Endocrine Abstracts

A 53 year old female weighing 117 kg was thought to be slightly cushingoid by her GP who checked a morning cortisol. This was surprisingly undetectable (<28nM) on 13th June 2022. The patient was urgently referred for a medical opinion. A repeat cortisol in A&E was 29nM with an undetectable ACTH. Given the lack of clinical features of adrenal failure, further history was obtained. The patient appeared well on examination, and denied any inhaled, oral/ topical steroid use. Review of the radiology reports revealed that the patient had had a spinal injection of Tricamcinolone 40 mg 4 weeks previously in May 2022. When reminded of this, the patient agreed, and was discharged without steroids, given that she had recent depot of triamcinolone. The patients diabetic control deteriorated following the injection and additional steroid replacement was not deemed necessary. Given her diabetes and obesity, extra steroids may have been harmful. The patient remained well off steroids for several months. A synacthen test done in August, 3 months after the injection, revealed a baseline cortisol of 99nM, 30 minutes 232nM and 60 minutes 268nM. This confirms partial adrenal recovery. Given the complete lack of features of adrenal failure, we have elected to not give any extra steroids. The patient remains well. Patients given depot steroids for musculoskeletal pain lose their diurnal rhythm of cortisol, which is replaced by slow release of potent steroids for at least 3 months. The time for recovery of the HPA axis varies from a few weeks to several months. Endocrinologist do not routinely see these patients and no steroid cover are given following these procedures. When patients are found incidentally to have a low cortisol after injection of depot steroids, the reflexive prescription of steroid cover may cause more harm. Each case needs to be assessed clinically.