Endocrine Abstracts

Context: Hypothalamic-pituitary-adrenal axis (HPA) may be disrupted by drugs, including opioids. Opioids are widely used for treatment of acute and chronic pain, but they also carry a wide range of adverse effects. Opioid receptors are present in the pituitary gland and hypothalamus and chronic use of opioids may lead to adrenal insufficiency because of central suppression of the hypothalamic-pituitary-adrenal axis (HPA).

Case Presentation: We report a 26-year-old female with a history of severe Migraines and autoimmune primary hypothyroidism who presented with decreased energy, weakness, fatigue, myalgia, arthralgia, nausea, vomiting, diarrhea and urinary frequency. She is checking blood pressure, which is little higher than 130/90 mmHg. Since 2013 the patient had 5 hospitalizations (twice in Germany) in connection with status migranosus. To manage her symptoms during hospitalizations multiple medications would be tried for pain without any success. The patient describes that fentanyl, propofol, morphine and tramadol would have to be ultimately used. Given the patient’s symptoms Cortisol deficiency was suspected. Cortisol was measured and was found to be very low, repeated several times. ACTH at the same time was very low suggestive of secondary adrenal insufficiency. To investigate the reason for secondary adrenal insufficiency, patient had MRI of pituitary gland which was normal, revealing no pituitary tumors or pituitary stalk lesions/other lesions. Additional pituitary hormonal workup was performed. Overall, the biochemical picture was consistent with idiopathic ACTH deficiency. Hydrocortisone therapy was initiated 30 mg QD, lead to significant improvement of symptoms. Hyperglycemia and secondary hyperaldosteronism was incidentally found during workup for above symptoms. Hemoglobin A1c was above normal ranges-5.9 %, but GAD antibodies and C-peptide were not indicative of autoimmune type 1 diabetes. Blood pressure measurements were high and aldosterone and renin plasma activity was elevated.

Patient continuous levothyroxine supplementation therapy. However, after 3 years of hydrocortisone therapy patient suddenly started gaining weight and developed Cushing’s symptoms so we performed trial with slow down titration of hydrocortisone which lead to improvement of symptoms. We checked morning cortisol and ACTH which were normal. For migraines she is using NSAID’S and is aware of overuse headaches and is trying to be mindful of that.

Conclusion: We should bear in mind the possibility of adrenocorticotropic hormone deficiency even when patients with history pain syndromes and opioid use.