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dc.contributor.authorSimons, Henry
dc.contributor.authorTivey, Ann
dc.contributor.authorAbdullah, Ahmad
dc.contributor.authorMurray, John
dc.contributor.authorHigham, Claire E
dc.date.accessioned2021-07-19T10:28:38Z
dc.date.available2021-07-19T10:28:38Z
dc.date.issued2021en
dc.identifier.citationSimons 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.en
dc.identifier.urihttp://hdl.handle.net/10541/624060
dc.description.abstractNearly 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.en
dc.language.isoenen
dc.titleAdrenal insufficiency following prolonged exogenous steroid treatment for graft versus host diseaseen
dc.typeMeetings and Proceedingsen
dc.contributor.departmentThe Christie NHS Foundation Trust, Manchesteren
dc.identifier.journalBritish Journal of Haematologyen
dc.description.noteen]


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