Abstract
BackgroundGlucocorticoids (GCs) are frequently used to treat glomerular diseases but are associated with multiple adverse effects including hypothalamic-pituitary-adrenal axis inhibition that can lead to adrenal insufficiency (AI) on withdrawal. There is no agreed GC tapering strategy to minimise this risk.MethodsThis is a single centre retrospective study, between 2013 to 2016, of patients with glomerular disease on GC therapy for more than 3 months screened for GC induced AI with short synacthen stimulation tests (SSTs) done prior to complete GC withdrawal. We investigated the prevalence of AI, predictors, choice of screening tool and recovery.ResultsBiochemical evidence of GC induced AI was found in 57 (46.3%) patients. Total duration of GC did not differ between those with and without AI (p = 0.711). Patients with GC induced AI had a significantly lower pre-synacthen baseline cortisol as compared to patients without AI. A cut off pre-synacthen baseline cortisol of ≥223.5 nmol/l had a specificity of 100% for identifying individuals without biochemical AI. Patients with GC induced AI took a mean of 8.7 ± 4.6 months (mean ± SD) to recover. Patients with persistent AI had a significantly lower index post-synacthen cortisol measurement.ConclusionsWe demonstrate that biochemically proven GC induced AI is common in patients with glomerular diseases, is not predicted by daily dose or duration and takes a considerable time to recover. The study supports the use of morning basal cortisol testing as an appropriate means to avoid the need for SSTs in all patients and should be performed in all patients prior to consideration of GC withdrawal after 3 months duration.
Highlights
Glucocorticoids (GCs) are frequently used to treat glomerular diseases but are associated with multiple adverse effects including hypothalamic-pituitary-adrenal axis inhibition that can lead to adrenal insufficiency (AI) on withdrawal
At the time of stimulation test (SST) testing, all patients were on Prednisolone doses of 5 mg or less. 80 (65%) of the patients had been on a dose of 5 mg or less for at least 6 months before the test with the remaining patients receiving higher doses during this period
The duration of Prednisolone use was available for 63 patients (51%) and ranged from 4 to 100 months (Table 1)
Summary
Glucocorticoids (GCs) are frequently used to treat glomerular diseases but are associated with multiple adverse effects including hypothalamic-pituitary-adrenal axis inhibition that can lead to adrenal insufficiency (AI) on withdrawal. Glucocorticoids (GCs) are a widely used and effective treatment for glomerular diseases such as lupus nephritis, ANCA associated vasculitis and primary glomerular diseases. GCs are effective in managing these conditions but are associated with significant adverse effects such as weight gain, diabetes mellitus, stomach ulceration, GCs inhibit the hypothalamic-pituitary-adrenal (HPA) axis through negative feedback. Chronic inhibition can result in adrenal insufficiency (AI) which is unmasked on withdrawal. This can be serious and potentially life threatening as patients are unable to mount an adequate cortisol stress response.
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