Endocrine Abstracts

A 57 year-old female patient was admitted for the supervision of supplementary parenteral feeding, due to excessive weight loss and difficulty with gastric motility since having Roux-en-Y gastric bypass surgery a decade ago.

During her stay she was noted to have regular episodes of significant resting hypotension, postural hypotension, and tachycardia, which did not respond to fluid replacement or nutritional support.

Endocrinology specialist advice were requested by her gastroenterology team because of abnormal test result.  Her 9am cortisol level was 227 nmol/l, which was abnormal in the context of acute illness, and was also significantly lower than that from 6 months ago (to 858nmol/l). Subsequent short synacthen test result showed incomplete response: 66 nmol/l at 0-minute (at 9am), 391 nmol/l at 30-minute, and 460nmol/l at 60-minute.  Her baseline 9am ACTH was also abnormally suppressed  (15ng/l).

Her other relevant medical history include chronic malabsorption after bariatric surgery, and active musculoskeletal conditions (Sero negative inflammatory arthritis, lumbar vertebral disc prolapse) resulting in chronic pain.

As a result, we identified her regular medication include high dose of codeine phosphate (240mg daily total), morphine sulphate (60mg daily total), alongside gabapentin, amitriptyline, and sertraline.   She also requires long term total parental nutritional support at home, administered via Hickman line.  She is not exposed to regular exogenous glucocorticoid therapy.

There was no clinical or biochemical feature suggestive of other concerning acute pituitary abnormality.

The diagnosis was opiod-induced secondary hypoadrenalism.  She was treated with glucocorticoid replacement therapy, which results in significant clinical improvement.

Increasing prevalence of both appropriate and inappropriate of long term usage of opiod-based analgesia has been reported in UK and world-wide.  The adverse negative side effect profiles has been drawing increasing attention among healthcare community.  However, secondary hypoadrenalism appears to remain one of the significant side effects that is still not fully aware by healthcare professionals involved in the care of this particular patient group.

 Tabet EJ, Clarke AJ, Twigg SM

Opioid-induced hypoadrenalism resulting in fasting hypoglycaemia

BMJ Case Reports CP 2019;12:e230551) . Rabi,

(128) A case of adrenal insufficiency secondary to chronic opioid use- keep this diagnosis in mind!,

The Journal of Pain,

Volume 15, Issue 4, Supplement,

2014,

Page S8,

ISSN 1526-5900,

https://doi.org/10.1016/j.jpain.2014.01.034.

(https://www.sciencedirect.com/science/article/pii/S1526590014000625)

https://eje.bioscientifica.com/view/journals/eje/181/2/EJE-19-0154.xml