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Adrenal insufficiency
Presenter: PGY Hsu Jin-YiSupervisor: VS Chen Hsiao-Lian
J Clin Endocrinol Metab. 2015 Apr 6
N Engl J Med 2005;353:1711-23. Stress
Stress
N Engl J Med 2005;353:1711-23.
Inflammation ⬇
N Engl J Med 2005;353:1711-23.
Inflammation ⬇
Inflammtory
Malignancy
Transplantation
N Engl J Med 2005;353:1711-23.
Negative feedback
N Engl J Med 2005;353:1711-23.
Negative feedback
Adrenal insufficiency
ObjectivePrimary outcome
The percentage of patients that develops adrenal insufficiency after the use of corticosteroids
Secondary outcome
Route of administration
Underlying disease
Treatment dose
DurationJ Clin Endocrinol Metab. 2015 Apr 6
Materials and Methods Inclusion criteria
Insulin tolerance test (ITT)
ACTH stimulation tests (0.5 ︎g, 1 ︎g, or 250︎g)
CRH (corticotropin releasing hormone)
Metyrapone test
J Clin Endocrinol Metab. 2015 Apr 6
Materials and Methods Exclusion criteria
Not at risk of adrenal insufficiency
No or insufficient data were presented to analyze adrenal insufficiency
Pregnant women, intensive care patients and patients receiving corticosteroids peri-operatively
J Clin Endocrinol Metab. 2015 Apr 6
Statistical analysis Mainly random effects logistic regression
A fixed logistic regression model was used when the number of studies in a particular subgroup was ︎ 5
J Clin Endocrinol Metab. 2015 Apr 6
Statistical analysis Treatment duration
Short term: < 1 month
Medium term: 1 month to 1 year
Long term use: ︎ 1 year
Treatment dose: by recommended dosage
Low dose
Medium dose
High doseJ Clin Endocrinol Metab. 2015 Apr 6
Results
J Clin Endocrinol Metab. 2015 Apr 6
J Clin Endocrinol Metab. 2015 Apr 6
J Clin Endocrinol Metab. 2015 Apr 6
J Clin Endocrinol Metab. 2015 Apr 6
Autoimmune
Transplantation
Malignancy
Skin problemAsthma
J Clin Endocrinol Metab. 2015 Apr 6
Still at risk
DiscussionAdministration form
4.2% for nasal corticosteroids
52.2% for intra-articular corticosteroids
Disease
6.8% for asthma patients with inhalation corticosteroids only
60.0% for patients with hematological malignancies J Clin Endocrinol Metab. 2015 Apr 6
DiscussionTreatment dose
2.4% ( low dose)
21.5% ( high dose)
Treatment duration in asthma patients
1.4% (28 days)
27.4% ( ︎1 year)
J Clin Endocrinol Metab. 2015 Apr 6
Administration Disease
Treatment doseTreatment duration
J Clin Endocrinol Metab. 2015 Apr 6
Administration Disease
Treatment doseTreatment duration
Heterogeneity
J Clin Endocrinol Metab. 2015 Apr 6
Administration Disease
Treatment doseTreatment duration
Heterogeneity Practically
J Clin Endocrinol Metab. 2015 Apr 6
Short termLow doseInhaled
Long termHigh dose
Intra-articularIncidence rate
J Clin Endocrinol Metab. 2015 Apr 6
DiscussionCorticosteroids are used by at least 1% of the population
The risk of developing adrenal insufficiency in these patients is 1.4 to 60.0%
Symptoms of mild to moderate adrenal insufficiency, like fatigue and abdominal discomfort
There is insufficient evidence to prove any withdrawal scheme after steroid use to be efficient or safe
In case of insufficient response, treatment should be initiated with physiological doses of hydrocortisone
J Clin Endocrinol Metab. 2015 Apr 6
ConclusionAll patients using corticosteroid therapy are at risk for adrenal insufficiency
This implicates that clinicians should
1. Inform patients about the risk and symptoms of adrenal insufficiency
2. Consider testing patients after cessation of high dose or long-term treatment with corticosteroids
3. Display a low threshold for testing especially in those patients with nonspecific symptoms after cessation
J Clin Endocrinol Metab. 2015 Apr 6
Thanks for your attention!
