ECE2024 Poster Presentations Adrenal and Cardiovascular Endocrinology (95 abstracts)
How to assess adrenal function during low dose prednisolone treatment – impact of a 1- vs 2-day prednisolone pause before the ACTH test: Results from the Double Edge-Rescue Study
Stina Willemoes Borresen 1 , SimonBøggild Hansen 2,3 , Hajir Al-Jorani 4,5 , LiseSofie Bislev 2 , VictorBrun Boesen 1 , LouiseLehmann Christensen 4,5 , Ulla Feldt-Rasmussen 1 , AnjaFenger Dreyer 4,5 , Dorte Glintborg 4 , RichardChristian Jensen 4 , NannaThurmann Jørgensen 1,6 , MarieLouise Lund 1 , Sema Okutan 1,6 , Jelena Stankovic 2,3 , Randi Tei 2,3 , MereteLund Hetland 6,7 , Henning Locht 8 , Ellen Hauge 9 , Kresten Keller 9 , SørenAndreas Just 10 , Anne Voss 11 , Henrik Toft Sørensen 12 , PaulM Stewart 13 , JensOtto Jørgensen 2,3 , Marianne Andersen 4,5 & Marianne Klose 1
1Copenhagen University Hospital, Rigshospitalet, Department of Endocrinology and Metabolism, Copenhagen, Denmark; 2Aarhus University Hospital, Department of Endocrinology and Internal Medicine, Aarhus, Denmark; 3Aarhus University, Department of Clinical Medicine, Aarhus, Denmark; 4Odense University Hospital, Department of Endocrinology and Metabolism, Odense, Denmark; 5University of Southern Denmark, Department of Clinical Research, Odense, Denmark; 6University of Copenhagen, Department of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen, Denmark; 7Copenhagen University Hospital, Rigshospitalet Glostrup, Center of Rheumatology and Joint Diseases, Glostrup, Denmark; 8Copenhagen University Hospital, Frederiksberg Hospital, Center of Rheumatology and Joint Diseases, Frederiksberg, Denmark; 9Aarhus University Hospital, Department of Rheumatology, Aarhus, Denmark; 10Odense University Hospital, Svendborg Hospital, Department of Rheumatology, Svendborg, Denmark; 11Odense University Hospital, Department of Rheumatology, Odense, Denmark; 12Aarhus University Hospital, Department of Clinical Epidemiology, Aarhus, Denmark; 13University of Leeds, Faculty of Medicine and Health, Leeds, United Kingdom
Background: Correctly identifying glucocorticoid-induced adrenal insufficiency in patients tapering prednisolone treatment to ≤5 mg daily is crucial. Pausing prednisolone before an ACTH-test is standard, yet the optimal pause duration is uncertain.
Aim: To determine the outcome of an ACTH-test after 1 vs 2 days’ prednisolone pause before the test.
Methods: Baseline data from an ongoing randomised clinical trial (EudraCT:2021-002528-18) including 281 patients with polymyalgia rheumatica/giant cell arteritis receiving prednisolone treatment for >12 weeks, current dose ≤5 mg/day. Patients were instructed to pause prednisolone on the ACTH-test day, which was performed at any timepoint. Variation in pause duration resulted from different timing of regular prednisolone administration, ACTH-test timing, and compliance (some patients paused longer). A 1-day prednisolone pause was defined as last prednisolone dose taken the day before the ACTH-test (22–33 hours’ pause); a 2-day pause as the last prednisolone taken 2 days before the test (34–54 hours’ pause). P-cortisol was measured before (basal) and 30 min after (stimulated) 250 g ACTH injection. Adrenal insufficiency: stimulated P-cortisol <420 nmol/l (Roche Elecsys® Cortisol II assay or mass spectrometry); delta cortisol: stimulated minus basal P-cortisol concentrations. Subgroup analyses examined potential confounding from current prednisolone dose.
Results: Overall, 56/281 patients (20%) had an insufficient response to the ACTH-test. Patients who paused prednisolone for 1 day (n=251) vs 2 days (n=30) had 43 nmol/l lower mean basal cortisol [mean(s.d.) 262(86) vs 305(106), P=0.013]; 103 nmol/l lower mean stimulated P-cortisol [498(119) vs 601(140), P<0.0001]; and 61 nmol/l lower mean delta cortisol [235(91) vs 296(125), P=0.015]. The prevalence of adrenal insufficiency was 53/251 (21%) vs 3/30 (10%) in patients who paused prednisolone for 1 vs 2 days (P=0.22). Stimulated P-cortisol was positively associated with hours of prednisolone pause [5 nmol/l per hour, CI 95%: 2.6–6.8, P<0.0001]. There was no difference in current dose between groups (1-day vs 2-day). In the 172 patients treated with current dose 5 mg/day, mean basal, stimulated, and delta P-cortisol was 51 nmol/l, 111 nmol/l, and 61 nmol/l lower, respectively, after 1 vs 2 days’ prednisolone pause (all P<0.05). Both after 1- and 2-days prednisolone pause, basal morning (before 0010 h) P-cortisol and random (any timepoint) basal P-cortisol >300 nmol/l provided 100% specificity for passing the ACTH-test.
Conclusion: During ongoing low-dose prednisolone treatment, a 1-day compared with a 2-day prednisolone pause before an ACTH-test resulted in lower basal, stimulated, and delta cortisol concentrations. The clinical implications remain to be examined, but awareness of the length of prednisolone withdrawal before an ACTH-test is important for proper interpretation.
Funding: NNF20OC0063280
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Endocrine Abstracts
ISSN 1470-3947 (print) | ISSN 1479-6848 (online)
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