Endocrine Abstracts

Introduction: Adrenal insufficiency is a common problem in our country due to steroid abuse in various forms. In many occasions the patients even do not know about its side effects and consequences of non-prescribed usage. Many of them presents with sudden withdrawal and adrenal crisis. Many of them admits in Gastroenterology unit due to vomiting, some of them in Medical unit with unexplained fever, weakness, anaemia, etc. Many of them having subtle features of Iatrogenic Cushing’s. In this case series, patients of history of chronic steroid use but, are not taking steroid at least since last 4 weeks are evaluated due to their minimal symptoms.

Methods: All patients having history of supraphysiological dose of steroid use more than 3 months in any form but not taking for at least 1 month. Clinically stable, not at crisis. All 34 subjects were evaluated by short synacthen test 250 μg i.v. Three samples S.cortisol were test 0 h, and after Inj. synacthen 250 μg i.v. 30 and 60 min. S.ACTH was tested with 0 min cortisol.

Result: At 0 h S.cortisol value ranges from 53 to 313 nmol/l. At 30 min after Inj. synacthen 250 μg i.v. S.cortisol ranges from 76 to 622 nmol/l and at 60 min 87–587 nmol/l. In the group who has 0900 h S.cortisol <140 nmol/l (n=15) they have at 30 min S.cortisol 53–411 nmol/l and at 60 min 76–527 nmol/l. S.ACTH at 0900 h was within normal limit.

Conclusion: In cases of suspected secondary adrenal insufficiency due to steroid abuse (basal S.cortisol <240 nmol/l) synacthen test with 250 μg Tetracosactren (Synacthen) i.v. mostly shows partial adrenal insufficiency. In most cases immediate replacements were depended on clinical presentation not on lab values. So for representative lab values (whom to treat or not to treat with steroid) dose of synnacthen for the ‘TEST’ can be reconsidered at lower dose between 1 and 250 μg. As 1 μg is not available, preparation by self-dilution method, is not standardised in lab always. Pharmaceutical companies should be requested for standard strength of ACTH may be 10–100 μg/ml for dispensing. Further RCT with 1 μg to 10 μg can be considered to find the standard dose of the ‘Low Dose Test’.