Adrenal suppression from glucocorticoids: preventing an iatrogenic cause of morbidity and mortality in children

Ahmet, Alexandra; Mokashi, Arati; Goldbloom, Ellen B; Huot, Céline; Juřenčák, Roman; Krishnamoorthy, Preetha; Rowan-Legg, Anne; Kim, Harold; Pancer, Larry; Kovesi, Tom

doi:10.1136/bmjpo-2019-000569

Cited by 23 publications

(12 citation statements)

References 70 publications

(135 reference statements)

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“…The requirement for rescue corticosteroids and the use of ICS decreased from the first year. This corticosteroid‐sparing effect confirms that reported in previous real‐life studies, 12,19,29 and is of major importance in children, as both the exposure to rescue corticosteroids and long‐term use of ICS increase the risk of adrenal suppression, 30 and ICS have a dose‐dependent negative effect on growth 31 . The sparing effect extended to all other asthma medications.…”

Section: Discussionsupporting

confidence: 87%

Omalizumab outcomes for up to 6 years in pediatric patients with severe persistent allergic asthma

Nieto

Garriga‐Baraut

Martín

et al. 2021

Pediatric Allergy Immunology

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Background Various studies have assessed omalizumab outcomes in the clinical practice setting but follow‐up and/or number of patients included were limited. We aim to describe the long‐term outcomes of pediatric patients with severe persistent allergic asthma receiving omalizumab in the largest real‐life cohort reported to date. Methods ANCHORS was a multicenter, observational, retrospective cohort study conducted in 25 Pediatric Allergy and Pulmonology units in Spain. We collected data of patients < 18 years and initiating omalizumab between 2006 and 2018, from the year prior to omalizumab initiation to discontinuation or last available follow‐up. The primary outcome was the evolution of the annual number of moderate‐to‐severe exacerbations compared with the baseline period. Results Of the 484 patients included, 101 (20.9%) reached 6 years of treatment. The mean ± standard deviation number of exacerbations decreased during the first year of treatment (7.9 ± 6.6 to 1.1 ± 2.0, P < .001) and remained likewise for up to 6 years. The other clinical parameters assessed also improved significantly during the first year and stabilized or continued to improve thereafter. The percentage of patients experiencing adverse events was consistently low, and the main reason for discontinuation was good disease evolution. Conclusion In this large, long‐term, observational study, moderate‐to‐severe exacerbations decreased significantly from the first year of treatment with omalizumab. The beneficial effect was maintained in the long term, along with a good safety profile. Our results position omalizumab as an effective long‐term treatment in pediatric patients with severe persistent allergic asthma.

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Section: Discussionsupporting

confidence: 87%

Omalizumab outcomes for up to 6 years in pediatric patients with severe persistent allergic asthma

Nieto

Garriga‐Baraut

Martín

et al. 2021

Pediatric Allergy Immunology

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“…Host disease (GvHD) ( 10 ) treatment. Numerous side effects may be associated such as diabetes, growth retardation or glucocorticoid-induced adrenal insufficiency (GI-AI) ( 11 , 12 ).…”

Section: Introductionmentioning

confidence: 99%

Glucocorticoid induced adrenal insufficiency in children: Morning cortisol values to avoid LDSST

et al. 2022

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ObjectivesGlucocorticoid-induced adrenal insufficiency (GI-AI) is a common side effect of glucocorticoid therapy. However, its diagnosis currently relies on the realization of a Low Dose Short Synacthen Test (LD-SST) that requires an outpatient hospital and several blood samples. Our goal was to evaluate whether morning cortisol values could predict the response to LD-SST, in children, to avoid useless dynamic tests and facilitate diagnosis of glucocorticoid induced adrenal insufficiency.Study DesignWe recorded data of 91 pediatric patients who underwent a LD-SST in our center between 2016 and 2020 in a retrospective observational study. We selected LD-SST realized following administration of supra-physiologic doses of glucocorticoids during more than 3 weeks and performed at least four weeks after treatment was stopped. Adrenal deficiency was defined as a plasma cortisol concentration inferior to 500 nmol/l at LD-SST.ResultsGlucocorticoid-induced adrenal insufficiency was diagnosed in 60% of our cohort. Morning cortisol values were predictive of the response to the LD-SST (AUC ROC 0.78). A plasma cortisol concentration of less than 144 nmol/l predicted glucocorticoid induced adrenal insufficiency with a specificity of 94% and a value over 317 nmol/l predicted recovery of the HPA axis with a sensitivity of 95%. We did not find any other predictive factor for glucocorticoid-induced adrenal insufficiency.ConclusionsMorning cortisol values can safely assess recovery of the HPA axis in children treated chronically with glucocorticoids. Using these thresholds, more than 50% of LD-SST could be avoided in children.

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“…Patients with adrenal suppression may be at higher risk of presenting with an adrenal crisis during an acute illness, such as COVID-19 [ 31 ]. However, there is currently no clear evidence that adrenal insufficiency patients are more likely to develop a severe course of disease.…”

Section: Discussion/conclusionmentioning

confidence: 99%

Association between Endocrine Disorders and Severe COVID-19 Disease in Pediatric Patients

et al. 2022

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Introduction: Though severe illness due to COVID-19 is uncommon in children, there is an urgent need to better determine the risk factors for disease severity in youth. This study aims to determine the impact a preexisting endocrine diagnosis has on severity of COVID-19 presentation in youth. Methods: Cross-sectional chart review study included all patients less than 25 years old with a positive SARS-CoV-2 PCR at St. Louis Children’s Hospital between March 2020 and February 2021. Electronic medical record data for analysis included: patient demographics, BMI percentile, inpatient hospitalization or admission to the pediatric intensive care unit, presence of a preexisting endocrine diagnosis such as: diabetes mellitus (Type 1 and Type 2), adrenal insufficiency, and hypothyroidism. Two outcome measures were analyzed in multivariate analysis: inpatient admission and PICU admission. Adjusted Odds ratios with 95% CI were calculated using binary logistic regression, along with p values after Wald Chi-Square analysis. Results: 390 patients were included in the study. Mean age 123.1 (+ 82.2) months old. 50.3% of patients were hospitalized, and 12.1% of patients were admitted to intensive care. Preexisting diagnosis of diabetes mellitus, obesity, and hypothyroidism were associated with an increased risk of hospital and ICU admission, independent of socioeconomic status. Discussion/Conclusion: This study provides evidence that unvaccinated youth with a preexisting diagnosis of obesity, hypothyroidism, or diabetes mellitus infected with COVID-19 are more likely to have a more severe clinical presentation requiring inpatient hospital admission and/or intensive care.

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Adrenal suppression from glucocorticoids: preventing an iatrogenic cause of morbidity and mortality in children

Cited by 23 publications

References 70 publications

Omalizumab outcomes for up to 6 years in pediatric patients with severe persistent allergic asthma

Omalizumab outcomes for up to 6 years in pediatric patients with severe persistent allergic asthma

Glucocorticoid induced adrenal insufficiency in children: Morning cortisol values to avoid LDSST

Association between Endocrine Disorders and Severe COVID-19 Disease in Pediatric Patients

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