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Martel-Duguech L, Poirier J, Bourdeau I, Lacroix A. Diagnosis and management of secondary adrenal crisis. Rev Endocr Metab Disord 2024; 25:619-637. [PMID: 38411891 DOI: 10.1007/s11154-024-09877-x] [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] [Accepted: 02/17/2024] [Indexed: 02/28/2024]
Abstract
Adrenal crisis (AC) is a life threatening acute adrenal insufficiency (AI) episode which can occur in patients with primary AI but also secondary AI (SAI), tertiary AI (TAI) and iatrogenic AI (IAI). In SAI, TAI and IAI, AC may develop when the HPA axis is unable to mount an adequate glucocorticoid response to severe stress due to pituitary or hypothalamic disruption. It manifests as an acute deterioration in multi-organ homeostasis that, if untreated, leads to shock and death. Despite the availability of effective preventive strategies, its prevalence is increasing in patients with SAI, TAI and IAI due to more frequent exogenous steroid administration, pituitary immune-related effects of immune checkpoint inhibitors and opioid use in pain management. The delayed diagnosis of acute AI which remains infrequently suspected increases the risk of AC. Its main precipitating factors are infections, emotional distress, surgery, cessation or reduction in GC doses, pituitary infarction or surgical cure of endogenous Cushing's syndrome. In patients not known previously to have SAI/TAI/IAI, recognition of its symptoms, signs, and biochemical abnormalities can be challenging and cause delay in proper diagnosis and therapy. Effective therapy of AC is rapid intravenous administration of hydrocortisone (initial bolus of 100 mg followed by 200 mg/24 h as continuous infusion or bolus of 50 mg every 6 h) and 0.9% saline. In diagnosed patients, preventive education in sick-day rules adjustment of glucocorticoid replacement and hydrocortisone parenteral self-administration must be performed repeatedly by trained health care providers. Strategies to improve the adequate preventive education in patients at risk for secondary AI should be promoted in collaboration with various medical specialist societies and patients support associations.
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Affiliation(s)
- Luciana Martel-Duguech
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - Jonathan Poirier
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), 900 Saint-Denis Street, Montréal, QC H2X 0A9, Québec, Canada.
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Einarsdottir MJ, Trimpou P, Johannsson G, Ragnarsson O. Undiagnosed adrenal insufficiency as a cause of premature death in glucocorticoid users. Endocr Connect 2024; 13:e230535. [PMID: 38428141 PMCID: PMC10959030 DOI: 10.1530/ec-23-0535] [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] [Received: 12/18/2023] [Accepted: 02/29/2024] [Indexed: 03/03/2024]
Abstract
Objective It is unknown whether glucocorticoid (GC)-induced adrenal insufficiency may cause premature mortality in GC users. We conducted a retrospective cohort study to investigate if undiagnosed and undertreated GC-induced adrenal insufficiency is a contributor to premature death in GC users. Methods Information on dispensed prescriptions in West Sweden from 2007 to 2014 was obtained from the Swedish Prescribed Drug Register. Cause of death was collected from the Swedish Cause of Death Register. Of 223,211 patients who received oral GC prescriptions, 665 died from sepsis within 6 months of their last prescription. Three hundred of these patients who had died in hospital were randomly selected for further investigation. Medical records were initially reviewed by one investigator. Furthermore, two additional investigators reviewed the medical records of patients whose deaths were suspected to be caused by GC-induced adrenal insufficiency. Results Of 300 patients (121 females, 40%), 212 (75%) were prescribed GC treatment at admission. The mean age was 76 ± 11 years (range 30-99). Undiagnosed or undertreated GC-induced adrenal insufficiency was considered a probable contributor to death by at least two investigators in 11 (3.7%) patients. In five of these 11 cases, long-term GC therapy was abruptly discontinued during hospitalization. Undiagnosed or undertreated GC-induced adrenal insufficiency was considered a possible contributing factor to death in a further 36 (12%) patients. Conclusion GC-induced adrenal insufficiency is an important contributor to premature death in GC users. Awareness of the disorder during intercurrent illness and following cessation of GC treatment is essential.
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Affiliation(s)
- Margret J Einarsdottir
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Penelope Trimpou
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Center for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
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Baek SW, Noh JH, Heo YS. Prevalence of Adrenal Insufficiency in Korean Patients undergoing Total Knee Arthroplasty. Ann Geriatr Med Res 2024; 28:20-26. [PMID: 37984965 PMCID: PMC10982440 DOI: 10.4235/agmr.23.0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/29/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND This study investigated the prevalence of adrenal insufficiency among patients admitted for total knee arthroplasty (TKA) due to osteoarthritis and identified factors contributing to adrenal insufficiency. METHODS We divided the patients into two groups based on the results of preoperative standard-dose short synchronous stimulation tests: group 1 (adrenal insufficiency) and group 2 (normal adrenal function). We also assessed the prevalence of adrenal insufficiency and compared the numbers of patients who received oral steroids, the frequency of previous steroid injection use, and the frequency of systemic symptoms of steroid depletion such as fatigue and loss of appetite between the two groups. Multiple regression analysis was performed to identify factors related to adrenal insufficiency. RESULTS The prevalence of adrenal insufficiency was 60.0% (120/200). Group 1 had higher numbers of previous steroid injections (12.8±10.2 vs. 6.8±7.9) and patients taking oral steroids (18/120 vs. 3/80) (p<0.001 and p=0.011, respectively). The frequency of systemic symptoms of steroid depletion, such as fatigue and loss of appetite, was also higher in group 1 (94/120 vs. 42/80, p<0.001). Recent steroid injections and loss of appetite were associated with adrenal insufficiency (p=0.002 and p=0.009, respectively). CONCLUSION The results of this study revealed a high prevalence of adrenal insufficiency in Korean patients hospitalized for TKA due to end-stage osteoarthritis. Recent steroid injections were causally related to the development of adrenal insufficiency. Therefore, adrenal function should be assessed preoperatively to prevent postoperative complications related to adrenal insufficiency.
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Affiliation(s)
- So Won Baek
- Nursing Department, Kangwon National University Hospital, Chuncheon, Republic of Korea
| | - Jung Ho Noh
- Department of Orthopaedic Surgery, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Yeon Sik Heo
- Department of Orthopaedic Surgery, Kangwon National University Hospital, Chuncheon, Republic of Korea
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Willett AC, Hartman E, Chandler N, Brown J. Asymptomatic trigger of adrenal crisis in a patient with Sheehan syndrome: importance of timely recognition and intervention. BMJ Case Rep 2023; 16:e257023. [PMID: 38103900 PMCID: PMC10728928 DOI: 10.1136/bcr-2023-257023] [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] [Indexed: 12/19/2023] Open
Abstract
Our patient is a female in her 70s who initially presented following an episode of bowel and bladder incontinence, as well as unresponsiveness. Her family denied any preceding illness or sick symptoms. During her workup, it was noted that she was wearing a medical bracelet, which listed prednisone as one of her daily medications, raising concern for an acute adrenal crisis (AC). Ultimately, our patient's condition improved with high-dose intravenous steroids before being tapered to her home regimen. Current literature highlights the pathophysiological complexity of an AC but fails to identify clear risk factors that trigger such events, especially in asymptomatic patients. Accordingly, our case highlights this gap, arguing the importance of appropriate patient education and timely intervention for such clinically ambiguous yet life-threatening presentations.
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Affiliation(s)
- Andrew Charles Willett
- School of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Emily Hartman
- School of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Natasha Chandler
- School of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Julianna Brown
- School of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Knowles G, Warmington E, Shepherd LM, Hazlehurst JM, de Bray A, Gleeson H, Arlt W, Prete A. Impact of coronavirus disease 2019 on patients with primary adrenal insufficiency: a cross-sectional study. Endocr Connect 2023; 12:e230122. [PMID: 37253239 PMCID: PMC10388655 DOI: 10.1530/ec-23-0122] [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] [Received: 04/02/2023] [Accepted: 05/26/2023] [Indexed: 06/01/2023]
Abstract
Objective Patients with primary adrenal insufficiency (PAI) are thought to be particularly vulnerable to coronavirus disease 2019 (COVID-19); however, little is known about its true impact on this group. We assessed morbidity and health promotion attitudes during the pandemic amongst a large cohort of patients with PAI. Design Cross-sectional, single-centre study. Methods In May 2020, COVID-19 advice on social distancing and sick-day rules was distributed to all patients with PAI registered with a large secondary/tertiary care centre. A semi-structured questionnaire was used to survey patients in early 2021. Results Of 207 contacted patients, 162 responded (82/111 with Addison's disease, AD; 80/96 with congenital adrenal hyperplasia, CAH). Patients with AD were older than those with CAH (median age 51 vs 39 years; P < 0.001) and had more comorbidities (Charlson comorbidity index ≥2 47.6% vs 10.0%; P< 0.001). By the time of the survey, 47 patients (29.0%) had been diagnosed with COVID-19, the second commonest cause of sick-day dosing during the study and the leading trigger of adrenal crises (4/18 cases). Patients with CAH had a higher risk of COVID-19 compared to AD (adjusted odds ratio 2.53 (95% CI 1.07-6.16), P= 0.036), were less inclined to have the COVID-19 vaccine (80.0% vs 96.3%; P = 0.001), and were less likely to have undergone hydrocortisone self-injection training (80.0% vs 91.5%; P = 0.044) or wear medical alert jewellery (36.3% vs 64.6%; P = 0.001). Conclusions COVID-19 was a principal trigger for adrenal crises and sick-day dosing in patients with PAI. Despite a higher risk of COVID-19, patients with CAH showed less engagement with self-protective attitudes. Significance statement We conducted a cross-sectional study on a large and well-characterised group of patients with PAI and demonstrated that COVID-19 was a leading cause of morbidity during the early phases of the pandemic. Patients with AD were older and had a greater burden of comorbidity than those with CAH, including non-adrenal autoimmune disorders. However, patients with CAH were more likely to develop COVID-19 and demonstrated reduced engagement with healthcare services and health promotion strategies.
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Affiliation(s)
| | - Emily Warmington
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Lisa M Shepherd
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Jonathan M Hazlehurst
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Anne de Bray
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Helena Gleeson
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Wiebke Arlt
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Medical Research Council London Institute of Medical Sciences, London, UK
| | - Alessandro Prete
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Llahana S, Mulligan K, Hirani SP, Wilson S, Baldeweg SE, Grossman A, Norton C, Sharman P, McBride P, Newman S. Using the behaviour change wheel and person-based approach to develop a digital self-management intervention for patients with adrenal insufficiency: the Support AI study protocol. Front Endocrinol (Lausanne) 2023; 14:1207715. [PMID: 37455898 PMCID: PMC10349524 DOI: 10.3389/fendo.2023.1207715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/30/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction Most patients with Adrenal insufficiency (AI) require lifelong glucocorticoid replacement. They need to increase glucocorticoids during physical illness or major stressful situations and require parenteral hydrocortisone in the event of an adrenal crisis. Patients with AI have impaired quality of life and high mortality; approximately 1 in 6-12 patients are hospitalised at least once/year from a potentially preventable adrenal crisis. Adoption of self-management behaviours are crucial; these include adherence to medication, following "sick day rules" and associated behaviours that aid prevention and treatment of adrenal crisis such as symptom monitoring, having extra tablets, carrying a medical-alert ID and injection kit, and self-injecting when necessary. Current patient education is ineffective at supporting self-management behaviour change or reducing adrenal crisis-related hospitalisations. This research study aims to gain an in-depth understanding of the barriers and enablers to self-management for patients with AI and to develop an evidence-based digital self-management behaviour change intervention. Methods The study is conducted in accordance with the MRC Framework for developing complex interventions. Underpinned by the Behaviour Change Wheel (BCW), the Theoretical Domains Framework (TDF), and the Person-Based Approach, this research will be conducted in two phases: Phase 1 will involve a sequential qualitative/quantitative mixed-methods study involving focus group interviews followed by a cross-sectional survey with patients with AI recruited from patient advocacy groups and endocrine clinics in the UK. Phase 2 will develop the Support AI, a website-based digital behaviour change intervention (DBCI) informed by Phase 1 findings to support self-management for patients with AI. The most appropriate behaviour change techniques (BCTs) will be selected utilising a nominal group technique with an Expert Panel of 10-15 key stakeholders. The design of the Support AI website will be guided by the Person-Based Approach using an Agile iterative "think-aloud" technique with 12-15 participants over 3 usability testing iterations. Conclusion A theory- and evidence-based digital behaviour change intervention will be developed which will be tested in a feasibility randomised trial following completion of this study. The projected benefit includes cost-effective health care service (reduced hospitalisations and demand for specialist services) and improved health outcomes and quality of life for patients with AI.
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Affiliation(s)
- Sofia Llahana
- School of Health & Psychological Sciences, City, University of London, London, United Kingdom
- Department of Diabetes and Endocrinology, University College London Hospitals National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Kathleen Mulligan
- School of Health & Psychological Sciences, City, University of London, London, United Kingdom
- Community Health Newham, East London National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Shashivadan P. Hirani
- School of Health & Psychological Sciences, City, University of London, London, United Kingdom
| | - Stephanie Wilson
- Centre for Human Computer Interaction (HCI) Design, School of Science and Technology, City, University of London, London, United Kingdom
| | - Stephanie E. Baldeweg
- Department of Diabetes and Endocrinology, University College London Hospitals National Health Service (NHS) Foundation Trust, London, United Kingdom
- Centre for Obesity and Metabolism, Department of Experimental and Translational Medicine, Division of Medicine, University College London, London, United Kingdom
| | - Ashley Grossman
- Neuroendocrine Tumour (NET) Unit, Royal Free Hospital, London, United Kingdom
- Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, United Kingdom
| | - Philippa Sharman
- The Addison’s Disease Self-Help Group Patient Advocacy Group, Bristol, United Kingdom
| | - Pat McBride
- The Pituitary Foundation Patient Advocacy Group, Bristol, United Kingdom
| | - Stanton Newman
- School of Health & Psychological Sciences, City, University of London, London, United Kingdom
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Rushworth RL, Torpy DJ. The Changing Epidemiology of Adrenal Insufficiency: Iatrogenic Factors Predominate. J Endocr Soc 2023; 7:bvad017. [PMID: 36777466 PMCID: PMC9909161 DOI: 10.1210/jendso/bvad017] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Indexed: 02/01/2023] Open
Abstract
Context Adrenal insufficiency (AI)-related morbidity persists despite efforts to minimize its effect. Reasons for this are unknown and warrant examination. Objective This work aimed to investigate trends in AI hospitalizations and glucocorticoid (GC) replacement therapy use. Methods Data on hospitalizations for a principal diagnosis of AI and prescriptions for short-acting GCs between 2000 and 2019 were extracted from national repositories. Age-standardized admission and prescription rates were calculated using census data. Rates were compared over time overall and according to age, sex, and disease subtype. Results AI admissions increased by 62.0%, from 36.78/million to 59.59/million (trend P < .0001). Adrenal crisis (AC) admissions also increased, by 90.1% (from 10.73/million to 20.40/million; trend, P < .00001). These increases were more pronounced in the second decade. Prescriptions for short-acting GCs also increased (by 67.2%, from 2198.36/million in 2000/2001 to 3676.00/million in 2017/2018). Females had higher average admission rates and a greater increase in admission rates than males. Increased AI admissions were found in all age groups among females but only in men aged 70+ yrs. Secondary AI (SAI) admission rates increased by 91.7%, whereas admission rates for primary AI (PAI) remained unchanged. Conclusion The prevalence of AI and hospitalizations for this disorder (including ACs) have increased since 2000, with a greater increase occurring after 2010. Admission rates for SAI increased but PAI admissions remained stable. Possible causes include immunotherapies for malignancy, increased cranial imaging detecting pituitary tumors and their subsequent treatment, and increased use of low-dose, short-acting GC-replacement therapy.
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Affiliation(s)
- R Louise Rushworth
- Correspondence: R. Louise Rushworth, MBBS, PhD, School of Medicine Sydney, The University of Notre Dame, Australia, 160 Oxford St, Darlinghurst, NSW 2010, Australia.
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia 5000, Australia
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Rushworth RL, Chrisp GL, Bownes S, Torpy DJ, Falhammar H. Adrenal crises in adolescents and young adults. Endocrine 2022; 77:1-10. [PMID: 35583847 PMCID: PMC9242908 DOI: 10.1007/s12020-022-03070-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/03/2022] [Indexed: 12/19/2022]
Abstract
PURPOSE Review the literature concerning adrenal insufficiency (AI) and adrenal crisis (AC) in adolescents and young adults. METHODS Searches of PubMed identifying relevant reports up to March 2022. RESULTS AI is rare disorder that requires lifelong glucocorticoid replacement therapy and is associated with substantial morbidity and occasional mortality among adolescents and young adults. Aetiologies in this age group are more commonly congenital, with acquired causes, resulting from tumours in the hypothalamic-pituitary area and autoimmune adrenalitis among others, increasing with age. All patients with AI are at risk of AC, which have an estimated incidence of 6 to 8 ACs/100 patient years. Prevention of ACs includes use of educational interventions to achieve competency in dose escalation and parenteral glucocorticoid administration during times of physiological stress, such as an intercurrent infection. While the incidence of AI/AC in young children and adults has been documented, there are few studies focussed on the AC occurrence in adolescents and young adults with AI. This is despite the range of developmental, psychosocial, and structural changes that can interfere with chronic disease management during this important period of growth and development. CONCLUSION In this review, we examine the current state of knowledge of AC epidemiology in emerging adults; examine the causes of ACs in this age group; and suggest areas for further investigation that are aimed at reducing the incidence and health impact of ACs in these patients.
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Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, 160 Oxford St, Darlinghurst, NSW, 2010, Australia
| | - Georgina L Chrisp
- School of Medicine, Sydney, The University of Notre Dame, 160 Oxford St, Darlinghurst, NSW, 2010, Australia
| | - Suzannah Bownes
- School of Medicine, Sydney, The University of Notre Dame, 160 Oxford St, Darlinghurst, NSW, 2010, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, SE-17176, Stockholm, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden.
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Chifu I, Detomas M, Dischinger U, Kimpel O, Megerle F, Hahner S, Fassnacht M, Altieri B. Management of Patients With Glucocorticoid-Related Diseases and COVID-19. Front Endocrinol (Lausanne) 2021; 12:705214. [PMID: 34594302 PMCID: PMC8476969 DOI: 10.3389/fendo.2021.705214] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/25/2021] [Indexed: 12/15/2022] Open
Abstract
The ongoing coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a global health crisis affecting millions of people worldwide. SARS-CoV-2 enters the host cells by binding to angiotensin-converting enzyme 2 (ACE2) after being cleaved by the transmembrane protease serine 2 (TMPRSS2). In addition to the lung, gastrointestinal tract and kidney, ACE2 is also extensively expressed in endocrine tissues, including the pituitary and adrenal glands. Although glucocorticoids could play a central role as immunosuppressants during the cytokine storm, they can have both stimulating and inhibitory effects on immune response, depending on the timing of their administration and their circulating levels. Patients with adrenal insufficiency (AI) or Cushing's syndrome (CS) are therefore vulnerable groups in relation to COVID-19. Additionally, patients with adrenocortical carcinoma (ACC) could also be more vulnerable to COVID-19 due to the immunosuppressive state caused by the cancer itself, by secreted glucocorticoids, and by anticancer treatments. This review comprehensively summarizes the current literature on susceptibility to and outcome of COVID-19 in AI, CS and ACC patients and emphasizes potential pathophysiological mechanisms of susceptibility to COVID-19 as well as the management of these patients in case of SARS-CoV-2. Finally, by performing an in silico analysis, we describe the mRNA expression of ACE2, TMPRSS2 and the genes encoding their co-receptors CTSB, CTSL and FURIN in normal adrenal and adrenocortical tumors (both adenomas and carcinomas).
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Affiliation(s)
- Irina Chifu
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - Mario Detomas
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - Ulrich Dischinger
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - Otilia Kimpel
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - Felix Megerle
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - Stefanie Hahner
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
- Central Laboratory, University Hospital Würzburg, Würzburg, Germany
| | - Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
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Younes N, Bourdeau I, Lacroix A. Latent Adrenal Insufficiency: From Concept to Diagnosis. Front Endocrinol (Lausanne) 2021; 12:720769. [PMID: 34512551 PMCID: PMC8429826 DOI: 10.3389/fendo.2021.720769] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/09/2021] [Indexed: 11/22/2022] Open
Abstract
Primary adrenal insufficiency (PAI) is a rare disease and potentially fatal if unrecognized. It is characterized by destruction of the adrenal cortex, most frequently of autoimmune origin, resulting in glucocorticoid, mineralocorticoid, and adrenal androgen deficiencies. Initial signs and symptoms can be nonspecific, contributing to late diagnosis. Loss of zona glomerulosa function may precede zona fasciculata and reticularis deficiencies. Patients present with hallmark manifestations including fatigue, weight loss, abdominal pain, melanoderma, hypotension, salt craving, hyponatremia, hyperkalemia, or acute adrenal crisis. Diagnosis is established by unequivocally low morning serum cortisol/aldosterone and elevated ACTH and renin concentrations. A standard dose (250 µg) Cosyntropin stimulation test may be needed to confirm adrenal insufficiency (AI) in partial deficiencies. Glucocorticoid and mineralocorticoid substitution is the hallmark of treatment, alongside patient education regarding dose adjustments in periods of stress and prevention of acute adrenal crisis. Recent studies identified partial residual adrenocortical function in patients with AI and rare cases have recuperated normal hormonal function. Modulating therapies using rituximab or ACTH injections are in early stages of investigation hoping it could maintain glucocorticoid residual function and delay complete destruction of adrenal cortex.
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Affiliation(s)
| | | | - Andre Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
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Rushworth RL, Goubar T, Ostman C, McGrath S, Torpy DJ. Interaction between hypotension and age on adrenal crisis diagnosis. Endocrinol Diabetes Metab 2021; 4:e00205. [PMID: 33855208 PMCID: PMC8029553 DOI: 10.1002/edm2.205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/01/2020] [Indexed: 11/11/2022] Open
Abstract
Objective To determine whether adrenal crisis (AC) identification may be affected by the definition of hypotension. Context Delays in AC diagnosis can result in adverse outcomes. AC-related cardiovascular compromise may vary according to baseline blood pressure and may be associated with delayed AC detection in some patients. Design A retrospective study of paired systolic blood pressure (sBP) measurements in hospitalized patients with primary AI (PAI). Patients Patients with PAI and an acute illness admitted for urgent treatment between 2000 and 2017. Measurements A comparison between sBP on hospital arrival and on discharge. Hypotension was classified as either absolute hypotension (sBP 100mg or lower) or relative hypotension (sBP over 100 mg but at least 20 mm Hg lower than discharge sBP). Results Of 152 admissions with paired blood pressure measurements, 46 (30.3%) included a medically diagnosed AC. Absolute hypotension was found in 38 (25.0%) records, and a further 21 (13.8%) patients were classified as having relative hypotension. Patients aged 65 years and older had the lowest (14.8%, n = 8) proportion with absolute hypotension but the highest (27.8%, n = 15) with relative hypotension. Use of either absolute or relative hypotension as the criterion for AC diagnosis increased the proportion of patients with an AC by 28.3% and the proportion of patients with an AC in the oldest age group by 130%. Conclusions Failure to detect cardiovascular compromise is common in older AI patients, may underestimate the AC rate in this group, and delay essential treatment. Relative hypotension may play a role in AC diagnosis.
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Affiliation(s)
- R. Louise Rushworth
- School of Medicine, SydneyThe University of Notre DameDarlinghurstNSWAustralia
| | - Thomas Goubar
- School of Medicine, SydneyThe University of Notre DameDarlinghurstNSWAustralia
| | | | | | - David J. Torpy
- Endocrine and Metabolic UnitRoyal Adelaide Hospital and University of AdelaideAdelaideSAAustralia
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12
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Hahner S, Ross RJ, Arlt W, Bancos I, Burger-Stritt S, Torpy DJ, Husebye ES, Quinkler M. Adrenal insufficiency. Nat Rev Dis Primers 2021; 7:19. [PMID: 33707469 DOI: 10.1038/s41572-021-00252-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/25/2022]
Abstract
Adrenal insufficiency (AI) is a condition characterized by an absolute or relative deficiency of adrenal cortisol production. Primary AI (PAI) is rare and is caused by direct adrenal failure. Secondary AI (SAI) is more frequent and is caused by diseases affecting the pituitary, whereas in tertiary AI (TAI), the hypothalamus is affected. The most prevalent form is TAI owing to exogenous glucocorticoid use. Symptoms of AI are non-specific, often overlooked or misdiagnosed, and are related to the lack of cortisol, adrenal androgen precursors and aldosterone (especially in PAI). Diagnosis is based on measurement of the adrenal corticosteroid hormones, their regulatory peptide hormones and stimulation tests. The goal of therapy is to establish a hormone replacement regimen that closely mimics the physiological diurnal cortisol secretion pattern, tailored to the patient's daily needs. This Primer provides insights into the epidemiology, mechanisms and management of AI during pregnancy as well as challenges of long-term management. In addition, the importance of identifying life-threatening adrenal emergencies (acute AI and adrenal crisis) is highlighted and strategies for prevention, which include patient education, glucocorticoid emergency cards and injection kits, are described.
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Affiliation(s)
- Stefanie Hahner
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Richard J Ross
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Wiebke Arlt
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephanie Burger-Stritt
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Diseases, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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13
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Claessen KMJA, Andela CD, Biermasz NR, Pereira AM. Clinical Unmet Needs in the Treatment of Adrenal Crisis: Importance of the Patient's Perspective. Front Endocrinol (Lausanne) 2021; 12:701365. [PMID: 34354671 PMCID: PMC8329717 DOI: 10.3389/fendo.2021.701365] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/30/2021] [Indexed: 12/25/2022] Open
Abstract
Adrenal crisis is the most severe manifestation of adrenal insufficiency (AI), but AI can present with variable signs and symptoms of gradual severity. Despite current hormone replacement strategies, adrenal crisis is still one of the leading causes of mortality in AI patients. Although underlying factors explaining differences in interindividual susceptibility are not completely understood, several subgroups are particularly vulnerable to adrenal crises, such as patients with primary AI, and patients treated for Cushing's syndrome. Currently, the health care professional faces several challenges in the care for AI patients, including the lack of reliable biomarkers measuring tissue cortisol concentrations, absence of a universally used definition for adrenal crisis, and lack of clinical tools to identify individual patients at increased risk. Also from the patient's perspective, there are a number of steps to be taken in order to increase and evaluate self-management skills and, finally, improve health-related quality of life (HR-QoL). In this respect, the fact that inadequate handling of AI patients during stressful situations is a direct consequence of not remembering how to act due to severe weakness and cognitive dysfunction in the context of the adrenal crisis is quite underexposed. In this narrative review, we give an overview of different clinical aspects of adrenal crisis, and discuss challenges and unmet needs in the management of AI and the adrenal crisis from both the doctor's and patient's perspective. For the latter, we use original focus group data. Integration of doctor's and patient's perspectives is key for successful improvement of HR-QoL in patients with AI.
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14
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Rushworth RL, Torpy DJ, Falhammar H. Adrenal crises in older patients. Lancet Diabetes Endocrinol 2020; 8:628-639. [PMID: 32559478 DOI: 10.1016/s2213-8587(20)30122-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 12/21/2022]
Abstract
Adrenal crises are severe manifestations of adrenal insufficiency that result in hospital admission and incur a risk of cardiovascular events, acute renal injury, and death. Evidence from population-based studies indicate that adults older than 60 years have the highest adrenal insufficiency incidence, contribute to the highest number of adrenal crises, and have the highest age-specific incidence of adrenal crisis, which doubles between the age groups of 60-69 years and 80 years or older. Older patients might be more susceptible to adrenal crises because of a higher prevalence of comorbidities and a consequently higher risk of acute illness. This susceptibility might be compounded by shortfalls in the implementation of prevention strategies for adrenal crisis, because of individual and social factors that increase with age. Although little research has focused on adrenal crisis prevention in older patients, it seems logical that a timely diagnosis of adrenal insufficiency and the use of consensus driven adrenal crisis prevention and attenuation strategies might reduce adrenal crises in patients older than 60 years old.
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Affiliation(s)
- Ruth L Rushworth
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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15
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Mofokeng TRP, Beshyah SA, Mahomed F, Ndlovu KCZ, Ross IL. Significant barriers to diagnosis and management of adrenal insufficiency in Africa. Endocr Connect 2020; 9:445-456. [PMID: 32348958 PMCID: PMC7274557 DOI: 10.1530/ec-20-0129] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/28/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND The burden and management of primary adrenal insufficiency (PAI) in Africa have not been well documented. We aimed to identify specific disease characteristics, patient demographics, and patterns of clinical management in established PAI in Africa. METHODS An online survey of physicians' experience relating to PAI. RESULTS There were 1334 responses received, 589 were complete, and 332 respondents reported managing patients with hypoadrenalism. The described responses were related to a calculated pool of 5787 patients with hypoadrenalism (2746 females, 3041 males), of whom 2302 had PAI. The likely causes of PAI in Sub-Saharan Africa (SSA) vs the Middle East and North Africa (MENA) regions included autoimmune disease (20% vs 60.3%; P < 0.001), tuberculosis (34% vs 4.1%; P < 0.001), AIDS (29.8% vs 1%; P < 0.001), malignancy, and genetic conditions. Sixteen percent of AD patients (376/2302) presented in an adrenal crisis. Medical emergency identification was not used by 1233 (83.6%) SSA vs 330 (40.4%) MENA patients (P < 0.001), respectively. Relative non-availability of diagnostic tests across both regions included adrenal antibodies 63% vs 69.6% (P = 0.328), s-cortisol 49.4 % vs 26.7% (P = 0.004), s-ACTH 55.7% vs 53.3% (P = 0.217), and adrenal CT scans 52.4% vs 31.8% (P = 0.017) in the SSA and MENA region, respectively. Across the entire cohort, the overall hydrocortisone use and extrapolated proportion of synacthen use were 59.4% and 50.7%, respectively. CONCLUSIONS Through the perception and practice of healthcare professionals, we identified significant challenges in the diagnosis and management of PAI which may herald high mortality. Differences between regions may reflect the allocation of healthcare resources.
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Affiliation(s)
- Thabiso R P Mofokeng
- Department of Medicine, University of the Free State, Bloemfontein, South Africa
- Correspondence should be addressed to T R P Mofokeng:
| | - Salem A Beshyah
- Department of Medicine, Dubai Medical College, Duabi, United Arab Emirates
- Department of Endocrinology, Mediclinic Airport Road Hospital, Abu Dhabi, United Arab Emirates
| | - Fazleh Mahomed
- Department of Medicine, University of the Free State, Bloemfontein, South Africa
| | - Kwazi C Z Ndlovu
- Department of Medicine, University of the Free State, Bloemfontein, South Africa
| | - Ian L Ross
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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16
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White KG. A retrospective analysis of adrenal crisis in steroid-dependent patients: causes, frequency and outcomes. BMC Endocr Disord 2019; 19:129. [PMID: 31791297 PMCID: PMC6889201 DOI: 10.1186/s12902-019-0459-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 11/19/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Adrenal patients have a lifelong dependency on steroid replacement therapy and are vulnerable to sudden death from undertreated adrenal crisis. Urgent treatment with parenteral steroids is needed, often with IV saline for volume repletion. Episodes of adrenal crisis are, for most patients, relatively infrequent and they may not be well prepared to respond. This study explores how patients recall previous episodes of adrenal crisis and their satisfaction with UK emergency medical treatment. METHODS We invited members of the main UK support groups representing steroid-dependent adrenal patients to complete an online questionnaire identifying the number, causes and location of previous adrenal crises (episodes needing injected steroids and/or IV fluids). Respondents were asked to rate the adequacy of their medical treatment in 2 successive questionnaires, conducted 2013 and 2017-18. RESULTS Vomiting was the major factor identified as a cause of adrenal crisis, indicated by 80% of respondents. The most common location, at 70%, was the home. Of the 30% away from home, 1 in 3 were overseas or travelling long-distance. Self-treatment played an increasing role in emergency response: in the 5 year interval between questionnaires an increasing number of patients self-injected. By the time of the 2017-18 survey self-injection was the most common method of initial treatment, with less than two-thirds travelling to hospital for follow-up medical treatment. This finding help to explain the higher rate of adrenal crisis identified in patient surveys than in hospital records. Satisfaction with medical care received stayed constant between the 2 surveys despite growing resourcing pressures across the NHS. Two-thirds were happy with the quality of the medical treatment they received for their most recent adrenal emergency; timeliness was the main factor influencing satisfaction. CONCLUSIONS Around one-third of adrenal patients report sub-optimal treatment at emergency medical departments. Medical staff have a low probability of encountering adrenal crisis and may be unfamiliar with either the urgency of adrenal crisis or the specific treatment response it requires. Comprehensive protocols for emergency medical staff with detailed patient education and training are needed in how to respond to this infrequently encountered - but acutely life-threatening - scenario.
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Affiliation(s)
- Katherine G White
- Institut für Politikwissenschaft und Soziologie, Julius-Maximilians-Universität Würzburg, Wittelsbacherplatz 1, 97074, Würzburg, Germany.
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17
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Goubar T, Torpy DJ, McGrath S, Rushworth RL. Prehospital Management of Acute Addison Disease: Audit of Patients Attending a Referral Hospital in a Regional Area. J Endocr Soc 2019; 3:2194-2203. [PMID: 31723718 PMCID: PMC6839527 DOI: 10.1210/js.2019-00263] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/11/2019] [Indexed: 11/19/2022] Open
Abstract
Context Adrenal crisis (AC) causes morbidity and mortality in patients with Addison disease [primary adrenal insufficiency (PAI)]. Patient-initiated stress dosing (oral or parenteral hydrocortisone) is recommended to avert ACs. Although these should be effective, the continued incidence of ACs remains largely unexplained. Methods Audit of all attendances between 2000 and 2017 of adult patients with treated PAI to one large regional referral center in New South Wales, Australia. Measurements were those taken on arrival at hospital. Results There were 252 attendances by 56 patients with treated PAI during the study period. Women comprised 60.7% (n = 34) of the patients. The mean age of attendees was 53.7 (19.6) years. Nearly half (45.2%, n = 114) of the patients had an infection. There were 61 (24.2%) ACs diagnosed by the treating clinician. Only 17.9% (n = 45) of the hospital presentations followed any form of stress dosing. IM hydrocortisone was used prior to presentation 7 (2.8%) attendances only. Among patients with a clinician-diagnosed AC, only 32.8% (n = 20) had used stress dosing before presentation. Vomiting was reported by 47.6% (n = 120) of the patients but only 33 (27.5%) of these attempted stress dosing and 5 patients with vomiting used IM hydrocortisone. The number of prior presentations was an independent predictor of use of stress doses [1.05 (1.01, 1.09)]. Conclusion Dose-escalation strategies are not used universally or correctly by unwell patients with PAI; many patients do not use IM or subcutaneous hydrocortisone injections. Previous hospital treatment increases the likelihood of stress dosing, and hospital attendance offers the opportunity for reinforcement of prevention strategies.
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Affiliation(s)
- Thomas Goubar
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, Australia
| | | | - R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, Australia
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18
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Affiliation(s)
- R Louise Rushworth
- From the School of Medicine, Sydney (R.L.R.), the University of Notre Dame Australia, Darlinghurst, NSW (R.L.R.), the Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, SA (D.J.T.), and the Menzies School of Health Research and Royal Darwin Hospital, Tiwi, NT (H.F.) - all in Australia; and the Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, and the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm (H.F.)
| | - David J Torpy
- From the School of Medicine, Sydney (R.L.R.), the University of Notre Dame Australia, Darlinghurst, NSW (R.L.R.), the Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, SA (D.J.T.), and the Menzies School of Health Research and Royal Darwin Hospital, Tiwi, NT (H.F.) - all in Australia; and the Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, and the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm (H.F.)
| | - Henrik Falhammar
- From the School of Medicine, Sydney (R.L.R.), the University of Notre Dame Australia, Darlinghurst, NSW (R.L.R.), the Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, SA (D.J.T.), and the Menzies School of Health Research and Royal Darwin Hospital, Tiwi, NT (H.F.) - all in Australia; and the Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, and the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm (H.F.)
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19
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Rushworth RL, Chrisp GL, Torpy DJ. The use of medical identification jewellery in adults with adrenal insufficiency in Australia. Clin Endocrinol (Oxf) 2019; 91:41-47. [PMID: 30963602 DOI: 10.1111/cen.13985] [Citation(s) in RCA: 4] [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: 02/26/2019] [Revised: 03/28/2019] [Accepted: 04/06/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Hydrocortisone stress dosing during illness can prevent adrenal crises (AC) in patients with adrenal insufficiency (AI). When patients cannot communicate, medical identification jewellery may facilitate parenteral hydrocortisone provision but patient adoption rates are not known. DESIGN A cross-sectional analysis of Australian medical identification jewellery subscription data. PATIENTS Patients with AI aged 20 years and over with an active subscription to a large medical jewellery provider. MEASUREMENTS Subscription rates by AI subtype, geographic area, age and gender. RESULTS There were 1955 patients with AI and an active subscription in the database, corresponding to a subscription rate of 105.79/million or approximately one-third of the AI population. The subscription rate was substantially higher in primary AI (60.72/million) than secondary AI (23.16/million), corresponding to approximately 60.7% and 11.6% of the estimated population prevalence of each disorder, respectively. There was substantial variation in use by state/territory, with the highest subscribing state having a rate of over four times that of the lowest (P < 0.001). Women comprised 64.8% (n = 1266) of the group. Subscription also varied by age, being highest in the 60-69 year age group (165.15/million) and lowest in those aged 30-39 years (47.23/million) (P < 0.001). Few patients (4.8%, n = 94) mentioned, either in their record or on their jewellery, the need for urgent parenteral hydrocortisone in the event of severe illness. CONCLUSIONS Medical jewellery is a component of AC risk reduction. However, subscription appears to be underutilised in the Australian AI population, especially among patients with secondary AI. Urgent treatment recommendations should be inscribed on the jewellery.
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Affiliation(s)
- Rosemary Louise Rushworth
- School of Medicine Sydney, The University of Notre Dame, Australia, Sydney, New South Wales, Australia
| | - Georgina L Chrisp
- School of Medicine Sydney, The University of Notre Dame, Australia, Sydney, New South Wales, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
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20
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Iwasaku M, Tanaka S, Shinzawa M, Kawakami K. Impact of underlying chronic adrenal insufficiency on clinical course of hospitalized patients with adrenal crisis: A nationwide cohort study. Eur J Intern Med 2019; 64:24-28. [PMID: 30979617 DOI: 10.1016/j.ejim.2019.04.001] [Citation(s) in RCA: 4] [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: 12/01/2018] [Revised: 02/08/2019] [Accepted: 04/02/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Chronic adrenal insufficiency (AI) is an established risk factor for adrenal crisis (AC). However, the proportion of patients with newly diagnosed chronic AI during admission for AC is unclear. METHODS This retrospective cohort study used a Japanese claims database involving 7.39 million patients at 145 acute care hospitals between 2003 and 2014. Study patients with AC met these criteria: 1) newly coded in claims as AI; 2) glucocorticoid therapy administered; 3) admission; and 4) age ≥ 18 years. We investigated the prevalence of underlying chronic AI and assessed in-hospital mortality. Additionally, we explored risk factors for in-hospital mortality through multivariate analysis using a Cox proportional hazards model. RESULTS Among 504 patients with AC, chronic AI was diagnosed before and during admission in 73 (14.5%) and 86 (17.1%) patients, respectively. In-hospital mortality rates were 1.4% and 5.8%, respectively, lower than that of the total population (14.1%). Significant risk factors for increased mortality were: age (hazard ratio [HR] 1.45/10 years; 95% confidence interval [CI] 1.17-1.78), requiring mechanical ventilation (HR 3.81; 95% CI 1.88-7.72), vasopressor administration (HR 2.05; 95% CI 1.16-3.64), sepsis (HR 3.79; 95% CI 1.57-9.14), AI-related symptoms (HR 2.00; 95% CI 1.02-3.93), and liver disease (HR 3.24; 95% CI 1.10-9.58). CONCLUSIONS Relative to patients without chronic AI, those diagnosed before admission tended to survive to discharge; however, the difference with those diagnosed during admission was not significant. Hospital admission due to nonspecific AI-related symptoms was associated with an increased risk of in-hospital mortality.
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Affiliation(s)
- Masahiro Iwasaku
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Japan.
| | - Shiro Tanaka
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Japan.
| | - Maki Shinzawa
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Japan.
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Japan.
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Kim D, Taleban S. A Comprehensive Review of the Diagnosis and Pharmacological Management of Crohn's Disease in the Elderly Population. Drugs Aging 2019; 36:607-624. [PMID: 31055789 DOI: 10.1007/s40266-019-00672-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Crohn's disease (CD) in the elderly is rising in prevalence, which is related to an increase in its incidence and improving life expectancies. There are differences in the presentation, natural history, and treatment of CD between adult-onset patients who progress to older age and patients who are initially diagnosed at an older age. Presentation at an older age may also delay or make diagnosis challenging due to accumulating co-morbidities that mimic inflammatory bowel disease. Differences exist between adult- and older-onset disease, yet many guidelines do not specifically distinguish the management of these two distinct populations. Identifying patients at high risk for progression or aggressive disease is particularly important as elderly patients may respond differently to medical and surgical treatment, and may be at higher risk for adverse effects. Despite newer agents being approved for CD, the data regarding efficacy and safety in the elderly are currently limited. Balancing symptom management with risks of medical and surgical therapy is an ongoing challenge and requires special consideration in these two distinct populations.
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Affiliation(s)
- David Kim
- Division of Gastroenterology and Hepatology, Banner University Medical Center, Tucson, AZ, USA.,Division of Gastroenterology and Hepatology, University of Arizona School of Medicine, Tucson, AZ, USA
| | - Sasha Taleban
- Division of Gastroenterology and Hepatology, University of Arizona School of Medicine, Tucson, AZ, USA. .,Arizona Center on Aging, University of Arizona, Tucson, AZ, USA.
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Burger-Stritt S, Bachmann L, Kurlbaum M, Hahner S. Emergency treatment of adrenal crisis with prednisone suppositories: a bioequivalence study in female patients with Addison's disease. Endocr Connect 2019; 8:425-434. [PMID: 30952111 PMCID: PMC6454300 DOI: 10.1530/ec-19-0024] [Citation(s) in RCA: 4] [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: 03/08/2019] [Accepted: 03/18/2019] [Indexed: 12/02/2022]
Abstract
Objective Patients with adrenal insufficiency (AI) need to adapt their glucocorticoid replacement under stressful conditions to prevent adrenal crisis (AC). Prednisone (PN) suppositories are used for emergency treatment. Pharmacokinetics of 100 mg PN suppositories after vaginal or rectal administration was evaluated. Design Single-center, open-label, sequence-randomized, cross-over, bioequivalence study. Methods Twelve females with primary AI were included. Comparison of pharmacokinetics after vaginal and rectal administration of 100 mg PN suppositories. Main outcome measures: bioequivalence (Cmax: maximum plasma concentration of prednisolone; AUC0 -360: area under the plasma concentration curve of prednisolone from administration to 360 min), adrenocorticotropin (ACTH) levels, safety and tolerability. Comparison of ACTH-suppressive effect with subcutaneous and intramuscular administration of 100 mg hydrocortisone. Results Vaginal administration of PN suppositories was not bioequivalent to rectal administration: Cmax and AUC0-360 were significantly lower after vaginal compared to rectal administration: 22 ng/mL (109%) vs 161 ng/mL (28%), P < 0.001; 4390 ng/mL * min (116%) vs 40,302 ng/mL * min (26%), P < 0.001; (mean (coefficient of variation), respectively). A suppression of ACTH by >50% of baseline values was observed 149 min (32%) after rectal PN administration; after vaginal PN administration, the maximum decrease within 360 min was only 44%. Adverse events were more frequent after vaginal administration and mainly attributable to the glucocorticoid deficit due to inadequate vaginal absorption. The ACTH-suppressive effect was more pronounced after parenteral hydrocortisone compared to rectal or vaginal PN. Conclusion Vaginal administration of PN suppositories in the available form is not useful for prevention of AC. Pharmacokinetics after rectal use of PN show inferiority compared to available data on parenteral glucocorticoids. In adrenal emergencies, hydrocortisone injection should be the first choice.
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Affiliation(s)
- Stephanie Burger-Stritt
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Linda Bachmann
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Max Kurlbaum
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Stefanie Hahner
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
- Correspondence should be addressed to S Hahner:
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Dineen R, Thompson CJ, Sherlock M. Adrenal crisis: prevention and management in adult patients. Ther Adv Endocrinol Metab 2019; 10:2042018819848218. [PMID: 31223468 PMCID: PMC6566489 DOI: 10.1177/2042018819848218] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/04/2019] [Indexed: 12/24/2022] Open
Abstract
Adrenal crisis is an acute life-threatening emergency contributing to the excess mortality that is reported in patients with adrenal insufficiency. The incidence of adrenal crisis is estimated to be 8 per 100 patient years in patients with adrenal insufficiency. Patients with adrenal crisis present systemically unwell with nonspecific signs and symptoms often leading to misdiagnosis and delayed treatment. An adrenal crisis may be the first presentation of adrenal insufficiency or can occur in patients who have been established on glucocorticoid replacement therapy. Infections are the major precipitating factor, but other causes include physical stress such as a surgical procedure or trauma, forgetting or discontinuing glucocorticoid therapy, pronounced physical activity, and psychological stress. The emergency treatment involves prompt recognition and administration of parenteral hydrocortisone, rehydration and management of electrolyte abnormalities. Prevention is centred around patient education. All patients should be educated on stress dosing and parenteral glucocorticoid administration. They should carry a steroid dependency alert card and wear a medical alert bracelet or similar identification. Despite many improvements in the management of patients with adrenal insufficiency, adrenal crisis continues to occur and represents a major source of morbidity, mortality and distress for patients. Improved patient and clinician education and measures to facilitate parenteral hydrocortisone self-administration in impending crisis are central to the management of this life-threatening event.
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Affiliation(s)
- Rosemary Dineen
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
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Adrenal crisis presented as acute onset of hypercalcemia and hyponatremia triggered by acute pyelonephritis in a patient with partial hypopituitarism and pre-dialysis chronic kidney disease. CEN Case Rep 2018; 8:83-88. [PMID: 30456557 DOI: 10.1007/s13730-018-0371-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 11/12/2018] [Indexed: 12/18/2022] Open
Abstract
A 57-year-old woman with pre-dialysis chronic kidney disease (CKD) was hospitalized because of fever and fatigue. On admission, increased inflammatory response and pyuria with bacteriuria were observed. Pyelonephritis was successfully treated with antibiotics, whereas her fatigue continued and she developed progressive hypercalcemia and hyponatremia; serum sodium level, 116 mEq/L and corrected serum calcium level, 13.4 mg/dL. Plasma concentrations of adrenocorticotropic hormone and cortisol and serum luteinizing hormone were under the detection level. Although the reaction of other anterior pituitary hormones and the serum antidiuretic hormone (ADH) was preserved, the response of serum luteinizing hormone to administration of luteinizing hormone releasing hormone was impaired. Magnetic resonance imaging showed no structural abnormality in the thalamus, hypothalamus, and pituitary gland. She was diagnosed with adrenal insufficiency caused by partial hypopituitarism in concomitant with pyelonephritis. After starting hydrocortisone replacement, serum levels of sodium and calcium were rapidly normalized. This case highlights the importance of adrenal insufficiency as a differential diagnosis of hypercalcemia in patients with pre-dialysis CKD, especially when hyponatremia was concomitantly observed. Besides, infection should be considered as an important trigger for the development of latent adrenal insufficiency since it could increase the physiological demand of corticosteroid in the body. Also, CKD may enhance the magnitude of hypercalcemia since CKD patients have decreased capacity to increase urinary calcium excretion.
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Rushworth RL, Torpy DJ, Stratakis CA, Falhammar H. Adrenal Crises in Children: Perspectives and Research Directions. Horm Res Paediatr 2018; 89:341-351. [PMID: 29874655 DOI: 10.1159/000481660] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/20/2017] [Indexed: 11/19/2022] Open
Abstract
Adrenal crises (AC) are life-threatening physiological disturbances that occur at a rate of 5-10/100 patient years in patients with adrenal insufficiency (AI). Despite their seriousness, there is a paucity of information on the epidemiology of AC events in the paediatric population specifically, as most investigations have focused on AI and ACs in adults. Improved surveillance of AC-related morbidity and mortality should improve the delineation of AC risk overall and among different subgroups of paediatric patients with AI. Valid incidence measures are essential for this purpose and also for the evaluation of interventions aimed at reducing adverse health outcomes from ACs. However, the absence of an agreed AC definition limits the potential benefit of research and surveillance in this area. While approaches to the treatment and prevention of ACs have much in common across the lifespan, there are important differences between children and adults with regards to the physiological, psychological, and social milieu in which these events occur. Education is considered to be an essential element of AC prevention but studies have shown that ACs occur even among well-educated patients, suggesting that new strategies may be needed. In this review, we examine the current knowledge regarding AC events in children with AI; assess the existing definitions of an AC and offer a new definition for use in research and the clinic; and suggest areas for further investigation that are aimed at reducing the incidence and health impact of ACs in the paediatric age group.
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Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Menzies School of Health Research and Royal Darwin Hospital, Tiwi, Northwest Territories, Australia
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Transient adrenal insufficiency in diffuse large B cell lymphoma patients after chemotherapy with short-course, high-dose corticosteroids. Ann Hematol 2018; 97:2403-2410. [PMID: 30109424 PMCID: PMC6208676 DOI: 10.1007/s00277-018-3470-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 08/03/2018] [Indexed: 11/17/2022]
Abstract
Data on the rate of adrenal insufficiency (AI) in patients receiving short-course and high-dose corticosteroids are limited. In this study, we aimed to determine the incidence of AI in newly diagnosed, diffuse large B cell lymphoma (DLBCL) patients after receiving rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone [or prednisolone] (R-CHOP/CHOP) regimen. We enrolled newly diagnosed DLBCL patients who were scheduled to receive 6–8 cycles of R-CHOP/CHOP regimen. One-microgram adrenocorticotropic hormone (ACTH) stimulation tests were performed at the study entry and 3 weeks after each cycle of chemotherapy (CMT). AI was defined by a peak-stimulated serum cortisol of less than 18 μg/dL. For patients who had AI after completing a course of CMT, 1-μg ACTH stimulation tests were carried out at 60 and 90 days after the last CMT cycle to assess the duration of hypothalamic-pituitary-adrenal (HPA) axis recovery. Ten DLBCL patients were included in this study, with a total of 84 1-μg ACTH stimulation tests. Their mean age was 52 years. AI occurred in 3 out of the 10 patients (30%). The first occurrence of AI was after the third CMT cycle, and the incidence was highest after the fifth cycle. Adrenal function recovered completely 3 to 5 weeks after completing the course of CMT, except for 1 patient, whose HPA axis suppression persisted 90 days after the last CMT cycle. Receiver operating characteristic (ROC) analysis revealed that a basal cortisol level of < 8.7 μg/dL was predictive of AI, with a sensitivity and specificity of 80% and 72.2%, respectively. Transient HPA axis suppression can occur in DLBCL patients receiving R-CHOP/CHOP regimen. We strongly encourage careful observation and examination for potential adrenal insufficiency in such patients, particularly after the fifth cycle of chemotherapy.
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Rushworth RL, Chrisp GL, Dean B, Falhammar H, Torpy DJ. Hospitalisation in Children with Adrenal Insufficiency and Hypopituitarism: Is There a Differential Burden between Boys and Girls and between Age Groups? Horm Res Paediatr 2018; 88:339-346. [PMID: 28898882 DOI: 10.1159/000479370] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 07/07/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND/AIMS To determine the burden of hospitalisation in children with adrenal insufficiency (AI)/hypopituitarism in Australia. METHODS A retrospective study of Australian hospitalisation data. All admissions between 2001 and 2014 for patients aged 0-19 years with a principal diagnosis of AI/hypopituitarism were included. Denominator populations were extracted from national statistics datasets. RESULTS There were 3,779 admissions for treatment of AI/hypopituitarism in patients aged 0-19 years, corresponding to an average admission rate of 48.7 admissions/million/year. There were 470 (12.4%) admissions for an adrenal crisis (AC). Overall, admission for AI/hypopituitarism was comparable between the sexes. Admission rates for all AI, hypopituitarism, congenital adrenal hyperplasia (CAH), and "other and unspecified causes" of AI were highest among infants and decreased with age. Admissions for primary AI increased with age in both sexes. Males had significantly higher rates of admission for hypopituitarism. AC rates differed by both sex and age group. CONCLUSION This nationwide study of the epidemiology of hospital admissions for a principal diagnosis of AI/hypopituitarism shows that admissions generally decreased with age; males had higher rates of admission for hypopituitarism; females had higher rates of admission for CAH and "other and unspecified causes" of AI; and AC incidence varied by age and sex. Increased awareness of AI and AC prevention strategies may reduce some of these admissions.
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Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - Georgina L Chrisp
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - Benjamin Dean
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Menzies School of Health Research and Royal Darwin Hospital, Tiwi, Northwest Territories, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
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Burger-Stritt S, Kardonski P, Pulzer A, Meyer G, Quinkler M, Hahner S. Management of adrenal emergencies in educated patients with adrenal insufficiency-A prospective study. Clin Endocrinol (Oxf) 2018; 89:22-29. [PMID: 29617051 DOI: 10.1111/cen.13608] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To evaluate the management of adrenal emergencies (AE) requiring parenteral glucocorticoid (GC) treatment in patients with chronic adrenal insufficiency (AI). DESIGN Prospective, multicentre, questionnaire-based study. PATIENTS AND MEASUREMENTS Participating patients (n = 150) with chronic AI were provided with a questionnaire on the management of emergency situations, which had to be completed and sent back in case of an AE. In addition, patients were contacted by phone on a regular basis. RESULTS Fifty-nine AE in 39 patients were documented. The time interval from contact to arrival of a medical professional was 20 minutes (1-240). In total, in 43 AE, patients received parenteral GC by a medical professional. The time interval between showing the emergency card and GC injection by a medical professional was 60 minutes (5-360). A total of 26 patients administered GC by self-injection. The time from the beginning of symptoms to GC injection was significantly shorter in case of self-injection (self-injection vs injection by medical professional; 85 minutes [20-280] vs 232.5 minutes [1-3135]; P < .001). After self-injection, 62% of the patients were treated outpatient, compared to 27% of the patients after exclusive injection by a medical professional (P = .008). To improve the emergency management, most of the patients (84%) indicated a need for an easier way of self-injection. CONCLUSION While management of AE by both patients and medical professionals still shows high variability, patients profit from the option of self-injection. Patient care, including education of patients and health-professionals, as well as the way of GC administration, needs further optimization.
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Affiliation(s)
- Stephanie Burger-Stritt
- Department of Medicine I, Endocrinology and Diabetes Unit, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Pavel Kardonski
- Department of Medicine I, Endocrinology and Diabetes Unit, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Alina Pulzer
- Department of Medicine I, Endocrinology and Diabetes Unit, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Gesine Meyer
- Division of Endocrinology, Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Stefanie Hahner
- Department of Medicine I, Endocrinology and Diabetes Unit, University Hospital Wuerzburg, Wuerzburg, Germany
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Quinkler M, Ekman B, Zhang P, Isidori AM, Murray RD. Mortality data from the European Adrenal Insufficiency Registry-Patient characterization and associations. Clin Endocrinol (Oxf) 2018; 89:30-35. [PMID: 29682773 DOI: 10.1111/cen.13609] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/23/2018] [Accepted: 03/29/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Mortality from primary and secondary adrenal insufficiency (AI; PAI and SAI, respectively) is 2-3-fold higher than in the general population. Mortality relates to cardiovascular disease, acute adrenal crisis (AC), cancer and infections; however, there has been little further characterization of patients who have died. DESIGN/METHODS We analysed real-world data from 2034 patients (801 PAI, 1233 SAI) in the European Adrenal Insufficiency Registry (EU-AIR; NCT01661387). Baseline clinical and biochemical data of patients who subsequently died were compared with those who remained alive. RESULTS From August 2012 to June 2017, 26 deaths occurred (8 PAI, 18 SAI) from cardiovascular disease (n = 9), infection (n = 4), suicide (n = 2), drug-induced hepatitis (n = 2), and renal failure, brain tumour, cachexia and AC (each n = 1); cause of death was unclear in 5 patients. Patients who died were significantly older at baseline than alive patients. Causes of AI were representative of patients with SAI; however, 3-quarters of deceased patients with PAI had undergone bilateral adrenalectomy (3 with uncontrolled Cushing's disease, 3 with metastatic renal cell cancer). There were no significant differences in body mass index, blood pressure, low-density lipoprotein cholesterol, total cholesterol or electrolytes between deceased and alive patients. Deceased patients with SAI were more frequently male individuals, were receiving higher daily doses of hydrocortisone (24.0 ± 7.6 vs 19.3 ± 5.7 mg, P = .0016) and experienced more frequent ACs (11.1 vs 2.49/100 patient-years, P = .0389) than alive patients. CONCLUSIONS This is the first study to provide detailed characteristics of deceased patients with AI. Older, male patients with SAI and frequent AC had a high mortality risk.
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Affiliation(s)
| | - Bertil Ekman
- Department of Endocrinology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | | | - Robert D Murray
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
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El-Maouche D, Hargreaves CJ, Sinaii N, Mallappa A, Veeraraghavan P, Merke DP. Longitudinal Assessment of Illnesses, Stress Dosing, and Illness Sequelae in Patients With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2018; 103:2336-2345. [PMID: 29584889 PMCID: PMC6276663 DOI: 10.1210/jc.2018-00208] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/19/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with congenital adrenal hyperplasia (CAH) are at risk for life-threatening adrenal crises. Management of illness episodes aims to prevent adrenal crises. OBJECTIVE We evaluated rates of illnesses and associated factors in patients with CAH followed prospectively and receiving repeated glucocorticoid stress dosing education. METHODS Longitudinal analysis of 156 patients with CAH followed at the National Institutes of Health Clinical Center over 23 years was performed. The rates of illnesses and stress-dose days, emergency room (ER) visits, hospitalizations, and adrenal crises were analyzed in relation to phenotype, age, sex, treatment, and hormonal evaluations. RESULTS A total of 2298 visits were evaluated. Patients were followed for 9.3 ± 6.0 years. During childhood, there were more illness episodes and stress dosing than adulthood (P < 0.001); however, more ER visits and hospitalizations occurred during adulthood (P ≤ 0.03). The most robust predictors of stress dosing were young age, low hydrocortisone and high fludrocortisone dose during childhood, and female sex during adulthood. Gastrointestinal and upper respiratory tract infections (URIs) were the two most common precipitating events for adrenal crises and hospitalizations across all ages. Adrenal crisis with probable hypoglycemia occurred in 11 pediatric patients (ages 1.1 to 11.3 years). Undetectable epinephrine was associated with ER visits during childhood (P = 0.03) and illness episodes during adulthood (P = 0.03). CONCLUSIONS Repeated stress-related glucocorticoid dosing teaching is essential, but revised age-appropriate guidelines for the management of infectious illnesses are needed for patients with adrenal insufficiency that aim to reduce adrenal crises and prevent hypoglycemia, particularly in children.
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Affiliation(s)
- Diala El-Maouche
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | | | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health,
Bethesda, Maryland
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human
Development, National Institutes of Health, Bethesda, Maryland
- Correspondence and Reprint Requests: Deborah P. Merke, MD, National Institutes of Health Clinical Center, 10 Center
Drive, Room 1-2740, Bethesda, Maryland 20892. E-mail:
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Cortet C, Barat P, Zenaty D, Guignat L, Chanson P. Group 5: Acute adrenal insufficiency in adults and pediatric patients. ANNALES D'ENDOCRINOLOGIE 2017; 78:535-543. [DOI: 10.1016/j.ando.2017.10.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ferreira L, Silva J, Garrido S, Bello C, Oliveira D, Simões H, Paiva I, Guimarães J, Ferreira M, Pereira T, Bettencourt-Silva R, Martins AF, Silva T, Fernandes V, Pereira ML. Primary adrenal insufficiency in adult population: a Portuguese Multicentre Study by the Adrenal Tumours Study Group. Endocr Connect 2017; 6:935-942. [PMID: 29089364 PMCID: PMC5712836 DOI: 10.1530/ec-17-0295] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 10/31/2017] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Primary adrenal insufficiency (PAI) is a rare but severe and potentially life-threatening condition. No previous studies have characterized Portuguese patients with PAI. AIMS To characterize the clinical presentation, diagnostic workup, treatment and follow-up of Portuguese patients with confirmed PAI. METHODS This multicentre retrospective study examined PAI patients in 12 Portuguese hospitals. RESULTS We investigated 278 patients with PAI (55.8% were females), with a mean age of 33.6 ± 19.3 years at diagnosis. The most frequent presenting clinical features were asthenia (60.1%), mucocutaneous hyperpigmentation (55.0%) and weight loss (43.2%); 29.1% of the patients presented with adrenal crisis. Diagnosis was established by high plasma ACTH and low serum cortisol in most patients (43.9%). The most common aetiology of PAI was autoimmune adrenalitis (61.0%). There were 38 idiopathic cases. Autoimmune comorbidities were found in 70% of the patients, the most frequent being autoimmune thyroiditis (60.7%) and type 1 diabetes mellitus (17.3%). Seventy-nine percent were treated with hydrocortisone (mean dose 26.3 ± 8.3 mg/day) mostly in three (57.5%) or two (37.4%) daily doses. The remaining patients were treated with prednisolone (10.1%), dexamethasone (6.2%) and methylprednisolone (0.7%); 66.2% were also on fludrocortisone (median dose of 100 µg/day). Since diagnosis, 33.5% of patients were hospitalized for disease decompensation. In the last appointment, 17.2% of patients had complaints (7.6% asthenia and 6.5% depression) and 9.7% had electrolyte disturbances. CONCLUSION This is the first multicentre Portuguese study regarding PAI. The results emphasize the need for standardization in diagnostic tests and etiological investigation and provide a framework for improving treatment.
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Affiliation(s)
- Lia Ferreira
- Department of EndocrinologyCentro Hospitalar do Porto, Porto, Portugal
| | - João Silva
- Department of EndocrinologyHospital das Forças Armadas, Lisboa, Portugal
| | - Susana Garrido
- Department of EndocrinologyCentro Hospitalar Tâmega e Sousa, Porto, Portugal
| | - Carlos Bello
- Department of EndocrinologyCentro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Diana Oliveira
- Department of EndocrinologyCentro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Hélder Simões
- Department of EndocrinologyInstituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal
| | - Isabel Paiva
- Department of EndocrinologyCentro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joana Guimarães
- Department of EndocrinologyCentro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Marta Ferreira
- Department of EndocrinologyCentro Hospitalar de Leiria, Leiria, Portugal
| | - Teresa Pereira
- Department of EndocrinologyCentro Hospitalar de Leiria, Leiria, Portugal
| | | | - Ana Filipa Martins
- Department of EndocrinologyCentro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Tiago Silva
- Department of EndocrinologyHospital Garcia da Orta, Lisboa, Portugal
| | - Vera Fernandes
- Department of EndocrinologyHospital de Braga, Braga, Portugal
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Rushworth RL, Bischoff C, Torpy DJ. Preventing adrenal crises: home-administered subcutaneous hydrocortisone is an option. Intern Med J 2017; 47:231-232. [PMID: 28201867 DOI: 10.1111/imj.13347] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/16/2016] [Accepted: 06/04/2016] [Indexed: 11/29/2022]
Affiliation(s)
- R Louise Rushworth
- School of Medicine, The University of Notre Dame, Sydney, New South Wales, Australia
| | - Carmen Bischoff
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
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Iwasaku M, Shinzawa M, Tanaka S, Kimachi K, Kawakami K. Clinical characteristics of adrenal crisis in adult population with and without predisposing chronic adrenal insufficiency: a retrospective cohort study. BMC Endocr Disord 2017; 17:58. [PMID: 28893233 PMCID: PMC5594557 DOI: 10.1186/s12902-017-0208-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 09/05/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Adrenal crisis (AC) occurs in various clinical conditions but previous epidemiological studies in AC are limited to chronic adrenal insufficiency (AI) and sepsis. The aim of this study was to investigate characteristics of AC patients, including predisposing diseases and to describe candidate risk factors for AC such as comorbidities and glucocorticoid (GC) therapy. METHODS We conducted a retrospective cohort study using a claims database on 7.4 million patients from 145 acute care hospitals between January 1, 2003 and April 30, 2014. We identified AC patients who met the following criteria: 1) disease name with ICD-10 corresponded with AI; 2) therapeutic GC administration (hydrocortisone equivalent dose ≥100 mg/day); 3) admission; and 4) age ≥18 years. RESULTS We identified 504 patients with AC (median age, 71 years; interquartile range, 59 to 80; 50.6% male). As predisposing conditions, primary AI and central AI accounted for 23 (4.6%) and 136 patients (27.0%), respectively. In the remaining AC patients (68.5%), comorbidities such as cancer, autoimmune diseases, and renal failure were frequent. The most frequent indication for hospitalization was AC (16.3%), followed by pituitary disease (14.7%), cancer (14.7%), AI-related clinical symptoms (11.5%), and infection (11.1%). Admission under oral GC treatment was reported in 104 patients (20.6%). Twenty-six patients were admitted within 14 days after GC cessation (5.2%). CONCLUSIONS These findings present an overview of patients with AC in general practice settings, clarifying that predisposing factors for AC were complicated and that patients other than those with chronic AI were older and had more comorbid conditions than those with primary and central AI.
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Affiliation(s)
- Masahiro Iwasaku
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501 Japan
| | - Maki Shinzawa
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501 Japan
| | - Shiro Tanaka
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501 Japan
| | - Kimihiko Kimachi
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501 Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501 Japan
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Roque C, Fonseca R, Bello CT, Vasconcelos C, Galzerano A, Ramos S. Thyrotoxicosis leading to adrenal crises reveals primary bilateral adrenal lymphoma. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170002. [PMID: 28567296 PMCID: PMC5445442 DOI: 10.1530/edm-17-0002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 04/06/2017] [Indexed: 11/13/2022] Open
Abstract
Primary adrenal lymphoma is a rare malignancy. It frequently presents bilaterally and with symptoms of adrenal insufficiency. Amiodarone may induce secondary organ dysfunction, and thyrotoxicosis develops in 15% of cases. The symptomatology of both conditions is nonspecific, especially in the elderly, and a high suspicion index is necessary for appropriate diagnosis. A 78-year-old female presented to the emergency department with confusion, nausea and vomiting. She had recently been to the emergency department with urinary tract infection, vomiting and acute hypochloremic hyponatremia. Upon re-evaluation, the leukocyturia persisted and because of TSH 0.01 µU/mL and free-T4 68 (10–18) pmol/L, she was admitted to the Endocrinology ward. Further evaluation supported amiodarone-induced thyroiditis type 2. Sepsis ensued, in the setting of nosocomial pneumonia. Hemodynamic instability, hyponatremia, hypoglycemia and vomiting raised the suspicion of adrenocortical insufficiency. Fluid resuscitation and hydrocortisone led to clinical improvement, and adrenal insufficiency was admitted. The thoracoabdominal tomography suggested an endobronchic primary lesion with hepatic and adrenal secondary deposits (6.6 and 7 cm), but this was confirmed neither on pleural effusion nor on bronchofibroscopic fluid analyses. The adrenals were not accessible for biopsy. Despite high-dose hydrocortisone maintenance, the patient died before definite diagnosis. The autopsy confirmed primary non-Hodgkin lymphoma.
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Affiliation(s)
| | | | | | | | - António Galzerano
- 2Anatomopathology Department, Hospital de Egas Moniz C.H.L.O.-E.P.E, Lisbon Portugal
| | - Sância Ramos
- 2Anatomopathology Department, Hospital de Egas Moniz C.H.L.O.-E.P.E, Lisbon Portugal
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Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical features and practice patterns of treatment for adrenal crisis: a nationwide cross-sectional study in Japan. Eur J Endocrinol 2017; 176:329-337. [PMID: 28130352 DOI: 10.1530/eje-16-0803] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 12/15/2016] [Accepted: 01/10/2017] [Indexed: 11/08/2022]
Abstract
CONTEXT Adrenal crisis is an endocrine emergency that requires prompt diagnosis and treatment. However, the clinical features and practice patterns of treatment for adrenal crisis are not completely understood. OBJECTIVE To investigate patient characteristics, comorbidities and treatments of adrenal crisis. METHODS We conducted a cross-sectional study of patients who received intravenous glucocorticoids for adrenal crisis at admission from 1 July 2007 to 31 March 2014, using a national inpatient database in Japan. RESULTS Among approximately 34 million inpatients in the database, we identified 799 patients diagnosed with adrenal crisis and coexisting primary or secondary adrenal insufficiency at admission. The median (interquartile range) age was 58 (28-73) years, and the overall in-hospital mortality was 2.4% (19 of 799 patients). The most common comorbidity at admission was infections excluding pneumonia and gastroenteritis (15.0%). There were 68 (8.5%) patients with gastroenteritis, and no deaths occurred among these patients. The patients with secondary adrenal insufficiency showed significantly higher proportions of admission to ICU, extracellular fluid resuscitation, insulin therapy and catecholamine use than the patients with primary adrenal insufficiency. There were no significant between-group differences in mortality rate and variation in intravenous glucocorticoids (short-acting glucocorticoid, hydrocortisone; moderate-acting glucocorticoid, prednisolone or methylprednisolone; long-acting glucocorticoid, dexamethasone or betamethasone). Of the 19 dead patients, 15 were aged above 60 years, 12 had impaired consciousness at admission and 13 received insulin therapy. CONCLUSIONS Clinicians should be aware that older patients with impaired consciousness and diabetes mellitus are at relatively high risk of death from adrenal crisis.
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Affiliation(s)
- Yosuke Ono
- Department of General MedicineNational Defense Medical College, Tokorozawa, Saitama, Japan
| | - Sachiko Ono
- Department of Clinical Epidemiology and Health EconomicsSchool of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health EconomicsSchool of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health EconomicsSchool of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and InformaticsTokyo Medical and Dental University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Yuji Tanaka
- Department of General MedicineNational Defense Medical College, Tokorozawa, Saitama, Japan
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Rushworth RL, Torpy DJ, Falhammar H. Adrenal crises: perspectives and research directions. Endocrine 2017; 55:336-345. [PMID: 27995500 DOI: 10.1007/s12020-016-1204-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 12/08/2016] [Indexed: 01/25/2023]
Abstract
Adrenal crises are life-threatening complications of adrenal insufficiency. These events have an estimated incidence of between 5 and 10 adrenal crises/100 patient years and are responsible for some of the increased morbidity and excess mortality experienced by patients with adrenal insufficiency. Treatment involves urgent administration of IV/IM hydrocortisone and IV fluids. Patient education regarding preventive measures, such as increasing the dose of replacement therapy ("stress dosing") when sick, using parenteral hydrocortisone as necessary and accessing medical assistance promptly, is still considered the best approach to averting the onset of an adrenal crisis at times of physiological stress, most commonly an infection. However, recent evidence has demonstrated that patient education does not prevent many adrenal crisis events and the reasons for this are not fully understood. Furthermore, there is no widely accepted definition of an adrenal crisis. Without a validated adrenal crisis definition it is difficult to interpret variations in the incidence of adrenal crises and determine the effectiveness of preventive measures. This article aims to review the clinical aspects of adrenal crisis events, to explore the epidemiology, and to offer a definition of an adrenal crisis and to offer a perspective on future directions for research into adrenal crisis prevention.
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Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Sydney, NSW, Australia.
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research and Royal Darwin Hospital, Darwin, NT, Australia
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Hummel SR, Sadler S, Whitaker MJ, Ara RM, Dixon S, Ross RJ. A model for measuring the health burden of classic congenital adrenal hyperplasia in adults. Clin Endocrinol (Oxf) 2016; 85:361-98. [PMID: 26991412 DOI: 10.1111/cen.13060] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/03/2016] [Accepted: 03/15/2016] [Indexed: 11/30/2022]
Abstract
AIM Patients with classic congenital adrenal hyperplasia (CAH) have poor health outcomes. In the absence of a comprehensive observational study, this manuscript provides a model to estimate the lifetime disease burden of adults with classic CAH. METHODS The model, built in Excel, comprises subdomains addressing the health consequences of CAH and synthesises evidence from clinical and epidemiological studies on health outcomes. RESULTS The model estimates that adults with classic CAH will implement 'sick day rules' (doubling or tripling glucocorticoid and/or use of parenteral therapy) 171 times over their lifetime and attend hospital for adrenal crisis on 11 occasions. In a population of 1000, over 200 will die of a condition complicated by adrenal crisis resulting, on average, in a loss of 7 years of life. Patients with CAH may also suffer from excess CVD events. Treatment with glucocorticoids almost doubles the risk of bone fractures in patients with CAH compared to the general population, leading on average to an additional 0·8 fractures per patient with CAH over their lifetime. CONCLUSIONS The disease burden model highlights gaps in evidence, particularly regarding intensity of care and adrenal crisis, and the relationship between control of CAH and risks of CVD, osteoporosis, diabetes and infertility. The model can be used for research on the impact of new clinical pathways and therapeutic interventions in terms of clinical events and cost.
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Meyer G, Badenhoop K, Linder R. Addison's disease with polyglandular autoimmunity carries a more than 2·5-fold risk for adrenal crises: German Health insurance data 2010-2013. Clin Endocrinol (Oxf) 2016; 85:347-53. [PMID: 26896640 DOI: 10.1111/cen.13043] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 01/23/2016] [Accepted: 02/16/2016] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Adrenal crises are potentially life-threatening complications in patients with adrenal insufficiency (AI). Our objective was to investigate the frequency of adrenal crises in different forms of AI. DESIGN/PATIENTS The Statutory Health Insurance (SHI) database of the Techniker Krankenkasse - covering more than 12% of the German population - was analysed for diagnostic codes from 1 January 2010 to 31 December 2013. MEASUREMENTS By analysis of routine data from a large healthcare provider. Diagnoses of AI were recorded and classified in primary AI, secondary AI and autoimmune polyglandular syndrome (APS). The ICD-code E27·2 (AC) was retrieved in all cohorts. RESULTS We found a prevalence of 222/million for secondary and 126/million for primary AI. AC was documented with a frequency of 4·8/100 patient years. Crises were significantly more frequent in patients with primary (7·6/100 patient years) compared to those with secondary AI (3·2/100 patient years; P < 0·0001). Prevalence of crises was higher in individuals with APS (10·9/100 patient years) and highest in patients with primary AI and type 1 diabetes (12·5/100 patient years). CONCLUSIONS Applying a SHI database comprising more than 9 million individuals, we identified robust data about the risk of AC in different groups of patients with AI. Our data confirm and extend the clinical observation that patients with APS are at highest risk for AC. Approximately 1 of 8 patients with primary AI and type 1 diabetes suffers from an AC each year. Specific targeting of efforts aiming at the prevention of AC is necessary.
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Affiliation(s)
- Gesine Meyer
- Department of Medicine 1 - Endocrinology, Goethe-University Hospital, Frankfurt, Germany
| | - Klaus Badenhoop
- Department of Medicine 1 - Endocrinology, Goethe-University Hospital, Frankfurt, Germany
| | - Roland Linder
- WINEG, Scientific Institute of the TK for Benefit and Efficiency in Health Care, Hamburg, Germany
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Rushworth RL, Falhammar H, Munns CF, Maguire AM, Torpy DJ. Hospital Admission Patterns in Children with CAH: Admission Rates and Adrenal Crises Decline with Age. Int J Endocrinol 2016; 2016:5748264. [PMID: 26880914 PMCID: PMC4736605 DOI: 10.1155/2016/5748264] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/05/2015] [Accepted: 12/07/2015] [Indexed: 11/18/2022] Open
Abstract
Objective. To examine patterns of hospitalisation for acute medical conditions in children with congenital adrenal hyperplasia (CAH). Design. A retrospective study of hospitalisation using administrative data. Setting. All hospitals in NSW, Australia. Patients. All patients admitted with CAH and a random sample of admissions in patients aged 0 to 18 years without adrenal insufficiency (AI). Main Outcome Measures. Admissions and comorbidities by age and sex. Results. Of 573 admissions for medical problems in CAH children, 286 (49.9%) were in males, and 236 (41.2%) had a principal diagnosis of CAH or had an adrenal crisis (AC). 37 (6.5%) ACs were recorded. An infection was found in 43.5% (n = 249) of the CAH patient admissions and 51.7% (n = 1613) of the non-AI group, p < 0.001. Children aged up to one year had the highest number of admissions (n = 149) and six ACs (four in males). There were 21 ACs recorded for children aged 1-5 years. Older CAH children had fewer admissions and fewer ACs. No in-hospital deaths were recorded. Conclusions. Admission for medical problems in CAH children declines with age. An AC was recorded in 6.5% of the admissions, with the majority of ACs occurring in the 1 to 5 years age group and there were no deaths.
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Affiliation(s)
- R. Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Australia, 160 Oxford Street, Darlinghurst, NSW 2010, Australia
- *R. Louise Rushworth:
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, 171 76 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
- Menzies School of Health Research and Royal Darwin Hospital, 105 Rocklands Drive, Tiwi, NT 0810, Australia
| | - Craig F. Munns
- Endocrinology and Diabetes, The Children's Hospital Westmead, Hawkesbury Road, Westmead, NSW 2145, Australia
- Paediatrics and Child Health, Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia
| | - Ann M. Maguire
- Endocrinology and Diabetes, The Children's Hospital Westmead, Hawkesbury Road, Westmead, NSW 2145, Australia
| | - David J. Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, SA 5000, Australia
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