Endocrine Abstracts

We present here a case of 70 year old female, seen in endocrine clinic for Hypothalamic-Pituitary-Adrenal (HPA) axis suppression after prolonged glucocorticoid use. History revealed that she had prolonged use of prednisolone for her asthma in the past. In 2011, Prednisolone was stopped but she had to be started on Hydrocortisone replacement due to HPA axis suppression. She was taking Hydrocortisone 20 mg BD. Trials to wean her off Hydrocortisone failed due to ongoing tiredness and dizziness. She, generally, had very low energy levels and was struggling with daily activities. She had to quit her demanding job as an Event Manager. There was no other confounding medical history. Her care was transferred to us in 2015, Short Synacthen test showed inadequate response with peak cortisol level of 216 nmol/l at 60 min (normal >420 nmol/l) and ACTH <5 ng/ml (10–50 ng/ml). Other investigations for tiredness including pituitary profile, TFT, haematinics and bone profile were normal. She subsequently had a Hydrocortisone day curve that showed excess replacement of Hydrocortisone with 60 min Cortisol of 859 nmol/l. Several attempts were made to decrease her hydrocortisone dose but she failed to cope with any reductions. In October 2016, she was switched to Prednisolone 5 mg OD, as a trial therapy, but no improvement in her symptoms was observed. In April 2017, it was noticed that her Dehydroepiandrosterone Sulphate (DHEA-S) level was <0.4 μmol/l (0.9–11.6 μmol/l) and she was given a trial of DHEA 25 mg once a day. On further follow up, she reported significant improvement in her energy levels and performance. She also managed to wean her Prednisolone from 5mg to 3mg and returned to work, active as before. Although, clinical evidence is debatable, this case signifies individualised role of DHEA replacement in HPA axis suppression.