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Maguire D, McLaren DS, Rasool I, Shah PM, Lynch J, Murray RD. ChAdOx1 SARS-CoV-2 vaccination: A putative precipitant of adrenal crises. Clin Endocrinol (Oxf) 2023; 99:470-473. [PMID: 34358373 PMCID: PMC8444815 DOI: 10.1111/cen.14566] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/06/2021] [Accepted: 07/19/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with adrenal insufficiency (AI) have excess mortality, in part due to the occurrence of life-threatening adrenal crises. Infective processes, including that of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), are recognised as the major precipitant of adrenal crises. Adverse reactions to the ChAdOx1 SARS-CoV-2 vaccine occur in a significant proportion of individuals, however, are mild-moderate in the majority of cases. DESIGN Case series. PATIENTS & RESULTS We describe five cases where more severe adverse reactions to the ChAdOx1 SARS-CoV-2 vaccine led to actual or incipient adrenal crises requiring parenteral hydrocortisone within 24 h of receiving the first ChAdOx1 SARS-CoV-2 vaccination. CONCLUSION In individuals with adrenal insufficiency, adverse reactions to the initial dose of the ChAdOx1 SARS-CoV-2 vaccination can precipitate adrenal crises. We recommend that patients with AI should immediately increase their maintenance glucocorticoid dosage 2-3 fold on experiencing any symptoms in the initial 24 h following vaccination.
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Affiliation(s)
- Deirdre Maguire
- Department of Diabetes and EndocrinologyHarrogate Hospital NHS Foundation TrustHarrogateUK
| | - David S. McLaren
- Department of Endocrinology, Leeds Centre for Diabetes and EndocrinologySt James's University HospitalLeedsUK
| | - Irum Rasool
- Department of Diabetes and EndocrinologyHarrogate Hospital NHS Foundation TrustHarrogateUK
| | - Preet M. Shah
- Department of Diabetes and EndocrinologyHarrogate Hospital NHS Foundation TrustHarrogateUK
| | - Julie Lynch
- Department of Endocrinology, Leeds Centre for Diabetes and EndocrinologySt James's University HospitalLeedsUK
| | - Robert D. Murray
- Department of Endocrinology, Leeds Centre for Diabetes and EndocrinologySt James's University HospitalLeedsUK
- Leeds Institute for Cardiovascular and Metabolic Medicine (LICAMM), Faculty of Medicine and Health, School of MedicineUniversity of LeedsLeedsUK
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Abstract
Adrenal insufficiency (AI), first described by Thomas Addison in 1855, is characterised by inadequate hormonal production by the adrenal gland, which could either be primary, due to destruction of the adrenal cortex, or secondary/tertiary, due to lack of adrenocorticotropic hormone or its stimulation by corticotropin-releasing hormone. This was an invariably fatal condition in Addison's days with most patients dying within a few years of diagnosis. However, discovery of cortisone in the 1940s not only improved the life expectancy of these patients but also had a dramatic effect on their overall quality of life. The diagnosis, easily confirmed by demonstrating inappropriately low cortisol secretion, is often delayed by months, and many patients present with acute adrenal crisis. Sudden withdrawal from chronic glucocorticoid therapy is the most common cause of AI. Currently, there remains a wide variation in the management of this condition across Europe. As primary AI is a relatively rare condition, most medical specialists will only manage a handful of these patients in their career. Despite many advances in recent years, there is currently no curative option, and modern cortisol replacement regimens fail to adequately mimic physiological cortisol rhythm. A number of new approaches including allograft of adrenocortical tissue and stem cell therapy are being tried but remain largely experimental.
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Affiliation(s)
- Rajeev Kumar
- Diabetes and Endocrinology, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - W S Wassif
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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Gurnell M, Heaney LG, Price D, Menzies‐Gow A. Long-term corticosteroid use, adrenal insufficiency and the need for steroid-sparing treatment in adult severe asthma. J Intern Med 2021; 290:240-256. [PMID: 33598993 PMCID: PMC8360169 DOI: 10.1111/joim.13273] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/04/2021] [Accepted: 01/20/2021] [Indexed: 12/24/2022]
Abstract
Secondary adrenal insufficiency (AI) occurs as the result of any process that disrupts normal hypothalamic and/or anterior pituitary function and causes a decrease in the secretion of steroid hormones from the adrenal cortex. The most common cause of secondary AI is exogenous corticosteroid therapy administered at supraphysiologic dosages for ≥ 1 month. AI caused by oral corticosteroids (OCS) is not well-recognized or commonly diagnosed but is often associated with reduced well-being and can be life-threatening in the event of an adrenal crisis. Corticosteroid use is common in respiratory diseases, and asthma is a representative condition that illustrates the potential challenges and opportunities related to corticosteroid-sparing therapies. For individuals with severe asthma (approximately 5%-10% of all cases), reduction or elimination of maintenance OCS without loss of control can now be accomplished with biologic therapies targeting inflammatory mediators. However, the optimal strategy to ensure early identification and treatment of AI and safe OCS withdrawal in routine clinical practice remains to be defined. Many studies with biologics have involved short evaluation periods and small sample sizes; in addition, cautious approaches to OCS tapering in studies with a placebo arm, coupled with inconsistent monitoring for AI, have contributed to the lack of clarity. If the goal is to greatly reduce and, where possible, eliminate long-term OCS use in severe asthma through the increasing adoption of biologic treatments, there is an urgent need for clinical trials that address both the speed of OCS withdrawal and how to monitor for AI.
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Affiliation(s)
- M. Gurnell
- From theMetabolic Research LaboratoriesWellcome–MRC Institute of Metabolic ScienceUniversity of CambridgeNIHR Cambridge Biomedical Research CentreAddenbrooke’s HospitalCambridgeUK
| | - L. G. Heaney
- Centre for Experimental MedicineQueens University BelfastBelfastUK
| | - D. Price
- Observational and Pragmatic Research Institute Pte LtdSingaporeSingapore
- Division of Applied Health SciencesCentre of Academic Primary CareUniversity of AberdeenAberdeenUK
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Ngaosuwan K, Johnston DG, Godsland IF, Cox J, Majeed A, Quint JK, Oliver N, Robinson S. Mortality Risk in Patients With Adrenal Insufficiency Using Prednisolone or Hydrocortisone: A Retrospective Cohort Study. J Clin Endocrinol Metab 2021; 106:2242-2251. [PMID: 33993277 DOI: 10.1210/clinem/dgab347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Prednisolone has been recommended rather than hydrocortisone for glucocorticoid replacement in adrenal insufficiency due its longer duration of action and lower cost. OBJECTIVE To determine mortality rates with prednisolone versus hydrocortisone. METHODS In this observational study, we used data extracted from a UK primary care database (Clinical Practice Research Datalink) to measure the relative mortality of patients with primary and secondary adrenal insufficiency, who were treated with either prednisolone or hydrocortisone, and control individuals who were individually matched for age, sex, period, and place of follow-up. RESULTS As expected, mortality in adrenal insufficiency irrespective of cause was increased, based on 5478 patients (4228 on hydrocortisone; 1250 on prednisolone) and 54 314 controls (41 934 and 12 380, respectively). Overall, the adjusted hazard ratio (HR) was similar with the 2 treatments (prednisolone, 1.76 [95% CI, 1.54-2.01] vs hydrocortisone 1.69 [1.57-1.82]; P = 0.65). This was also the case for secondary adrenal insufficiency. In primary disease (1405 on hydrocortisone vs 137 on prednisolone; 13 965 and 1347 controls, respectively), prednisolone users were older, more likely to have another autoimmune disease and malignancy, and less likely to have mineralocorticoid replacement. Nevertheless, after adjustment, the HR for prednisolone-treated patients remained higher than for those taking hydrocortisone (2.92 [2.19-3.91] vs 1.90 [1.66-2.16]; P = 0.0020). CONCLUSION In primary but not in secondary adrenal insufficiency, mortality was higher with prednisolone. The study was large, but the number of prednisolone-treated patients was small, and they had greater risk factors. Nonetheless, the increased mortality associated with prednisolone persisted despite statistical adjustment. Further evidence is needed regarding the long-term safety of prednisolone as routine replacement.
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Affiliation(s)
- Kanchana Ngaosuwan
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College, London, UK
- Faculty of Medicine and Public Health, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Desmond G Johnston
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College, London, UK
| | - Ian F Godsland
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College, London, UK
| | - Jeremy Cox
- Department of Metabolic Medicine, St. Mary's Hospital, Imperial College; NHS trust, London,UK
| | - Azeem Majeed
- School of Public Health, Imperial College, London, UK
| | | | - Nick Oliver
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College, London, UK
| | - Stephen Robinson
- Department of Metabolic Medicine, St. Mary's Hospital, Imperial College; NHS trust, London,UK
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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: 63] [Impact Index Per Article: 21.0] [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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Puglisi S, Rossini A, Tabaro I, Cannavò S, Ferrau' F, Ragonese M, Borretta G, Pellegrino M, Dughera F, Parisi A, Latina A, Pia A, Terzolo M, Reimondo G. What factors have impact on glucocorticoid replacement in adrenal insufficiency: a real-life study. J Endocrinol Invest 2021; 44:865-872. [PMID: 32779106 PMCID: PMC7946659 DOI: 10.1007/s40618-020-01386-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/02/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The impact of patient's characteristics on glucocorticoid (GC) replacement therapy in adrenal insufficiency (AI) is poorly evaluated. Aims of this study were to assess the influence of sex and body weight on GC dosing and to describe the choice of GC in AI of different etiologies. METHODS We retrospectively evaluated hydrocortisone (HC) equivalent total daily dose (HC-TDD) and per-kg-daily dose (HC-KDD) in 203 patients (104 primary AI [pAI], 99 secondary AI [sAI]) followed up for ≥ 12 months. They were treated with HC, modified-release HC (MRHC) or cortisone acetate (CA) and fludrocortisone acetate (FCA) in pAI. RESULTS At baseline, CA was preferred both in pAI and sAI; at last visit, MRHC was most used in pAI (49%) and CA in sAI (73.7%). Comparing the last visit with baseline, in pAI, HC-TDD and HC-KDD were significantly lower (p = 0.04 and p = 0.006, respectively), while FCA doses increased during follow-up (p = 0.02). The reduction of HC-TDD and HC-KDD was particularly relevant for pAI women (p = 0.04 and p = 0.002, respectively). In sAI patients, no change of HC-KDD and HC-TDD was observed, and we found a correlation between weight and HC-TDD in males (r 0.35, p = 0.02). CONCLUSIONS Our real-life study demonstrated the influence of etiology of AI on the type of GC used, a weight-based tailoring in sAI, a likely overdosage of GC treatment in pAI women at the start of treatment and the possibility to successfully increase FCA avoiding GC over-treatment. These observations could inform the usual clinical practice.
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Affiliation(s)
- S Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy.
| | - A Rossini
- Endocrinology and Diabetes Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - I Tabaro
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - S Cannavò
- Department of Human Pathology 'G.Barresi', University of Messina, Messina, Italy
| | - F Ferrau'
- Department of Human Pathology 'G.Barresi', University of Messina, Messina, Italy
| | - M Ragonese
- Department of Human Pathology 'G.Barresi', University of Messina, Messina, Italy
| | - G Borretta
- Division of Endocrinology, AO S. Croce E Carle, Cuneo, Italy
| | - M Pellegrino
- Division of Endocrinology, AO S. Croce E Carle, Cuneo, Italy
| | - F Dughera
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - A Parisi
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - A Latina
- Division of Endocrinology, AO S. Croce E Carle, Cuneo, Italy
| | - A Pia
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - M Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - G Reimondo
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
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7
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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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Bannon CAM, Border D, Hanson P, Hattersley J, Weickert MO, Grossman A, Randeva HS, Barber TM. Early Metabolic Benefits of Switching Hydrocortisone to Modified Release Hydrocortisone in Adult Adrenal Insufficiency. Front Endocrinol (Lausanne) 2021; 12:641247. [PMID: 33776936 PMCID: PMC7992002 DOI: 10.3389/fendo.2021.641247] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 02/09/2021] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To compare metabolic effects of modified release hydrocortisone (MR-HC) with standard hydrocortisone (HC) therapies in adults with Adrenal Insufficiency (AI). METHODS Adult patients (n = 12) with AI, established on HC therapy, were recruited from Endocrinology clinics at University Hospitals Coventry and Warwickshire (UHCW), UK. Baseline (HC) metabolic assessments included fasting serum HbA1C, lipid and thyroid profiles, accurate measures of body composition (BodPod), and 24-h continuous measures of energy expenditure including Sleeping Metabolic Rate (SMR) using indirect calorimetry within the Human Metabolism Research Unit, UHCW. All participants then switched HC to MR-HC with repeat (MR-HC) metabolic assessments at 3 months. Paired-sample t-tests were used for data comparisons between HC and MR-HC assessments: P-value <0.05 was considered significant. RESULTS Following exclusion of 2 participants, analyses were based on 10 participants. Compared with baseline HC data, following 3 months of MR-HC therapy mean fat mass reduced significantly by -3.2 kg (95% CI: -6.0 to -0.4). Mean (SD) baseline HC fat mass vs repeat MR-HC fat mass: 31.9 kg (15.2) vs 28.7 kg (12.8) respectively, P = 0.03. Mean SMR increased significantly by +77 kcal/24 h (95% CI: 10-146). Mean (SD) baseline HC SMR vs repeat MR-HC SMR: 1,517 kcal/24 h (301) vs 1,594 kcal/24 h (344) respectively, P = 0.03. Mean body fat percentage reduced significantly by -3.4% (95% CI: -6.5 to -0.2). Other measures of body composition, energy expenditure, and biochemical analytes were equivalent between HC and MR-HC assessments. CONCLUSIONS In adults with AI, switching from standard HC to MR-HC associates with early metabolic benefits of reduced fat mass and increased SMR.
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Affiliation(s)
- Christopher A. M. Bannon
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Daniel Border
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Petra Hanson
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - John Hattersley
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Faculty of Health & Life Sciences, Centre of Applied Biological & Exercise Sciences, Coventry University, Coventry, United Kingdom
| | - Martin O. Weickert
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Faculty of Health & Life Sciences, Centre of Applied Biological & Exercise Sciences, Coventry University, Coventry, United Kingdom
| | - Ashley Grossman
- Neuroendocrine Tumour Unit, Royal Free Hospital, London, United Kingdom
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Harpal S. Randeva
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Faculty of Health & Life Sciences, Centre of Applied Biological & Exercise Sciences, Coventry University, Coventry, United Kingdom
| | - Thomas M. Barber
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- *Correspondence: Thomas M. Barber,
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Susan Chen T, David Li S. Adrenal Insufficiency Caused by Chronic Corticosteroid Use, Identified through Medication Therapy Management. Sr Care Pharm 2021; 36:22-33. [PMID: 33384031 DOI: 10.4140/tcp.n.2021.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: To report a case of adrenal insufficiency caused by chronic corticosteroid treatment.Summary: This case study describes a 71-year-old Caucasian woman diagnosed with secondary adrenal insufficiency (SAI). She had a long history of multiple medical problems that affected her quality of life. The pharmacist reviewed 18 years (2001-2018) of medical records, including her corticosteroid usage history. The patient had been receiving chronic medium-high dose inhaled corticosteroids for asthma, with intermittent oral prednisone for exacerbations. The pharmacist suspected a possible SAI or tertiary adrenal insufficiency (TAI) caused by hypothalamic pituitary adrenal axis suppression induced by chronic corticosteroid use. After discussions with the patient's primary care physician and a screening adrenal function test, the patient was referred to an endocrinologist, and the diagnosis was confirmed. Low-dose hydrocortisone (<30 mg daily) was prescribed; the patient had improvements in mood, skin hyperpigmentation, and asthma symptoms, which eliminated the routine visits to the emergency room/clinic during the winter season.CONCLUSION: The case illustrated the benefits of utilizing a pharmacist's expertise. A consultant pharmacist can identify an underdiagnosed and rare condition, corticosteroid-induced adrenal insufficiency, through comprehensive medication review in a community medication therapy management service setting.
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Affiliation(s)
- Tsuhua Susan Chen
- 1President and Clinical Pharmacist, Medication Therapy Management Inc. P.C., Excelsior, Minnesota
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10
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Bannon CA, Gallacher D, Hanson P, Randeva HS, Weickert MO, Barber TM. Systematic review and meta-analysis of the metabolic effects of modified-release hydrocortisone versus standard glucocorticoid replacement therapy in adults with adrenal insufficiency. Clin Endocrinol (Oxf) 2020; 93:637-651. [PMID: 32621327 DOI: 10.1111/cen.14275] [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: 02/14/2020] [Revised: 06/01/2020] [Accepted: 06/22/2020] [Indexed: 12/29/2022]
Abstract
CONTEXT Published studies exploring the metabolic effects of Modified-Release Hydrocortisone (MR-HC) replacement in patients with adrenal insufficiency (AI). OBJECTIVE To compare metabolic effects of MR-HC with Standard Glucocorticoid (SG) replacement in adults with AI. Randomized control trials (RCTs) were meta-analysed; non-RCT studies described narratively with critical appraisal. DATA SOURCES PubMed/Medline, EMBASE, CINAHL and CENTRAL were searched to identify relevant articles, published before Aug 2019. STUDY SELECTION All study types that reported metabolic profile (including anthropometric, glucose and lipid-related parameters), on patients switched from SG to MR-HC replacement. Following independent screening from two reviewers, 390 studies were identified, of which 9 studies were included for review (RCT, n = 2; non-RCT, n = 7). DATA EXTRACTION Two independent reviewers assessed each paper for bias and data extraction. RESULTS Meta-analysis from RCTs (n = 2), 104 patients were switched from SG to MR-HC replacement. Combining treatment effects, at 3-months post-therapy switch there was significant reduction in body weight (-0.82 kg; 95% CI: -1.24 kg to -0.40 kg; P < .001) and HbA1c (-0.13%; 95% CI: -0.214% to -0.045%; P = .003). In the sub-group with Diabetes Mellitus (DM), reduction in HbA1C was more pronounced (-0.52%; 95% CI: -0.82% to -0.23%; P < .001). Non-RCT studies showed improved anthropometric measures and glucose metabolism up to 48-months following switch from SG to MR-HC replacement. CONCLUSIONS In adults with AI, replacement with MR-HC associates with significant improvements in anthropometric measurements and HbA1c compared with SG replacement, particularly those with DM.
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Affiliation(s)
- Christopher A Bannon
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Daniel Gallacher
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Petra Hanson
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Harpal S Randeva
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, UK
- Centre of Applied Biological & Exercise Sciences, Faculty of Health & Life Sciences, Coventry University, Coventry, UK
| | - Martin O Weickert
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, UK
- Centre of Applied Biological & Exercise Sciences, Faculty of Health & Life Sciences, Coventry University, Coventry, UK
| | - Thomas M Barber
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, UK
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11
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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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Kiko N, Kalhan A. Comparison of Various Glucocorticoid Replacement Regimens Used in Chronic Adrenal Insufficiency: A Systematic Review. DUBAI DIABETES AND ENDOCRINOLOGY JOURNAL 2020. [DOI: 10.1159/000508321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
<b><i>Objective:</i></b> Patients with adrenal insufficiency require life-long glucocorticoid replacement therapy. Hydrocortisone (15–30 mg/day) and prednisolone (3–7.5 mg/day) are the preferred agents used although there is a lack of consensus among endocrinologists regarding the impact of different steroid regimens on quality of life, bone metabolism, cardiometabolic outcomes, adrenal crisis and infections. We carried out a retrospective systematic review of the literature to compare the efficacy and side effects of various glucocorticoid replacement regimens in patients with chronic adrenal insufficiency. <b><i>Methods:</i></b> We searched PubMed, Cochrane Reviews and Google Scholar databases up to March 14, 2019, for studies evaluating various clinical outcomes with glucocorticoid replacement therapy. The abstracts and full studies were appraised and data extracted from the eligible studies. The quality of evidence was evaluated and risk of bias carried out. <b><i>Results:</i></b> A total of 47 studies including 9 randomised controlled trials (RCTs) and 38 observational studies were evaluated in this systematic review. Prednisolone therapy was observed to be safe as well as efficacious as hydrocortisone although a higher dose was associated with an increased risk of cardiovascular (CV) disease. A lower hydrocortisone dose (15–20 mg/day) was associated with a reduction of blood pressure and improved clinical outcomes although this observation was based on a solitary RCT. Modified release hydrocortisone was observed to reduce the risk of CV disease based upon results from 2 of the RCTs. However, there was no conclusive evidence of benefit of modified release hydrocortisone and continuous subcutaneous hydrocortisone infusion in improving subjective health status. <b><i>Conclusion:</i></b> Prednisolone therapy remains a safe and efficacious alternative to hydrocortisone although there are concerns of dyslipidaemia and CV disease with higher doses. There is limited level I evidence suggestive of a positive effect of modified release hydrocortisone on CV and metabolic outcomes, particularly weight reduction.
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Tresoldi AS, Sumilo D, Perrins M, Toulis KA, Prete A, Reddy N, Wass JAH, Arlt W, Nirantharakumar K. Increased Infection Risk in Addison's Disease and Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2020; 105:5571544. [PMID: 31532828 PMCID: PMC7046014 DOI: 10.1210/clinem/dgz006] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 09/13/2019] [Indexed: 12/24/2022]
Abstract
CONTEXT Mortality and infection-related hospital admissions are increased in patients with primary adrenal insufficiency (PAI). However, the risk of primary care-managed infections in patients with PAI is unknown. OBJECTIVE To estimate infection risk in PAI due to Addison's disease (AD) and congenital adrenal hyperplasia (CAH) in a primary care setting. DESIGN Retrospective cohort study using UK data collected from 1995 to 2018. MAIN OUTCOME MEASURES Incidence of lower respiratory tract infections (LRTIs), urinary tract infections (UTIs), gastrointestinal infections (GIIs), and prescription counts of antimicrobials in adult PAI patients compared to unexposed controls. RESULTS A diagnosis of PAI was established in 1580 AD patients (mean age 51.7 years) and 602 CAH patients (mean age 35.4 years). All AD patients and 42% of CAH patients were prescribed glucocorticoids, most frequently hydrocortisone in AD (82%) and prednisolone in CAH (50%). AD and CAH patients exposed to glucocorticoids, but not CAH patients without glucocorticoid treatment, had a significantly increased risk of LRTIs (adjusted incidence rate ratio AD 2.11 [95% confidence interval (CI) 1.64-2.69], CAH 3.23 [95% CI 1.21-8.61]), UTIs (AD 1.51 [95% CI 1.29-1.77], CAH 2.20 [95% CI 1.43-3.34]), and GIIs (AD 3.80 [95% CI 2.99-4.84], CAH 1.93 [95% CI 1.06-3.52]). This was mirrored by increased prescription of antibiotics (AD 1.73 [95% CI 1.69-1.77], CAH 1.77 [95% CI 1.66-1.89]) and antifungals (AD 1.89 [95% CI 1.74-2.05], CAH 1.91 [95% CI 1.50-2.43]). CONCLUSIONS There is an increased risk of infections and antimicrobial use in PAI in the primary care setting at least partially linked to glucocorticoid treatment. Future studies will need to address whether more physiological glucocorticoid replacement modes could reduce this risk.
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Affiliation(s)
- Alberto S Tresoldi
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Endocrinology, Diabetology and Medical Andrology Unit, Humanitas Clinical and Research Hospital, Rozzano (Milan), Italy
| | - Dana Sumilo
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Mary Perrins
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Konstantinos A Toulis
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Narendra Reddy
- Department of Diabetes and Endocrinology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK
| | - John A H Wass
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
- Correspondence and Reprint Requests: Wiebke Arlt, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Medical School IBR Tower, Rm 236, Birmingham, B15 2TT, United Kingdom. E-mail:
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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