Leeds Centre for Diabetes and Endocrinology, Leeds Teaching Hospitals Trust, Leeds, UK.
School of Medicine, University of Leeds, Leeds, UK.
Clin Endocrinol (Oxf). 2021 Mar;94(3):361-370. doi: 10.1111/cen.14405. Epub 2021 Jan 11.
Patients with rheumatic diseases are often treated with prolonged, high-dose systemic glucocorticoids which can cause hypothalamic-pituitary-adrenal (HPA) axis suppression and development of tertiary adrenal insufficiency. Adrenal insufficiency carries the risk of serious, potentially life-threatening adrenal crisis. Our study evaluated the prevalence, characteristics and recovery of patients with underlying rheumatology conditions who had received prolonged glucocorticoid treatment.
Retrospective, cross-sectional study. We evaluated 238 patients seen in outpatient rheumatology clinic, managed in accordance with current nationally and internationally accepted clinical guidelines.
Data collected included patient demographics, historical steroid data, 09.00 h cortisol/short synacthen test (SST) results and follow-up data on those with repeat assessments.
Overall, 65% of our cohort had a 09.00 h cortisol <350 nmol/L. On SST, 43% of patients demonstrated evidence of possible tertiary adrenal insufficiency. Prednisolone equivalent dose at time of SST was significantly higher in the group who failed SST vs. those who passed; mean of 5.57 mg vs. 3.59mg (p = .005). 09.00 h cortisol result correlated with 30-min cortisol on SST (R = .20, p = .002). 0-min cortisol on SST correlated more strongly with 30-min cortisol than 09.00 h cortisol (R = .59, p-value < .001). Patients with 0-min cortisol >350 nmol/L, all passed their SST. Patients who remained on prednisolone were more likely to recover (71%) vs. those switched to hydrocortisone (27%), P = .02. Peak steroid dose was predictive of recovery; significantly lower in those who recovered (mean of 22.3 mg vs. 33.8 mg, P = .03). Steroid duration was not found to be a predictor of recovery [recovery (64.2 months) vs. non-recovery (55.6 months), P = .58]. There was no correlation found to outcome on SST with age, sex, peak steroid dose, steroid duration, underlying rheumatological condition, additional exogenous steroid use or serum sodium.
Forty three percent of our patients demonstrated sub-optimal adrenal function on SST. Steroid dose at the time of SST was the only significant predictive risk factor for tertiary adrenal insufficiency. 09.00 h cortisol demonstrated good correlation with outcome on SST and could represent a valid screening test to reduce need for SST if 09.00 h >350 nmol/L. Further prospective data are required to further characterize risk factors, predictive features of recovery and establish optimal management strategy of steroids (prednisolone vs hydrocortisone) to encourage adrenal recovery.
患有风湿性疾病的患者通常需要接受长期、大剂量的全身糖皮质激素治疗，这可能导致下丘脑-垂体-肾上腺（HPA）轴抑制和三级肾上腺功能不全的发生。肾上腺功能不全存在发生严重、潜在危及生命的肾上腺危象的风险。本研究评估了接受长期糖皮质激素治疗的潜在风湿性疾病患者的患病率、特征和恢复情况。
回顾性、横断面研究。我们评估了在门诊风湿科就诊的 238 名患者，他们的管理符合当前国内外公认的临床指南。
收集的数据包括患者人口统计学、历史类固醇数据、09:00 时皮质醇/短 Synacthen 试验（SST）结果以及对那些接受重复评估的患者的随访数据。
总体而言，我们队列中有 65%的患者 09:00 时皮质醇<350nmol/L。在 SST 上，43%的患者表现出可能的三级肾上腺功能不全的证据。在 SST 时，泼尼松龙等效剂量在 SST 失败组显著高于通过组；分别为 5.57mg 和 3.59mg（p=0.005）。SST 时的 09:00 时皮质醇结果与 SST 时的 30 分钟皮质醇结果相关（R=0.20，p=0.002）。SST 时的 0 分钟皮质醇与 30 分钟皮质醇的相关性强于 09:00 时皮质醇（R=0.59，p 值<0.001）。0 分钟皮质醇>350nmol/L 的患者均通过了 SST。继续使用泼尼松龙的患者更有可能恢复（71%），而改用氢可的松的患者（27%），P=0.02。峰值类固醇剂量是恢复的预测因素；恢复组明显较低（均值 22.3mg 和 33.8mg，P=0.03）。类固醇持续时间未发现与恢复相关[恢复（64.2 个月）与非恢复（55.6 个月），P=0.58]。在 SST 上，年龄、性别、峰值类固醇剂量、类固醇持续时间、潜在风湿性疾病、额外外源性类固醇使用或血清钠与结果之间没有相关性。
我们的患者中有 43%在 SST 上表现出亚最佳的肾上腺功能。SST 时的类固醇剂量是三级肾上腺功能不全的唯一显著预测风险因素。SST 时的 09:00 时皮质醇与 SST 的结果有很好的相关性，如果 09:00 时皮质醇>350nmol/L，则可以代表一种有效的筛选测试，以减少对 SST 的需求。需要进一步的前瞻性数据来进一步确定风险因素、恢复的预测特征，并建立类固醇（泼尼松龙与氢可的松）的最佳管理策略，以鼓励肾上腺恢复。
