Endocrine Abstracts

Introduction: Opioids are commonly used for the treatment of pain, and their effects on the HPA (hypothalamic pituitary adrenal) axis may be under-recognised. In the present, a few non-systematic studies have investigated the effects of opioids on the HPA axis, but results have been conflicting. To our knowledge, there is only another case report of secondary adrenal insufficiency due to tramadol therapy, resulted in suppression on the HPA axis. We present the case of a 79 year old female who was referred to our clinic for endocrinological evaluation with a history of severe osteoporosis, treated with bisphosphonates and tramadol. At the referral, the patient was in mild distress due to the pain, with severe skeletal-muscle pain, fatigueness with the impossibility of maintain orthostatism, dispnea and dizziness. Clinical evaluation revealed normal blood pressure, IMC 34.7 kg/m² with pale skin. The paraclinic evaluation revealed undetectable values of ACTH <5 pg/ml with morning plasma cortisol concentrations of 3.14 microg/dl, respectively 7.93 microg/dl. Cortisol levels from the Synacthen test were 26.8 microg/dl, 34.6 microg/dl at 30 and 60 minutes respectively, but the normal values were correlated with the recent adrenal insufficiency. An incidental finding of a pituitary microadenoma was found on MRI. A diagnosis of tramadol-induced adrenal insufficiency was made. Other drugs containing glucocorticoids were excluded from her recent treatment. After three months under prednisone therapy 5 mg/day, the values of morning plasma cortisol 6.5 microg/dl and ACTH 11.16 pg/ml, with significant clinical improvement. Her prolactin levels raised to 52.6 ng/ml (RR 1.9–25 ng/ml), possible due to her secretant pituitary microadenoma.

Conclusion: This case raises awareness of the potential of opioids to influence adrenal status and is important that opiates should be added to the list of differential diagnosis in patients with newly diagnosed secondary adrenal insufficiency.

Keywords: opioids, Synacthen test, secondary adrenal insufficiency.