Adrenal response to glucocorticoid treatment.

Abstract

In their early report on the adrenal response after glucocorticoid treatment, Christoph Henzen and colleagues (Feb 12, p 542)1Henzen C Suter A Lerch E Urbinelli R Schorno XH Briner VA Suppression and recovery of adrenal response after short-term high-dose glucocorticoid treatment.Lancet. 2000; 355: 542-545Summary Full Text Full Text PDF PubMed Scopus (220) Google Scholar state that “a random plasma cortisol concentration does not reliably assess the adequacy of the adrenal response to stress”. In support of this statement they refer to a paper by Hagg and colleagues.2Hagg E Asplund K Lithner F Value of basal plasma cortisol assays in the assessment of pituitary-adrenal insufficiency.Clin Endocrinol. 1987; 26: 221-226Crossref PubMed Scopus (190) Google Scholar Hagg and colleagues showed that a basal plasma cortisol concentration of less than 100 nmol/L was strongly associated with adrenal dysfunction. From the data shown in figure 1 of the paper by Henzen and colleagues, all the patients who had a normal adrenal response to corticotropin had basal cortisol concentrations of at least 200 nmol/L. Those patients with a basal cortisol of less than 100 nmol/L all had a suppressed adrenal response to corticotropin. These results support the conclusion of Hagg and co-workers and show that basal plasma cortisol concentrations can help identify a proportion of patients with adrenal suppression, without the need for a stimulation test. If the basal plasma cortisol concentration is more than 100 nmol/L a stimulation test is needed to find out whether the adrenal response is suppressed. Although the study took place in a hospital, it is not clear how adherence to glucocorticoid treatment was monitored, and whether patients received some or all of their treatment as outpatients. If adherence to therapy was not complete, it is possible that the proportion (45%) of patients with a suppressed adrenal respone is an underestimate. We have begun to measure simultaneously prednisolone and cortisol concentrations, with high performance liquid chromatography, to assess adherence to therapy (2 weeks oral prednisolone, 40 mg/day) in children with severe asthma. Detection of prednisolone 4–6 h after the last dose gives a direct measure of adherence.3Rose JQ Nickelsen JA Ellis EF et al.Prednisolone disposition in steroid dependent asthmatic children.J Allergy Clin Immunol. 1981; 67: 188-193Summary Full Text PDF PubMed Scopus (19) Google Scholar Measurement of the cortisol concentration gives an indirect measure of longer-term adherence, due to the suppressive effect of prednisolone therapy on adrenal function. Detectable prednisolone, with a cortisol concentration of less than 100 nmol/L, is associated with adherence to therapy and provides useful information to aid management of symptoms for these patients. Adrenal response to glucocorticoid treatmentAuthor's reply Full-Text PDF