2022]
Abstract
Cystic fibrosis (CF) is not known to directly affect the adrenal gland, but commonly used CF therapies do impact the function of the hypothalamic-pituitary-adrenal (HPA) axis. By binding to the glucocorticoid receptor, medications such as inhaled and oral corticosteroids can enhance the systemic effects of cortisol and result in iatrogenic Cushing syndrome. Prolonged use suppresses the body's ability to make cortisol, resulting in iatrogenic adrenal insufficiency upon medication discontinuation. Chronic use of inhaled and oral corticosteroids can negatively affect bone health, growth, and glucose metabolism. This chapter provides practical guidelines regarding the screening, diagnosis, and treatment of iatrogenic adrenal insufficiency. As the guidelines are mainly derived from the asthma literature, this chapter also highlights the need for studies to evaluate the impact of CF therapies on adrenal function and other CF-endocrinopathies.
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Affiliation(s)
- Maria Socorro Rayas
- Division of Pediatric Endocrinology and Diabetes, University of Texas Health San Antonio, 7703 Floyd Curl, San Antonio, TX 78229, USA.
| | - Andrea Kelly
- Division of Pediatric Endocrinology and Diabetes, Children's Hospital of Philadelphia, Perelman School of Medicine of University of Pennsylvania, 2716 South Street, Philadelphia, PA 19146, USA.
| | - Kara S Hughan
- Division of Pediatric Endocrinology and Diabetes, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Tanicia Daley
- Division of Pediatric Endocrinology and Metabolism, Emory Children's Center/Emory Pediatric Institute, Emory University School of Medicine, 1400 Tullie Road, Atlanta, GA 30329, USA.
| | - David Zangen
- Division of Pediatric Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem 91240, Israel.
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Standardized clinical criteria and sweat test combined as a tool to diagnose Cystic Fibrosis. Heliyon 2018; 4:e01050. [PMID: 30582056 PMCID: PMC6299035 DOI: 10.1016/j.heliyon.2018.e01050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/29/2018] [Accepted: 12/11/2018] [Indexed: 11/23/2022] Open
Abstract
Context CF is under-diagnosed in Ecuador; one out of every 11,252 live births born in Ecuador could have CF. Aim To analyze the clinical findings, based on previously established criteria, with the results of the sweat test, in circumstances where we do not have the routine molecular study. Methods Epidemiological, observational, analytic, cross-sectional study. It analyzed 180 patients clinically suspected of CF. Inclusion criteria: children of both sexes older than 30 days and younger than 12 years, who meet at least three clinical criteria suggestive for CF, outpatient and referred by a specialist physician who made a preliminary diagnosis. This is a pilot study. Results The combination of criteria pneumonia, chronic cough and chronic obstructive bronchial syndrome is the most frequent, with not a significant relationship with a positive sweat test. On the contrary, a significant relationship was found between the clinical combinations of pneumonia with cough and rhinosinusitis; pneumonia with cough; presence of Pseudomonas aeruginosa; and pneumonia with digital cough and clubbing, so it is recommended to perform the test in all these associations. The most frequent clinical criterion for the reference and performance of the electrolyte test in sweat is pneumonia to repeat for two or more episodes. Conclusion Clinical combinations of pneumonia with cough and rhinosinusitis; pneumonia with cough; presence of Pseudomonas aeruginosa; and pneumonia with digital cough and clubbing are pathognomonic for CF and indication for the sweat test. The predictive performance in CF diagnosis, defined as compatible clinical presence plus high values of chloride in sweat test, was 91.1%.
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Regard L, Martin C, Chassagnon G, Burgel PR. Acute and chronic non-pulmonary complications in adults with cystic fibrosis. Expert Rev Respir Med 2018; 13:23-38. [PMID: 30472915 DOI: 10.1080/17476348.2019.1552832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Cystic fibrosis (CF) is a genetic disease that primarily affects the respiratory system and often leads to respiratory failure and premature death. Although pulmonary complications contribute to 85% of deaths, non-pulmonary complications are responsible for significant morbidity and mortality in adults with CF. Areas covered: This review summarizes acute and chronic non-pulmonary complications in CF patients, with emphasis on emerging complications and in the context of the current growth and aging of the CF adult population. It also addresses the potential benefits of CF transmembrane conductance regulator modulator therapy. Complications that occur after solid organ (e.g. lung and/or liver) transplantation have been excluded. The review is based on an extensive search of the available literature, using PubMed and international guidelines, and on the authors' clinical experience. Expert commentary: Acute non-pulmonary complications have been well described but should be recognized and managed carefully. Managing chronic non-pulmonary complications is an important and changing aspect of CF patient care, particularly with the emergence of novel complications in adults. Early detection of non-pulmonary complications is essential to the development of prevention and treatment strategies that aim to further improve the survival and health status of adult CF patients.
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Affiliation(s)
- Lucile Regard
- a Faculté de Médecine , Paris Descartes University , Sorbonne Paris Cité , Paris , France.,b Pulmonology Department , Cochin Hospital, AP-HP , Paris , France
| | - Clémence Martin
- a Faculté de Médecine , Paris Descartes University , Sorbonne Paris Cité , Paris , France.,b Pulmonology Department , Cochin Hospital, AP-HP , Paris , France
| | - Guillaume Chassagnon
- a Faculté de Médecine , Paris Descartes University , Sorbonne Paris Cité , Paris , France.,c Radiology Department , Cochin Hospital, AP-HP , Paris , France
| | - Pierre-Régis Burgel
- a Faculté de Médecine , Paris Descartes University , Sorbonne Paris Cité , Paris , France.,b Pulmonology Department , Cochin Hospital, AP-HP , Paris , France
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Regard L, Lafoeste H, Martin C, Chassagnon G, Burgel PR. [Ageing with cystic fibrosis: Classical and emerging comorbidities in adults with cystic fibrosis]. REVUE DE PNEUMOLOGIE CLINIQUE 2018; 74:279-291. [PMID: 30316653 DOI: 10.1016/j.pneumo.2018.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Cystic fibrosis (CF) is a genetic disease with pulmonary involvement being predominant and often leading to respiratory failure and premature death. Non-pulmonary complications related to CF transmembrane conductance regulator (CFTR) defect are numerous and account for significant morbidity (exocrine pancreatic insufficiency, diabetes, CF-related liver disease, chronic sinusitis, osteoporosis). Improvement in patients' care led to a continuous increase in life expectancy, with a subsequent increase in the number of adult CF patients worldwide. Increased life expectancy comes with increased prevalence of CF-related comorbidities, but also with new emerging complications directly related to ageing (chronic kidney disease, cardiovascular risk factors, cancers). CFTR modulators might also contribute to modify the face of CF epidemiology and prognosis. Ageing with CF has become a challenge for CF patients and caregivers. This review summarizes classic and emerging comorbidities in the context of current growth and ageing of the CF population. It also addresses potential roles of CFTR modulators.
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Affiliation(s)
- L Regard
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - H Lafoeste
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - C Martin
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - G Chassagnon
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service d'imagerie médicale, hôpital Cochin, AP-HP, 75014 Paris, France
| | - P-R Burgel
- Université Paris Descartes, Sorbonne Paris cité, 75006 Paris, France; Service de pneumologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France.
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