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Hee NKY, Lim QH, Paramasivam S, Lim LL, Vethakkan S, Ganapathy SS, Ratnasingam J. The use of prednisolone during Ramadan fasting in patients with adrenal insufficiency. Clin Endocrinol (Oxf) 2024; 100:221-229. [PMID: 38031259 DOI: 10.1111/cen.14999] [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] [Received: 08/04/2023] [Revised: 10/24/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE Once daily prednisolone taken at predawn has been proposed to be the glucocorticoid replacement of choice in patients with adrenal insufficiency (AI) who intend to fast for the month of Ramadan. However, the effects of prednisolone on metabolic parameters and quality of life during fasting for Ramadan are unknown. DESIGN, PATIENTS AND MEASUREMENTS Patients with AI on twice-daily hydrocortisone, who had low or moderate risk and intended to fast, were recruited. Patients were converted to prednisolone 5 mg once daily taken at sahur (predawn) and Ramadan education given. Weight, sleep duration, biochemical parameters and quality of life measures (SF-36 questionnaire) were analysed at the end of Ramadan and compared against baseline. RESULTS Twenty patients (13 men) were recruited, with a mean age of 59.9 ± 15.0 years. All patients were on hydrocortisone 15 mg daily (in divided doses) as pre-Ramadan glucocorticoid replacement. Half had type 2 diabetes with low IDF-DAR risk. Eighty-five percent of patients completed the full 29 days of fasting with no complications. There was a significant reduction in weight (-1.1 ± 1.6 kg, p = .005), with no significant change in blood pressure or sleep duration. There was a significant increase in urea (0.80 ± 1.1 mmol/L, p = .005) and haematocrit, (0.011 ± 0.019 L/L, p = .019) and decrease in serum sodium (-1.6 ± 3.0 mmol/L, p = .028), with no change in serum creatinine or liver function. Quality of life measures were preserved in all domains with significant improvement in role limitation due to physical health (15.3 ± 21.6, p = .005) and bodily pain (8.8 ± 16.3, p = .031). CONCLUSIONS This study has demonstrated that converting patients with AI who are fasting for Ramadan from twice-daily hydrocortisone to prednisolone 5 mg daily at sahur was safe, with no major short-term adverse effects. Despite the higher equivalent glucocorticoid doses, patients experienced weight loss and no clinically significant change in blood pressure, sleep, biochemical parameters or quality of life. This study paves the way to trial even lower doses of prednisolone once daily in patients fasting for Ramadan with AI.
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Affiliation(s)
- Nicholas Ken Yoong Hee
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Quan Hziung Lim
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Sharmila Paramasivam
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Lee Ling Lim
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shireene Vethakkan
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shubash Shander Ganapathy
- Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
| | - Jeyakantha Ratnasingam
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
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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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Caetano CM, Malchoff CD. Daily Glucocorticoid Replacement Dose in Adrenal Insufficiency, a Mini Review. Front Endocrinol (Lausanne) 2022; 13:897211. [PMID: 35846313 PMCID: PMC9276933 DOI: 10.3389/fendo.2022.897211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/18/2022] [Indexed: 11/23/2022] Open
Abstract
The Endocrine Society Guidelines and recent reviews of adrenal insufficiency (AI) recommend a daily glucocorticoid replacement dose of 15 to 25 mg with a midpoint of 20 mg of hydrocortisone (HC) (alternatively 3 to 5 mg prednisolone) in divided doses in otherwise healthy individuals with AI. In contrast, a daily glucocorticoid replacement dose of 4.3 to 26 mg/d HC with a midpoint of 15 mg/d is predicted from current measurements of daily cortisol production rates and oral HC bioavailability. The higher HC doses recommended in the current guidelines may result in glucocorticoid overtreatment of some AI patients and associated long-term adverse outcomes. A titration method for determination of the individual patient's daily glucocorticoid replacement dose and the impact of lower doses are reviewed. Future related research questions are identified.
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Wilkes EH, Whitlock MJ, Williams EL. A data-driven approach for the detection of internal standard outliers in targeted LC-MS/MS assays. J Mass Spectrom Adv Clin Lab 2021; 20:42-47. [PMID: 34820670 PMCID: PMC8600994 DOI: 10.1016/j.jmsacl.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 11/30/2022] Open
Abstract
Identifying internal standard outliers in clinical mass spectrometry assays is imperative. Current approaches for identifying outliers are arbitrary and do not account for assay drift. A robust modelling strategy allows laboratories to define their own acceptance criteria from their own data. This strategy is easily implemented and the code is freely available.
Heavy-labelled internal standard (IS) compounds are commonly used in liquid chromatography-tandem mass spectrometry (LC-MS/MS) assays to control for stochastic and systematic variation. Identifying samples that suffer from unwanted variation is critically important in order to avoid factitiously inaccurate results. Current approaches for outlier detection typically employ arbitrary thresholds and ignore systematic drift. To improve this, we applied robust linear mixed-effects models (LMMs) to capture the within- and between-run variability in IS signal and generate data-driven acceptance ranges for routine use. Data from in-house LC-MS/MS assays for 25-hydroxyvitamin D3 and D2 and prednisolone were retrospectively collected. The variation in the percentage deviation of the internal standard area from the mean of the calibrators was modelled through the use of robust LMMs. The fitted LMMs revealed significant positive drift in IS signal over the analytical runs for vitamin D, with slope coefficients of 0.118 (95% CI: 0.098, 0.138) and 0.192 (0.168, 0.215) for D3 and D2, respectively. In contrast, the models for prednisolone demonstrated a significant negative drift in IS signal, with a slope coefficient of −0.164 (−0.297, −0.036). Non-parametric, cluster bootstrap resampling enabled us to define acceptance ranges for use in future assays. Here, we have described a computational approach to extensively characterise the variation in IS signal in routinely-performed LC-MS/MS assays. This approach facilitates a robust quality assessment of IS outliers in routine practice and thus has the potential to improve patient safety. Importantly, this approach is applicable to other MS assays where linear variation in IS signal is observed.
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Affiliation(s)
- E H Wilkes
- Department of Clinical Biochemistry, North West London Pathology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom
| | - M J Whitlock
- Department of Clinical Biochemistry, North West London Pathology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom
| | - E L Williams
- Department of Clinical Biochemistry, North West London Pathology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom
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Chihaoui M, Yazidi M, Oueslati I, Khessairi N, Chaker F. Intermittent fasting in adrenal insufficiency patients: a review and guidelines for practice. Endocrine 2021; 74:11-19. [PMID: 34213700 DOI: 10.1007/s12020-021-02804-z] [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] [Received: 04/05/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
Ramadan fasting is a religious duty for adult Muslims. Even though sick people are exempted from fasting, numerous are those who insist on fasting, and seek advice from their physicians. The role of the physician is to support his patient and preserve his health. However, little is known about intermittent fasting in adrenal insufficiency. The aim of this review was to determine the risks of fasting in patients with adrenal insufficiency, the subjects at risk of complications, and the measures that can be undertaken for safe fasting. The analysis of the data of the different studies showed that there is a risk of complications during fasting in these patients. Optimal glucocorticoid replacement therapy for safe fasting has not yet been determined. Finally, a risk stratification and the modalities of the pre-Ramadan visit for adrenal insufficiency fasting patients have been suggested.
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Affiliation(s)
- Melika Chihaoui
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Meriem Yazidi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Nadia Khessairi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Suehs CM, Menzies-Gow A, Price D, Bleecker ER, Canonica GW, Gurnell M, Bourdin A. Expert Consensus on the Tapering of Oral Corticosteroids for the Treatment of Asthma. A Delphi Study. Am J Respir Crit Care Med 2021; 203:871-881. [PMID: 33112646 DOI: 10.1164/rccm.202007-2721oc] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: There is a need to minimize oral corticosteroid (OCS) use in patients with asthma to prevent their costly and burdensome adverse effects. Current guidelines do not provide recommendations for OCS tapering in patients with asthma.Objectives: To develop expert consensus on OCS tapering among international experts.Methods: A modified Delphi method was used to develop expert consensus statements relating to OCS use, tapering, adverse effects, adrenal insufficiency, and patient-physician shared decision-making. Initial statements proposed by experts were categorized, filtered for repetition, and presented back to experts over three ranking rounds to obtain consensus (≥70% agreement).Measurements and Main Results: One hundred thirty-one international experts participated in the study, and 296 statements were ranked. Numerous recommendations and guidance regarding appropriate OCS use were established. Experts agreed that OCS tapering should be attempted in all patients with asthma receiving maintenance OCS therapy, with personalization of tapering rhythm and speed. The importance of recognizing individual adverse effects was also established; however, a unified approach to the assessment of adrenal insufficiency was not reached. Shared decision-making was considered an important goal during the tapering process.Conclusions: In this Delphi study, expert consensus statements were generated on OCS use, tapering, adverse-effect screening, and shared decision-making, which may be used to inform clinical practice. Areas of nonconsensus were identified, highlighting uncertainty among the experts around some aspects of OCS use in asthma, such as adrenal insufficiency, which underscores the need for further research in these domains.
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Affiliation(s)
| | - Andrew Menzies-Gow
- PhyMedExp, Université de Montpellier, Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - David Price
- Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom.,Observational and Pragmatic Research Institute, Singapore
| | - Eugene R Bleecker
- Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
| | | | - Mark Gurnell
- Personalized Medicine, Asthma and Allergy Center, Humanitas University and IRCCS Research Hospital, Milan, Italy; and.,Wellcome Trust-Medical Research Council Institute of Metabolic Science and
| | - Arnaud Bourdin
- Département des Maladies Respiratoires and.,Cambridge National Institute for Health Research Biomedical Research Centre, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
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Choudhury S, Tan T, Lazarus K, Meeran K. The use of prednisolone versus dual-release hydrocortisone in the treatment of hypoadrenalism. Endocr Connect 2021; 10:R66-R76. [PMID: 33449916 PMCID: PMC7983484 DOI: 10.1530/ec-20-0473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/06/2021] [Indexed: 02/03/2023]
Abstract
The introduction of adrenocortical extract in 1930 improved the life expectancy of hyhpoadrenal patients, with further increases seen after the introduction of cortisone acetate from 1948. Most patients are now treated with synthetic hydrocortisone, and incremental advances have been made with optimisation of daily dosing and the introduction of multidose regimens. There remains a significant mortality gap between individuals with treated hypoadrenalism and the general population. It is unclear whether this gap is a result of glucocorticoid over-replacement, under-replacement or loss of the circadian and ultradian rhythm of cortisol secretion, with the risk of detrimental excess glucocorticoid exposure at later times in the day. The way forwards will involve replacement of the diurnal cortisol rhythm with better glucocorticoid replacement regimens. The steroid profile produced by both prednisolone and dual-release hydrocortisone (Plenadren), provide a smoother glucocorticoid profile of cortisol than standard oral multidose regimens of hydrocortisone and cortisone acetate. The individualisation of prednisolone doses and lower bioavailability of Plenadren offer reductions in total steroid exposure. Although there is emerging evidence of both treatments offering better cardiometabolic outcomes than standard glucocorticoid replacement regimens, there is a paucity of evidence involving very low dose prednisolone (2-4 mg daily) compared to the larger doses (~7.5 mg) historically used. Data from upcoming clinical studies on prednisolone will therefore be of key importance in informing future practice.
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Affiliation(s)
- Sirazum Choudhury
- Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, Commonwealth Building, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Tricia Tan
- Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, Commonwealth Building, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Katharine Lazarus
- Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, Commonwealth Building, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Karim Meeran
- Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, Commonwealth Building, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Correspondence should be addressed to K Meeran:
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8
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Chihaoui M, Madhi W, Yazidi M, Hammami B, Oueslati I, Khessairi N, Grira W, Bibi A, Feki M, Chaker F. Salivary cortisol levels during Ramadan fasting in hydrocortisone-treated secondary adrenal insufficiency patients. Endocrine 2020; 70:404-411. [PMID: 32789535 DOI: 10.1007/s12020-020-02452-9] [Citation(s) in RCA: 3] [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: 05/26/2020] [Accepted: 08/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Patients with adrenal insufficiency have difficulties in fasting during the month of Ramadan with an increased risk of complications. Cortisol levels are unknown in these patients. The objective of this study was to assess the daily cortisol profile in hydrocortisone-treated patients with secondary adrenal insufficiency (SAI) and healthy controls during a fasting day. METHODS A cross-sectional matched case-control study on 50 hydrocortisone-treated SAI patients and 69 controls who are used to fast. Clinical and therapeutic data were collected. Five salivary samples for cortisol measurement were collected throughout a fasting day of the third week of Ramadan 2019. RESULTS Salivary cortisol levels were significantly higher on awakening, at midnight and before the predawn meal in patients compared with controls. The circadian cortisol rhythm was disrupted in patients. The area under the salivary cortisol level versus time curve (AUC) was lower than the 2.5th percentile of the controls in one patient (2.5%) and higher than the 97.5th percentile in 23 patients (59%) who were considered overtreated. Age ≥ 35 years was independently associated with overtreatment (adjusted odds ratio = 12.0; 95% CI (2.0-70.4); p = 0.006). Seven patients broke their fasting for a complication compared with no one of the controls (p = 0.001). No factor was associated with this risk. CONCLUSIONS Salivary cortisol levels were high in fasting hydrocortisone-treated SAI patients with a disruption of the circadian rhythm.
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Affiliation(s)
- Melika Chihaoui
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Wiem Madhi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Bessem Hammami
- Department of Biochemistry, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Nadia Khessairi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Wafa Grira
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Amina Bibi
- Department of Biochemistry, National Institute of Nutrition, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Moncef Feki
- Department of Biochemistry, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Hussain S, Hussain S, Mohammed R, Meeran K, Ghouri N. Fasting with adrenal insufficiency: Practical guidance for healthcare professionals managing patients on steroids during Ramadan. Clin Endocrinol (Oxf) 2020; 93:87-96. [PMID: 32419166 DOI: 10.1111/cen.14250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/24/2023]
Abstract
There are limited recommendations for fasting in many chronic diseases such as adrenal insufficiency (AI). Research in such situations highlights potential for complications and need for education for patients with AI undertaking fasting during Ramadan. This article aimed to provide up-to-date guidance for healthcare professionals to educate, discuss and manage patients with AI who are considering fasting in Ramadan and is religiously compatible. Latest guidance on this topic and the evidence base for steroid dosing are reviewed and discussed. Risk stratification for patients with AI and optimal strategies for management, including steroid dosing, are detailed. Our review highlights that patients with AI wishing to fast should undergo a thorough risk assessment ideally several months before Ramadan. 'High risk' and 'Very high risk' patients should be encouraged to explore alternative options to fasting discussed below. Prior to the commencement of Ramadan, all patients must receive up-to-date education on sick day rules, instructions on when to terminate their fast or abstain from fasting, carry steroid warning information and must have a valid intramuscular (IM) hydrocortisone pack and know how to administer this. Switching patients with AI desiring to fast from multiple daily hydrocortisone replacement to prednisolone 5 mg once daily at dawn (during Suhoor or Sehri) is recommended and discussed. Patients on fludrocortisone for AI should be advised to take their total dose at dawn. We provide practically relevant case-based scenarios to help with the application of this guidance. Future efforts need to focus on healthcare professional awareness and further research in this setting.
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Affiliation(s)
- Sufyan Hussain
- Department of Diabetes and Endocrinology, Guy's and St Thomas' Hospital NHS Trust, London, UK
- Department of Diabetes and Endocrinology, King's College London, London, UK
| | - Shazia Hussain
- Department of Diabetes and Endocrinology, Barts Health NHS Trust, London, UK
| | | | - Karim Meeran
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Imperial College London, London, UK
- Department of Diabetes and Endocrinology, Imperial College London NHS Trust, London, UK
| | - Nazim Ghouri
- Department of Diabetes and Endocrinology, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Queen Elizabeth University Hospital, Glasgow, UK
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Isidori AM, Arnaldi G, Boscaro M, Falorni A, Giordano C, Giordano R, Pivonello R, Pozza C, Sbardella E, Simeoli C, Scaroni C, Lenzi A. Towards the tailoring of glucocorticoid replacement in adrenal insufficiency: the Italian Society of Endocrinology Expert Opinion. J Endocrinol Invest 2020; 43:683-696. [PMID: 31773582 DOI: 10.1007/s40618-019-01146-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/11/2019] [Indexed: 11/28/2022]
Abstract
CONTEXT Glucocorticoid (GC) replacement therapy in patients with adrenal insufficiency (AI) is life saving. After over 50 years of conventional GC treatment, novel formulations are now entering routine clinical practice. METHODS Given the spectrum of medications currently available and new insights into the understanding of AI, the authors reviewed relevant medical literature with emphasis on original studies, prospective observational data and randomized controlled trials performed in the past 35 years. The Expert Opinion of a panel of selected endocrinologists was sought to answer specific clinical questions. The objective was to provide an evidence-supported guide, for the use of GC in various settings from university hospitals to outpatient clinics, that offers specific advice tailored to the individual patient. RESULTS The Panel reviewed available GC replacement therapies, comprising short-acting, intermediate and long-acting oral formulations, subcutaneous formulations and the novel modified-release hydrocortisone. Advantages and disadvantages of these formulations were reviewed. CONCLUSIONS In the Panel's opinion, achieving the optimal GC timing and dosing is needed to improve the outcome of AI. No-single formulation offers the best option for every patients. Recent data suggest that more emphasis should be given to the timing of intake. Tailoring of GS should be attempted in all patients-by experts-on a case-by-case basis. The Panel identified specific subgroups of AI patients that could be help by this process. Long-term studies are needed to confirm the short-term benefits associated with the modified-release GCs. The impact of GC tailoring has yet to be proven in terms of hospitalization rate, morbidity and mortality.
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Affiliation(s)
- A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, 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
- Department of Clinical and Biological Sciences, Division of Endocrinology, Diabetes and Metabolism-Department of Medical Sciences, University of Turin, Turin, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - C Pozza
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - C Simeoli
- 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, Rome, Italy
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11
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Use of glucocorticoids in the critical care setting: Science and clinical evidence. Pharmacol Ther 2020; 206:107428. [DOI: 10.1016/j.pharmthera.2019.107428] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023]
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12
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Chihaoui M, Mimita W, Oueslati I, Rejeb O, Ben Amor Z, Grira W, Yazidi M, Chaker F. Prednisolone or hydrocortisone replacement in patients with corticotrope deficiency fasting during Ramadan result in similar risks of complications and quality of life: a randomized double-blind controlled trial. Endocrine 2020; 67:155-160. [PMID: 31552584 DOI: 10.1007/s12020-019-02082-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 09/03/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The aims of the study were to compare the risk of complications and the quality of life in patients with corticotrope deficiency, who fasted during Ramadan. Both hydrocortisone and prednisolone were compared as treatments. METHODS A randomized double-blind crossover clinical trial conducted in the department of Endocrinology of the University Hospital la Rabta in Tunis, during Ramadan 2018, on 53 patients with known corticotrope deficiency treated with hydrocortisone 20 mg per day and who were willing to fast during Ramadan. Patients were randomized into two groups; AB that received hydrocortisone twice daily for 14 days then prednisolone once daily with a placebo for 14 days and group BA that received the two treatments in the reverse order. Patients had to complete a daily follow-up sheet about their eating and sleeping habits, the occurrence of complications and blood glucose monitoring and also to respond to the AddiQoL questionnaire at the end of each treatment period. RESULTS Fifty patients' data were analyzed; 29 men, mean age: 42.4 ± 13.3 years, mean duration of the disease: 8.1 ± 7.6 years. The frequency of complications, mean blood glucose levels and the quality of life did not differ on hydrocortisone compared to prednisolone after adjustment for the sequence of the treatment. CONCLUSIONS the risks of Ramadan fasting in patients with corticotrope deficiency were the same on hydrocortisone or prednisolone.
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Affiliation(s)
- Melika Chihaoui
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Wafa Mimita
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ons Rejeb
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Zohra Ben Amor
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Wafa Grira
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Valentin A, Borresen SW, Rix M, Elung-Jensen T, Sørensen SS, Feldt-Rasmussen U. Adrenal insufficiency in kidney transplant patients during low-dose prednisolone therapy: a cross-sectional case–control study. Nephrol Dial Transplant 2019; 35:2191-2197. [DOI: 10.1093/ndt/gfz180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Indexed: 12/31/2022] Open
Abstract
Abstract
Background
Maintenance immunosuppressive regimens after renal transplantation (RTx) most often include prednisolone, which may induce secondary adrenal insufficiency, a potentially life-threatening side effect to glucocorticoid (GC) treatment due to the risk of acute adrenal crisis. We investigated the prevalence of prednisolone-induced adrenal insufficiency in RTx patients receiving long-term low-dose prednisolone treatment.
Methods
We performed a case–control study of patients on renal replacement therapy differing in terms of GC exposure. The study included 30 RTx patients transplanted >11 months before enrolment in the study and treated with prednisolone (5 or 7.5 mg prednisolone/day for ≥6 months) and 30 dialysis patients not treated with prednisolone. Patients underwent testing for adrenal insufficiency by a 250-µg Synacthen test performed fasting in the morning after a 48-h prednisolone pause. Normal adrenal function was defined as P-cortisol ≥420 nmol/L 30 min after Synacthen injection. This cut-off is used routinely for the new Roche Elecsys Cortisol II assay and is validated locally based on the Synacthen test responses in 100 healthy individuals.
Results
Thirteen RTx patients {43% [95% confidence interval (CI) 27–61]} had an insufficient response to the Synacthen test compared with one patient in the control group [3% (95% CI 0.6–17)] (P = 0.0004). Insufficient responses were seen in 9/25 and 4/5 RTx patients treated with 5 and 7.5 mg prednisolone/day, respectively.
Conclusions
We found a high prevalence of adrenal insufficiency among RTx patients receiving low-dose prednisolone treatment. We therefore advocate for increased clinical alertness towards prednisolone-induced adrenal insufficiency in RTx patients and thus their potential need of rescue GC supplementation during stress.
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Affiliation(s)
- Amalie Valentin
- Department of Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Stina Willemoes Borresen
- Department of Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Elung-Jensen
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Schwartz Sørensen
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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14
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Choudhury S, Lightman S, Meeran K. Improving glucocorticoid replacement profiles in adrenal insufficiency. Clin Endocrinol (Oxf) 2019; 91:367-371. [PMID: 31017681 DOI: 10.1111/cen.13999] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 12/11/2022]
Abstract
There is an increased mortality associated with adrenal insufficiency despite glucocorticoid replacement therapy with a standardized mortality ratio greater than two. The cause of the increased mortality is yet to be definitively elucidated, but may be due to excess steroid exposure, or replacement regimens that are uncoupled from the normal physiological cortisol profile. Cortisol secretion follows an ultradian pattern which is not possible to reproduce using oral replacement. With the advent of new pumps, it is now possible to mimic the pulsatility of the adrenal glands. While the cognitive and emotional benefits of reproducing the ultradian rhythm are known, the presence of long-term benefits is not yet clear. There is a dearth of evidence and high-quality studies to underline our current understanding of the pathophysiology of adrenal insufficiency and replacement therapy. There is a particular lack of research comparing objective outcomes between patients receiving hydrocortisone replacement (either standard therapy or new sustained release preparations), prednisolone replacement and ultradian pumps. Direct comparative studies are now warranted to understand the optimal approach.
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Affiliation(s)
- Sirazum Choudhury
- Department of Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Stafford Lightman
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, Department of Translational Health Science, University of Bristol, Bristol, UK
| | - Karim Meeran
- Department of Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
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15
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Choudhury S, Machenahalli P, Tan T, Meeran K. Inadvertent treatment of hypoadrenalism with prednisolone in pemphigus: A case report. Clin Case Rep 2019; 7:987-989. [PMID: 31110731 PMCID: PMC6510007 DOI: 10.1002/ccr3.2132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/04/2019] [Accepted: 03/14/2019] [Indexed: 01/09/2023] Open
Abstract
Pituitary and adrenal insufficiency must not be overlooked when weaning patients down from high-dose steroids. Prednisolone can be used as glucocorticoid replacement therapy, with most patients needing 3-4 mg once daily.
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Affiliation(s)
- Sirazum Choudhury
- Section of Investigative Medicine, Division of Diabetes, Endocrinology and MetabolismImperial College LondonLondonUK
- Department of Clinical BiochemistryImperial College Healthcare NHS TrustLondonUK
| | | | - Tricia Tan
- Section of Investigative Medicine, Division of Diabetes, Endocrinology and MetabolismImperial College LondonLondonUK
- Department of Clinical BiochemistryImperial College Healthcare NHS TrustLondonUK
- EndocrinologyImperial College Healthcare NHS TrustLondonUK
| | - Karim Meeran
- Section of Investigative Medicine, Division of Diabetes, Endocrinology and MetabolismImperial College LondonLondonUK
- EndocrinologyImperial College Healthcare NHS TrustLondonUK
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16
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Oprea A, Bonnet NCG, Pollé O, Lysy PA. Novel insights into glucocorticoid replacement therapy for pediatric and adult adrenal insufficiency. Ther Adv Endocrinol Metab 2019; 10:2042018818821294. [PMID: 30746120 PMCID: PMC6360643 DOI: 10.1177/2042018818821294] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 12/04/2018] [Indexed: 02/04/2023] Open
Abstract
Adrenal insufficiency is defined as impaired adrenocortical hormone synthesis. According to its source, the deficit is classified as primary (adrenal steroidogenesis impairment), secondary (pituitary adrenocorticotropic hormone deficit) or tertiary (hypothalamic corticotropin-releasing hormone deficit). The management of adrenal insufficiency resides primarily in physiological replacement of glucocorticoid secretion. Standard glucocorticoid therapy is shrouded in several controversies. Along the difficulties arising from the inability to accurately replicate the pulsatile circadian cortisol rhythm, come the uncertainties of dose adjustment and treatment monitoring (absence of reliable biomarkers). Furthermore, side effects of inadequate replacement significantly hinder the quality of life of patients. Therefore, transition to circadian hydrocortisone therapy gains prominence. Recent therapeutic advancements consist of oral hydrocortisone modified-release compounds (immediate, delayed and sustained absorption formulations) or continuous subcutaneous hydrocortisone infusion. In addition to illustrating the current knowledge on conventional glucocorticoid regimens, this review outlines the latest research outcomes. We also describe the management of pediatric patients and suggest a novel strategy for glucocorticoid replacement therapy in adults.
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Affiliation(s)
- Alina Oprea
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Nicolas C. G. Bonnet
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Olivier Pollé
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Philippe A. Lysy
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Pôle PEDI, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Av. Hippocrate 10, B-1200 Brussels, Belgium
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17
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Al-Essah Z, Meeran K. Does quality of life differ in patients with Addison's disease on different glucocorticoid therapies? Endocrine 2018; 62:740. [PMID: 30132260 DOI: 10.1007/s12020-018-1716-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/09/2018] [Indexed: 10/28/2022]
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18
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De Lucena DD, Rangel ÉB. Glucocorticoids use in kidney transplant setting. Expert Opin Drug Metab Toxicol 2018; 14:1023-1041. [DOI: 10.1080/17425255.2018.1530214] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Débora Dias De Lucena
- Department of Medicine, Division of Nephrology, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, Brazil
| | - Érika Bevilaqua Rangel
- Department of Medicine, Division of Nephrology, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, Brazil
- Instituto Israelita de Ensino e Pesquisa, Hospital Israelita Albert Einstein, São Paulo, Brazil
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19
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Affiliation(s)
| | - Karim Meeran
- Imperial College, Endocrinology and Diabetes, Charing Cross Hospital, London, UK.
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20
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Choudhury S, Tan T, Meeran K. Once-daily, modified-release hydrocortisone in patients with adrenal insufficiency. Lancet Diabetes Endocrinol 2018; 6:269-270. [PMID: 29571508 DOI: 10.1016/s2213-8587(18)30045-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 01/22/2018] [Indexed: 11/20/2022]
Affiliation(s)
- Sirazum Choudhury
- Department of Clinical Biochemistry, Imperial College Healthcare NHS Trust, London, UK
| | - Tricia Tan
- Department of Investigative Medicine, Imperial College London, London, UK
| | - Karim Meeran
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK.
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21
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Feeney C, Buell KG, Avari P, Buckley A, Meeran K, Rees DA. Addisonian crisis: assessment and management. Br J Hosp Med (Lond) 2018. [PMID: 29528741 DOI: 10.12968/hmed.2018.79.3.c34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- C Feeney
- Specialist Registrar in Endocrinology and Diabetes, Department of Medicine, The Diabetes Centre, Watford General Hospital, Watford WD18 0HB and Honorary Clinical Research Fellow, Faculty of Medicine, Imperial College London, London
| | - K G Buell
- Academic Foundation Year 2 Doctor, Department of Primary Care and Public Health, Imperial College London, London
| | - P Avari
- Specialist Registrar in Endocrinology and Diabetes and Clinical Research Fellow, Faculty of Medicine, Imperial College London, London
| | - A Buckley
- Specialist Registrar in Intensive Care Medicine, Department of Surgery and Cancer, Imperial College Healthcare NHS Trust, London
| | - K Meeran
- Professor of Endocrinology, Faculty of Medicine, Imperial College London, London
| | - D A Rees
- Reader in Neuroendocrinology, School of Medicine, Cardiff University, Cardiff
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22
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Quinkler M, Murray RD. In Response to: Prednisolone Replacement Therapy Mimics the Circadian Rhythm More Closely than Other Glucocorticoids. J Appl Lab Med 2017; 1:753-755. [DOI: 10.1373/jalm.2016.022616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 12/16/2016] [Indexed: 11/06/2022]
Affiliation(s)
| | - Robert D Murray
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
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