The epidemiology of primary and secondary adrenal malignancies and associated adrenal insufficiency in hospitalised patients: an analysis of hospital admission data, NSW, Australia

The Changing Epidemiology of Adrenal Insufficiency: Iatrogenic Factors Predominate

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.

Risk assessment, diagnosis, and treatment of cancer treatment-related adrenal insufficiency

INTRODUCTION

Adrenal insufficiency (AI) is an easily treatable, potentially life-threatening condition, which is increasingly recognized in malignancy. The recent introduction of immune checkpoint inhibitors, in particular, and increasing use of tyrosine kinase inhibitors have increased the frequency of AI in patients with malignancy. A review is therefore warranted to summarize current knowledge on the topic and guide safe clinical practices.

AREAS COVERED

Malignancy may directly impact the hypothalamic-pituitary-adrenal axis and cause AI, or their treatment including surgery, radiotherapy and medication. In this narrative review, we discuss new causes of AI, recognition of suggestive clinical features, diagnosis and subsequent treatment, aiming to avoid potentially fatal adrenal crisis (AC). Standard literature searching and authors assessment of clinical applicability were used.

EXPERT OPINION

Adrenal insufficiency can be easily treated once identified but life threatening if unrecognized. While use of new agents such as immune checkpoint inhibitors (ICIs) is increasing, greater understanding of the mechanism of AI is needed to target prediction tools and enhance risk stratification.