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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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Arshad MF, Elder C, Newell-Price J, Ross R, Debono M. A retrospective study on weaning glucocorticoids and recovery of the hypothalamic-pituitary-adrenal axis. J Clin Endocrinol Metab 2024:dgae059. [PMID: 38298131 DOI: 10.1210/clinem/dgae059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/09/2024] [Accepted: 01/26/2024] [Indexed: 02/02/2024]
Abstract
CONTEXT Glucocorticoids suppress the hypothalamic-pituitary-adrenal (HPA) axis resulting in tertiary adrenal insufficiency (AI). When weaning patients off glucocorticoids there is no consensus on whether to maintain patients on prednisolone or convert to hydrocortisone. OBJECTIVE Investigate HPA axis recovery in patients on long-term prednisolone and assess outcome after hydrocortisone conversion. DESIGN Retrospective cohort study. SETTING Outpatient endocrine steroid clinic. PATIENTS Patients on long-term prednisolone referred for HPA axis testing between 2015-2022. MAIN OUTCOMES MEASURED 1) HPA axis recovery rate in patients on prednisolone demonstrated by normal ACTH stimulation test (AST).2) HPA axis recovery rate sub-analysis of dose-matched patients with confirmed tertiary AI on prednisolone or hydrocortisone. RESULTS 206 patients on prednisolone were tested for tertiary AI. Of these 176 remained on prednisolone while 30 were converted to hydrocortisone. The overall HPA axis recovery rate for patients on prednisolone after interval testing was 137/206 (66.5%). HPA axis recovery rate in dose-matched prednisolone and hydrocortisone conversion groups was 7/10 (70%) and 2/13 (15%) (p=0.008), respectively. There was no difference in mean (SD) age (67.1(12.2) v 63.4(11.1) years; p=0.464) and baseline cortisol (5.3(4.2) v 4.6(3.1)µg/dL; p=0.648) and median [IQR] glucocorticoids duration (1213[1114] v 2316[4808] days; p=0.693) and baseline ACTH (20.5[29.0] v 16.3[14.8]ng/L; p=0.905) between dose-matched prednisolone and hydrocortisone groups. Follow-up duration in prednisolone group was significantly lower (median [IQR] 348[975] v 667[884] days; p=0.012). CONCLUSIONS Patients with glucocorticoid induced AI maintained on once-daily prednisolone can recover HPA axis function when weaning. There is no apparent advantage to recover HPA axis function in converting to multiple dosing hydrocortisone.
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Affiliation(s)
- Muhammad Fahad Arshad
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Charlotte Elder
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - John Newell-Price
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Richard Ross
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
| | - Miguel Debono
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Bulut Y, Brandt-Jacobsen N, Buhl L, Schou M, Frystyk J, Kistorp C, Rasmussen JJ. Persistently Decreased Quality of Life and its Determinants in Previous Illicit Androgen Users. J Clin Endocrinol Metab 2024; 109:e689-e697. [PMID: 37708363 DOI: 10.1210/clinem/dgad551] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/06/2023] [Accepted: 09/12/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Quality of life (QoL) has never been assessed in previous illicit users of androgens years following androgen cessation. Therefore, the objective of this study was to assess QoL in previous illicit androgen users compared with current illicit androgen users and controls who had never used androgens. METHODS Cross-sectional study including men involved in recreational strength training grouped according to their history of androgen use. We used the RAND Short-Form-36 questionnaire to assess physical and mental health-related QoL. RESULTS We included 77 previous and 118 current androgen users and 39 healthy nonusers. The mean (SD) age of all participants was 33 (8) years. The elapsed duration since androgen cessation, geometric mean (95% CI), was 2.0 (1.5-2.6) years in former users. Median (25th-75th percentiles) serum total testosterone was lower in former users than controls, 14 (11-17) vs 19 (16-21) nmol/L, P < .001. Previous users displayed lower mean (SD) across both mental and physical (PCS) component summary scores, 48 (10) vs 54 (4) (P = .004) and 48 (9) vs 53 (3) (P = .002) compared with controls.Using multivariate linear regressions, evaluating physical and mental component scores as dependent variables, lower serum total testosterone, longer duration since androgen cessation, study recruitment from an endocrine outpatient clinic, and established chronic diseases were all independently associated with reduced QoL in previous users, P < .05. CONCLUSIONS Previous illicit androgen users exhibited reduced QoL 2 years after androgen discontinuation, which may be a persistent condition.
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Affiliation(s)
- Yeliz Bulut
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, DK-2200, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Denmark, Copenhagen, DK-2200, Denmark
| | - Niels Brandt-Jacobsen
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, DK-2200, Denmark
| | - Laust Buhl
- Department of Endocrinology, Odense University Hospital, Odense, DK-5000, Denmark
- Faculty of Health Sciences, University of Southern Denmark, Odense, DK-5230, Denmark
| | - Morten Schou
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Denmark, Copenhagen, DK-2200, Denmark
- Department of Cardiology, Herlev/Gentofte University Hospital, Herlev, DK-2730, Denmark
| | - Jan Frystyk
- Department of Endocrinology, Odense University Hospital, Odense, DK-5000, Denmark
- Faculty of Health Sciences, University of Southern Denmark, Odense, DK-5230, Denmark
| | - Caroline Kistorp
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, DK-2200, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Denmark, Copenhagen, DK-2200, Denmark
| | - Jon Jarløv Rasmussen
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, DK-2200, Denmark
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Carsote M, Nistor C. Addison's Disease: Diagnosis and Management Strategies. Int J Gen Med 2023; 16:2187-2210. [PMID: 37287503 PMCID: PMC10243343 DOI: 10.2147/ijgm.s390793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 05/29/2023] [Indexed: 06/09/2023] Open
Abstract
We aim to overview Addison's disease (AD) with regard to current diagnosis and management. This is a narrative review of full-length articles published in English between January 2022 and December 2022 (including online ahead of print versions) in PubMed-indexed journals. We included original studies in living humans regardless of the level of statistical significance starting from the key search terms "Addison's disease" or "primary adrenal insufficiency" in title or abstract. We excluded articles with secondary adrenal insufficiency. Briefly, 199 and 355 papers, respectively were identified; we manually checked each of them, excluded the duplicates, and then selected 129 based on their clinical relevance in order to address our 1-year analysis. We organized the data in different subsections covering all published aspects on the subject of AD. To our knowledge, this is the largest AD retrospective from 2022 on published data. A massive role of genetic diagnosis especially in pediatric cases is highlighted; the importance of both pediatric and adult awareness remains since unusual presentations continue to be described. COVID-19 infection is a strong player amid this third year of pandemic although we still not do have large cohorts in this particular matter as seen, for instance, in thyroid anomalies. In our opinion, the most important topic for research is immune checkpoint inhibitors, which cause a large panel of endocrine side effects, AD being one of them.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Department of Gonads and Infertility, “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania
| | - Claudiu Nistor
- Department 4 – Cardio -Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Thoracic Surgery Department, “Dr. Carol Davila” Central Emergency University Military Hospital, Bucharest, Romania
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