Endocrine Abstracts

Background: Prolonged use of exogenous steroids is common for the treatment of many rheumatological conditions, this can result in suppression of the hypothalamic-pituitary-adrenal (HPA) axis. Adrenal insufficiency can lead to life threatening adrenal crisis if undertreated or not recognised.

Clinical Case: A 55-year-old woman with a history of sero-negative arthritis had been receiving monthly intramuscular (buttock/hip) injections of 120 mg Depo-medrone for the previous ten years prescribed by her rheumatologist. She was unable to avail of biologic therapies due to a previous history of breast carcinoma. She was awaiting a discectomy for back pain/lumbar disc prolapse and as a result had missed her regular monthly Depo-medrone IM injections. One week later and prior to the planned back surgery she present three times to her local emergency department with vomiting, hypotension and abdominal pain and was subsequently admitted to hospital on the third attendance when the possibility of an adrenal crisis was recognised. A short synacthen test, revealed a low baseline cortisol of 12, with a 30-minute cortisol of 68 nmol/l (RR > 450). Adrenal/sellar imaging was normal with negative adrenal antibodies. Subsequently, the patient was promptly initiated on intravenous hydrocortisone therapy and fluids, then stepped down to oral hydrocortisone with clinical improvement, a medi alert bracelet was recommended for enhanced patient safety and the patient was counselled on steroid sick day rules.

Discussion: The potential for long term systemic glucocorticoids to cause adrenal suppression appears to be under recognized. Chronic inflammatory rheumatological conditions can in themselves contribute to alterations in HPA axis function. Given the widespread use of exogenous steroids, clinicians who prescribe these medications need to be aware of the potential risks of HPA axis suppression in addition to adequately counselling their patients on the practicalities of not omitting regular steroid medication and education on the risk of adrenal crisis.