Tertiary adrenal insufficiency in rheumatology patients on long term systemic glucocorticoids
Sagar et al. detail incidence, features and progression of rheumatology patients prescribed long term, high dose glucocorticoids. The work emphasises iatrogenic adrenal insufficiency by chronic glucocorticoid use (tertiary adrenal insufficiency) as a major contributor in withdrawal from medication and significant reductions in quality of life.
This retrospective study examined data from 238 patients, making it the largest of the few studies to examine glucocorticoid excess in a rheumatology patient group. Interestingly, adrenal insufficiency occurred in 43% of the patients (doses of prednisolone 5mg and above), a figure similar to comparative reports examining different patient cohorts. The pass−fail rate of a short synacthen test was unaffected by intramuscular glucocorticoids, suggesting oral steroids are the primary source of risk of adrenal insufficiency, and also there was no benefit from switching to hydrocortisone to try and help weaning off steroids.
These are important data as they highlight the frequency of glucocorticoid-induced tertiary adrenal insufficiency in rheumatology patients. The findings are also in line with existing knowledge surrounding the inversely proportional relationship between peak glucocorticoid excess concentrations and chances of recovery. This work highlights the need for patient and healthcare professional education to minimise the risk of adrenal crisis for patients with hypothalamic-pituitary-adrenal axis suppression from exogenous steroids. As The Endocrinologist’s Editor would say, ‘Carry the steroid emergency card!’
Read the full article in Clinical Endocrinology doi:10.1111/cen.14405