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Chen Cardenas SM, Santhanam P, Morris-Wiseman L, Salvatori R, Hamrahian AH. Perioperative Evaluation and Management of Patients on Glucocorticoids. J Endocr Soc 2022; 7:bvac185. [PMID: 36545644 PMCID: PMC9760550 DOI: 10.1210/jendso/bvac185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Indexed: 12/04/2022] Open
Abstract
Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.
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Affiliation(s)
- Stanley M Chen Cardenas
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Prasanna Santhanam
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lilah Morris-Wiseman
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Amir H Hamrahian
- Correspondence: Amir Hamrahian, MD, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 E Monument St, Ste 333, Baltimore, MD 21287, USA.
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Ishii T, Kashimada K, Amano N, Takasawa K, Nakamura-Utsunomiya A, Yatsuga S, Mukai T, Ida S, Isobe M, Fukushi M, Satoh H, Yoshino K, Otsuki M, Katabami T, Tajima T. Clinical guidelines for the diagnosis and treatment of 21-hydroxylase deficiency (2021 revision). Clin Pediatr Endocrinol 2022; 31:116-143. [PMID: 35928387 PMCID: PMC9297175 DOI: 10.1297/cpe.2022-0009] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
Congenital adrenal hyperplasia is a category of disorders characterized by impaired
adrenocortical steroidogenesis. The most frequent disorder of congenital adrenal
hyperplasia is 21-hydroxylase deficiency, which is caused by pathogenic variants of
CAY21A2 and is prevalent between 1 in 18,000 and 20,000 in Japan. The
clinical guidelines for 21-hydroxylase deficiency in Japan have been revised twice since a
diagnostic handbook in Japan was published in 1989. On behalf of the Japanese Society for
Pediatric Endocrinology, the Japanese Society for Mass Screening, the Japanese Society for
Urology, and the Japan Endocrine Society, the working committee updated the guidelines for
the diagnosis and treatment of 21-hydroxylase deficiency published in 2014, based on
recent evidence and knowledge related to this disorder. The recommendations in the updated
guidelines can be applied in clinical practice considering the risks and benefits to each
patient.
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Affiliation(s)
- Tomohiro Ishii
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Kenichi Kashimada
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Naoko Amano
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | | | - Shuichi Yatsuga
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
| | - Tokuo Mukai
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Shinobu Ida
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | | | | | | | | | | | | | - Toshihiro Tajima
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
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Isidori AM, Arnaldi G, Boscaro M, Falorni A, Giordano C, Giordano R, Pivonello R, Pofi R, Hasenmajer V, Venneri MA, Sbardella E, Simeoli C, Scaroni C, Lenzi A. COVID-19 infection and glucocorticoids: update from the Italian Society of Endocrinology Expert Opinion on steroid replacement in adrenal insufficiency. J Endocrinol Invest 2020; 43:1141-1147. [PMID: 32335855 PMCID: PMC7182741 DOI: 10.1007/s40618-020-01266-w] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 01/15/2023]
Affiliation(s)
- A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - G Arnaldi
- Clinica Di Endocrinologia E Malattie del Metabolismo, Azienda Ospedaliero-Universitaria, Università Politecnica Delle Marche, Ancona, Italy
| | - M Boscaro
- UOC Endocrinologia, Dipartimento Di Medicina DIMED, Azienda Ospedaliera-Università Di Padova, Padua, Italy
| | - A Falorni
- Dipartimento Di Medicina, Università Di Perugia, Perugia, Italy
| | - C Giordano
- Section of Diabetology, Endocrinology and Metabolism, PROMISE, University of Palermo, Palermo, Italy
| | - R Giordano
- Division of Endocrinology, Department of Clinical and Biological Sciences, Diabetes and Metabolism‑Department of Medical Sciences, University of Turin, Turin, Italy
| | - R Pivonello
- Cattedra Unesco "Educazione Alla Salute E Allo Sviluppo Sostenibile", Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Università Federico II Di Napoli, Naples, Italy
| | - R Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - V Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - M A Venneri
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - C Simeoli
- Cattedra Unesco "Educazione Alla Salute E Allo Sviluppo Sostenibile", Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Università Federico II Di Napoli, Naples, Italy
| | - C Scaroni
- UOC Endocrinologia, Dipartimento Di Medicina DIMED, Azienda Ospedaliera-Università Di Padova, Padua, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
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Prete A, Taylor AE, Bancos I, Smith DJ, Foster MA, Kohler S, Fazal-Sanderson V, Komninos J, O’Neil DM, Vassiliadi DA, Mowatt CJ, Mihai R, Fallowfield JL, Annane D, Lord JM, Keevil BG, Wass JAH, Karavitaki N, Arlt W. Prevention of Adrenal Crisis: Cortisol Responses to Major Stress Compared to Stress Dose Hydrocortisone Delivery. J Clin Endocrinol Metab 2020; 105:5805157. [PMID: 32170323 PMCID: PMC7241266 DOI: 10.1210/clinem/dgaa133] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/09/2020] [Indexed: 01/16/2023]
Abstract
CONTEXT Patients with adrenal insufficiency require increased hydrocortisone cover during major stress to avoid a life-threatening adrenal crisis. However, current treatment recommendations are not evidence-based. OBJECTIVE To identify the most appropriate mode of hydrocortisone delivery in patients with adrenal insufficiency who are exposed to major stress. DESIGN AND PARTICIPANTS Cross-sectional study: 122 unstressed healthy subjects and 288 subjects exposed to different stressors (major trauma [N = 83], sepsis [N = 100], and combat stress [N = 105]). Longitudinal study: 22 patients with preserved adrenal function undergoing elective surgery. Pharmacokinetic study: 10 patients with primary adrenal insufficiency undergoing administration of 200 mg hydrocortisone over 24 hours in 4 different delivery modes (continuous intravenous infusion; 6-hourly oral, intramuscular or intravenous bolus administration). MAIN OUTCOME MEASURE We measured total serum cortisol and cortisone, free serum cortisol, and urinary glucocorticoid metabolite excretion by mass spectrometry. Linear pharmacokinetic modeling was used to determine the most appropriate mode and dose of hydrocortisone administration in patients with adrenal insufficiency exposed to major stress. RESULTS Serum cortisol was increased in all stress conditions, with the highest values observed in surgery and sepsis. Continuous intravenous hydrocortisone was the only administration mode persistently achieving median cortisol concentrations in the range observed during major stress. Linear pharmacokinetic modeling identified continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone, as best suited for maintaining cortisol concentrations in the required range. CONCLUSIONS Continuous intravenous hydrocortisone infusion should be favored over intermittent bolus administration in the prevention and treatment of adrenal crisis during major stress.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - David J Smith
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- School of Mathematics, University of Birmingham, Birmingham, UK
| | - Mark A Foster
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Sibylle Kohler
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Violet Fazal-Sanderson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - John Komninos
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Donna M O’Neil
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Christopher J Mowatt
- Department of Anaesthesiology, Royal Shrewsbury Hospital, The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford, UK
| | | | - Djillali Annane
- Critical Care Department, Hôpital Raymond-Poincaré, Laboratory of Infection & Inflammation U1173 INSERM/University Paris Saclay-UVSQ, Garches, France
| | - Janet M Lord
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Brian G Keevil
- Department of Clinical Biochemistry, University Hospital of South Manchester, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - John A H Wass
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Correspondence and Reprint Requests: Wiebke Arlt, MD, DSc, FRCP, FMedSci, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK. E-mail:
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