What factors have impact on glucocorticoid replacement in adrenal insufficiency: a real-life study

S Puglisi,M Ragonese,G Borretta,A Parisi,M Terzolo,G Reimondo,F Dughera,S Cannavò,A Pia,I Tabaro,A Latina,M Pellegrino,F Ferrau’,A Rossini

doi:10.1007/s40618-020-01386-3

Abstract

PurposeThe impact of patient’s characteristics on glucocorticoid (GC) replacement therapy in adrenal insufficiency (AI) is poorly evaluated. Aims of this study were to assess the influence of sex and body weight on GC dosing and to describe the choice of GC in AI of different etiologies.MethodsWe retrospectively evaluated hydrocortisone (HC) equivalent total daily dose (HC-TDD) and per-kg-daily dose (HC-KDD) in 203 patients (104 primary AI [pAI], 99 secondary AI [sAI]) followed up for ≥ 12 months. They were treated with HC, modified-release HC (MRHC) or cortisone acetate (CA) and fludrocortisone acetate (FCA) in pAI.ResultsAt baseline, CA was preferred both in pAI and sAI; at last visit, MRHC was most used in pAI (49%) and CA in sAI (73.7%). Comparing the last visit with baseline, in pAI, HC-TDD and HC-KDD were significantly lower (p = 0.04 and p = 0.006, respectively), while FCA doses increased during follow-up (p = 0.02). The reduction of HC-TDD and HC-KDD was particularly relevant for pAI women (p = 0.04 and p = 0.002, respectively). In sAI patients, no change of HC-KDD and HC-TDD was observed, and we found a correlation between weight and HC-TDD in males (r 0.35, p = 0.02).ConclusionsOur real-life study demonstrated the influence of etiology of AI on the type of GC used, a weight-based tailoring in sAI, a likely overdosage of GC treatment in pAI women at the start of treatment and the possibility to successfully increase FCA avoiding GC over-treatment. These observations could inform the usual clinical practice.

Highlights

Adrenal insufficiency (AI) is a rare but potentially lifethreatening condition, characterized by impaired cortisol secretion due to a primary loss of function of the adrenalS
The replacement therapy of AI in clinical practice is characterized by a significant heterogeneity in type and dosage of the prescribed GCs [22]
We evaluated how gender, weight, and AI etiology influenced the management of AI in three referral centers in Italy

Summary

Introduction

Adrenal insufficiency (AI) is a rare but potentially lifethreatening condition, characterized by impaired cortisol secretion due to a primary loss of function of the adrenalS. Adrenal insufficiency (AI) is a rare but potentially lifethreatening condition, characterized by impaired cortisol secretion due to a primary loss of function of the adrenal. The physiological pattern of cortisol secretion is difficult to mirror using the conventional oral replacement therapy regimens [immediate-release hydrocortisone (HC), cortisone acetate (CA) or prednisolone] [2]. For this reason, a new formulation of once daily HC, defined as modifiedrelease hydrocortisone (MRHC), has been recently introduced [3, 4]. MRHC use was associated with better quality of life and improved metabolic parameters compared with conventional GC regimens [5, 6]. A reliable biomarker to assess the adequacy of GC treatment in AI has not yet been identified and the dosage adjustments, whatever GC

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