Endocrinology Unit, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
First Department of Propaedeutic and Internal Medicine and Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
Clin Exp Rheumatol. 2022 Sep;40(9):1789-1792. doi: 10.55563/clinexprheumatol/x78tko. Epub 2022 Jun 13.
To examine adrenal cortex reserve in patients with rheumatic and musculoskeletal diseases (RMD) who relapse upon tapering of low glucocorticoid dose, despite concomitant treatment with disease-modifying anti-rheumatic drugs (DMARDs).
A morning standard dose of 250 mcg tetracosactide (Synacthen test) was given in 25 consecutive patients (13 rheumatoid arthritis, 2 psoriatic arthritis, 5 systemic lupus erythematosus, 2 dermatomyositis, 1 systemic sclerosis, 2 temporal arteritis) at the time of relapse upon small reductions (1-2 mg daily) of low prednisolone dose (<7.5 mg daily), while being on stable concomitant treatment with methotrexate, leflunomide, hydroxychloroquine, azathioprine, mycophenolate, tofacitinib, belimumab, anti-TNF, anti-IL-6 or anti-IL-1 regimens (n=14; 3; 9; 1; 2; 1; 1; 5; 2; 1, respectively). Sex-matched apparently healthy individuals (n=45) served as controls.
Baseline cortisol levels and time-integrated cortisol response to tetracosactide were lower in patients than controls (12.01±4.47 vs. 15.63±4.16 mcg/dl, p=0.001, and 1050±286 vs. 1284±182, p<0.001, respectively). No significant associations were observed between the cortisol response to tetracosactide and age, duration of disease or glucocorticoid treatment. An abnormal Synacthen test, indicative of adrenal insufficiency, presumably secondary to chronic glucocorticoid administration, was noted in 5/25 patients. The remaining 20 patients (80%) had normal Synacthen test demonstrating, however, lower cortisol response than controls, independently of age (β-coefficient=-0.373, p=0.033).
Patients with RMD in remission under DMARDs who relapse upon concomitant low glucocorticoid dose tapering should be tested for iatrogenic adrenal insufficiency. Whether a marginally normal Synacthen test should discourage further attempts to withdraw glucocorticoid treatment in these patients warrants further investigation.
在接受低剂量糖皮质激素减量治疗的风湿和肌肉骨骼疾病（RMD）患者中，当疾病缓解但因小剂量（每天 1-2mg）的泼尼松龙剂量减少而出现病情复发时，检查肾上腺皮质储备情况，尽管同时接受了改善病情的抗风湿药物（DMARDs）治疗。
在 25 例连续患者（13 例类风湿关节炎、2 例银屑病关节炎、5 例系统性红斑狼疮、2 例皮肌炎、1 例系统性硬化症、2 例巨细胞动脉炎）中，在小剂量（每天<7.5mg）的泼尼松龙剂量减少（每天 1-2mg）时，同时给予早晨标准剂量 250μg 促皮质素（Synacthen 试验），这些患者正在接受稳定的同时治疗，包括甲氨蝶呤、来氟米特、羟氯喹、硫唑嘌呤、霉酚酸酯、托法替布、贝利木单抗、抗 TNF、抗 IL-6 或抗 IL-1 方案（n=14；3；9；1；2；1；1；5；2；1，分别）。45 名性别匹配的健康个体（n=45）作为对照。
与对照组相比，患者的基础皮质醇水平和 Tetracosactide 的时间积分皮质醇反应较低（12.01±4.47 与 15.63±4.16 mcg/dl，p=0.001，和 1050±286 与 1284±182，p<0.001，分别）。Tetracosactide 皮质醇反应与年龄、疾病持续时间或糖皮质激素治疗之间未见显著相关性。在 25 例患者中有 5 例（20%）出现 Synacthen 试验异常，提示肾上腺功能不全，可能继发于慢性糖皮质激素治疗。其余 20 例患者（80%）的 Synacthen 试验正常，但皮质醇反应低于对照组，与年龄无关（β系数=-0.373，p=0.033）。
正在接受 DMARDs 治疗并缓解的 RMD 患者，如果因同时接受低剂量糖皮质激素剂量减少而出现病情复发，应检查医源性肾上腺功能不全。在这些患者中，轻度正常的 Synacthen 试验是否应阻止进一步尝试停用糖皮质激素治疗，还需要进一步研究。
