Adrenal insufficiency following prolonged exogenous steroid treatment for graft versus host disease
Simons, Henry Tivey, Ann Abdullah, Ahmad Murray, John Higham, Claire E
Simons, Henry
Tivey, Ann
Abdullah, Ahmad
Murray, John
Higham, Claire E
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Abstract
Nearly half of all patients who have undergone
allogeneic stem-cell transplantation will develop graft versus host disease
(GvHD) necessitating long term use of exogenous steroids.
Patients taking prolonged courses greater than 5 mg prednisolone
daily (or equivalent) are at risk of adrenal insufficiency (AI) due to
hypothalamic-pituitary axis suppression. A recent National Patient
Safety Alert highlighted omission of steroids in patients with AI risks
adrenal crisis or death. No guidelines exist for assessing adrenal function
when exogenous steroids are stopped at completion of GvHD
treatment.
Between January 2018 and January 2020 all patients at a tertiary
haematology centre completing long term steroid therapy for GvHD
underwent a short synacthen test (SST). 250 micrograms of
SynACTHen was administered intramuscularly. Serum cortisol was
measured at 0, 30 and 60 minutes (Roche Immunoassay). Oral steroids
were held prior to testing (48 hours for prednisolone, 18 hours
for hydrocortisone) with the exception of two patients taking budesonide.
30 minute cortisol >440 nmol/l was considered an adequate
response or ‘pass’ (local threshold). Time 0 cortisol <150 nmol/l was
considered a low baseline. Data was extracted from electronic patient
records for demographic, laboratory and clinical features. The relationship
between time from GvHD diagnosis (a surrogate for steroid
exposure) to SST and baseline/30 minute cortisol was assessed using
Pearson’s correlation coefficient. Institutional approval for audit purposes
was obtained.
Thirty patients, median age 51 years (range 18–72) were included.
27% (8/30) of patients failed at least one SST indicating AI. These
patients were all advised to continue physiological steroid replacement.
Six patients had low baseline cortisol (<150), of which three
passed the SST. In these, three patients steroids were not continued
although one was advised to take supplemental hydrocortisone
should they become unwell. Four patients had two SSTs during the
audit period. One passed an initial SST but resumed steroids for
GvHD and failed a subsequent SST. One failed an initial SST but following
weaning passed an SST 9 months later and was able to stop
steroids. No correlation was observed between time from GvHD
diagnosis and baseline cortisol (r = 0.03, P = 0.89) or SST result
(r = 0.10, P = 0.60). Descriptive analysis of demographic, clinical
and laboratory features did not suggest any predictive factors for SST
result (table 1). Both patients who continued budesonide passed the
SST.
One in four patients in our cohort had AI at cessation of steroids.
Identifying these patients, ensuring physiological steroid replacement
and patient education is critical to prevent morbidity and mortality
from AI. There were no identified factors predictive of inadequate
SST response. In line with national guidance all patients receiving
steroid therapy for GvHD should receive steroid emergency cards
and education. Patients identified to have AI at steroid cessation
need endocrinology referral for long term monitoring. As highlighted,
it is possible for patients who fail an initial SST to be subsequently
successfully weaned. At this centre SSTs are now performed routinely at cessation of steroid therapy with support for testing and
follow-up from an endocrinology service. Given the high incidence
of AI in our cohort and lack of predictive factors, we recommend
SSTs be considered for all patients receiving prolonged steroids for
GvHD.
Affiliation
Description
Date
2021
Publisher
Collections
Keywords
Type
Meetings and Proceedings
Citation
Simons H, Tivey A, Abdullah A, Murray J, Higham C. Adrenal insufficiency following prolonged exogenous steroid treatment for graft versus host disease. British Journal of Haematology. 2021;193:55.