P-60 Opioid induced secondary adrenal insufficiency: A case report

Abstract

Abstract Introduction Opioid treatment is common and useful in acute pain management, but long-term opioid treatment is not routinely recommended. Opioids influence the endocrine system by blunting the hypothalamic–pituitary–adrenal (HPA) axis: as ACTH is synthesized from the same precursor protein as beta-endorphins, opioids lower serum cortisol and supress cortisol response through a mechanism of negative feedback. In the same way, naloxone infusion leads to an increase in serum cortisol. Clinical Case A forty-nine-year-old woman was sent to an endocrinology appointment due to altered serum cortisol measurements. She had a past history of Graves’ disease currently in clinical and biochemical remission. Her history was also notable for chronic obstructive pulmonary disease under inhaled corticosteroids and previous toxicophilic habits under methadone replacement treatment. The patient was asymptomatic with a laboratory evaluation of the HPA axis suggestive of adrenal insufficiency –morning serum cortisol measurements persistently under 10μg/dL. Stimulation test with cosyntropin showed an insufficient response with a peak cortisol of 12 μg/dL, confirming adrenal insufficiency. As the patient had no clinical signs of adrenal insufficiency and was maintained under inhaled corticosteroid treatment, she was given an emergency glucocorticoid card and was instructed to take replacement treatment with hydrocortisone in stress situations. Conclusion In this patient, the HPA axis suppression might have been multifactorial resulting from inhaled glucocorticoids and chronic opioid use. Opioids are very common drugs and adrenal insufficiency is probably more frequent than it is accounted for in this population, with unspecific symptoms but possible serious consequences. Therefore, patients under opioid treatment with suggestive symptoms might benefit from adrenal insufficiency exclusion.