Glucocorticoids (GCs) are a cornerstone of treatment for various glomerular diseases due to their potent anti-inflammatory and immunosuppressive effects. However, these powerful medications come with a significant caveat: they can suppress the body’s hypothalamic-pituitary-adrenal (HPA) axis, leading to adrenal insufficiency (AI) upon withdrawal. This condition is not only debilitating but can be life-threatening if not managed appropriately. A landmark single-center retrospective study, recently published in BMC Nephrology, has shed light on the prevalence, screening, and management of glucocorticoid-induced adrenal insufficiency, pointing to a potential strategy for tackling this challenge. This article delves into the findings and implications of this study for patients with glomerular diseases.
DOI: 10.1186/s12882-019-1354-6
Keywords
1. Adrenal insufficiency
2. Glucocorticoids withdrawal
3. Glomerular diseases treatment
4. Cortisol screening
5. Short synacthen test
A recent study published in BMC Nephrology has highlighted a significant risk associated with the treatment of glomerular diseases—glucocorticoid-induced adrenal insufficiency (AI). The research, carried out at the Queen Elizabeth Hospital Birmingham, UK, underscores the need for a strategic approach to screen and manage this potentially life-threatening condition in patients treated with glucocorticoids for extended periods.
Adrenal insufficiency is a condition where the adrenal glands fail to produce adequate levels of cortisol, a critical hormone for stress response, metabolism, and immune function regulation. When a person takes glucocorticoids for a long time, the body’s natural cortisol production can be suppressed. Once the medication is withdrawn, the body may not immediately resume normal cortisol production, leading to AI.
The Study and Its Findings
The researchers at the University of Birmingham conducted a retrospective study on patients with glomerular diseases treated with glucocorticoids for more than three months. The study spanned from 2013 to 2016 and involved the use of short synacthen stimulation tests (SSTs), which assess adrenal gland function by measuring the body’s cortisol response to an injection of synthetic adrenocorticotropic hormone (ACTH).
The results were striking: 57 out of 124 patients, or 46.3%, showed biochemical evidence of glucocorticoid-induced AI. Interestingly, the duration of glucocorticoid use did not significantly differ between patients with and without AI. A low pre-synacthen baseline cortisol level was a reliable indicator of AI, and those with AI took a mean of approximately 8.7 months to recover adrenal function.
Significantly, a baseline cortisol level of ≥223.5 nmol/l before the SST had a specificity of 100% in ruling out biochemical AI, suggesting that morning basal cortisol testing could be an effective screening tool to avoid unnecessary SSTs in all patients.
Clinical Implications
The study provides strong evidence that glucocorticoid-induced AI is common among patients with glomerular diseases and not solely linked to the duration or daily dose. The findings support a more nuanced approach to tapering off glucocorticoids, one that involves assessing the HPA axis function before complete withdrawal.
The researchers demonstrated that morning basal cortisol testing could be utilized as a primary screening method. This measure could significantly streamline the management process, saving time and resources while ensuring patient safety.
Managing AI Risks
Moving forward, healthcare providers treating patients with glomerular diseases should incorporate adrenal function testing into their protocol. This would involve routinely measuring morning cortisol levels after three months of glucocorticoid therapy. Also, adjusting withdrawal strategies based on these measurements can prevent the development of clinical AI.
The adoption of this approach signifies a major step forward in personalized medicine. It allows clinicians to tailor glucocorticoid tapering schedules to individual patients based on objective physiological data rather than relying on a one-size-fits-all regimen.
Patient Education and Continuity of Care
Educating patients about the symptoms of AI and the importance of adhering to their tapering schedule is equally crucial. Symptoms of AI can include fatigue, muscle weakness, weight loss, low blood pressure, and abdominal pain. It’s vital that patients understand these risks and maintain open lines of communication with their healthcare teams.
Additionally, long-term follow-up is necessary to ensure complete recovery of the HPA axis function. The Birmingham study showed that recovery could take several months, highlighting the importance of ongoing monitoring.
Conclusion
The study featured in BMC Nephrology presents critical insights into the management of glucocorticoid-induced adrenal insufficiency in patients with glomerular diseases. As the medical community moves towards more patient-specific treatment models, data like those provided by this study will be crucial in shaping future guidelines and practices.
Healthcare practitioners must remain vigilant in screening for AI, and researchers must continue to explore the best methods for preventing and treating this condition. Adopting the study’s recommendations could lead to significant improvements in patient outcomes and quality of life for those affected by glomerular diseases.
References
Karangizi, A. H. K., et al. (2019). “Glucocorticoid induced adrenal insufficiency is common in steroid treated glomerular diseases – proposed strategy for screening and management.” BMC Nephrol 20(154): 154. DOI: 10.1186/s12882-019-1354-6
Liu, D., et al. (2013). “A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy.” Allergy, Asthma Clin Immunol 9(1): 30. DOI: 10.1186/1710-1492-9-30
Joseph, R. M., et al. (2016). “Systemic glucocorticoid therapy and adrenal insufficiency in adults: a systematic review.” Semin Arthritis Rheum 46(1): 133–141. DOI: 10.1016/j.semarthrit.2016.03.001
Broersen, L. H., et al. (2015). “Adrenal insufficiency in corticosteroids use: systematic review and meta-analysis.” J Clin Endocrinol Metab 100(6): 2171–2180. DOI: 10.1210/jc.2015-1218
Sherlock, M., & Stewart, P. M. (2019). “The short Synacthen test and its utility in assessing recovery of adrenal function in patients with central adrenal insufficiency.” J Clin Endocrinol Metab 104(1): 17–20. DOI: 10.1210/jc.2018-01317