Awareness of adrenal crisis prevention in long-term steroid users

Salehmohamed, Muhammad Ridhwaan; Griffin, Mark; Branigan, Tom; Cuesta, Martín; Thompson, Chris

doi:10.1530/endoabs.37.ep84

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“…Immunosuppressive steroids have been reported to cause adrenal suppression in a spectrum of clinical conditions (Dineen et al, 2019, Tomkins et al, 2022, which is often unrecognised. Patients prescribed immunosuppressive steroids for inflammatory conditions are also much less likely than endocrine patients to be made aware of sick day rules or to carry steroid warning cards (Salehmohamed et al, 2018), so the potential vulnerability to adrenal crisis in this situation is considerable (Dineen et al, 2019). Although synacthen testing is the gold standard to establish the presence of adrenal insufficiency, data in euvolaemic hyponatraemia has shown that a 09:00h plasma cortisol of >300 nmol/l (>10.9 ng/ml) is sufficient to exclude glucocorticoid deficiency in SIAD (Cuesta & Thompson, 2016).…”

Section: Diagnosis Of Siadmentioning

confidence: 99%

Hyponatraemia and the syndrome of inappropriate antidiuresis (SIAD) in cancer

2022

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Hyponatraemia is a common electrolyte abnormality seen in a wide range of oncological and haematological malignancies, and confers poorer performance status, prolonged hospital admission and reduced overall survival, in patients with cancer. Syndrome of inappropriate antidiuresis (SIAD) is the commonest cause of hyponatraemia in malignancy, and is characterised by clinical euvolaemia, low plasma osmolality, and concentrated urine, with normal renal, adrenal and thyroid function. Causes of SIAD include ectopic production of vasopressin (AVP) from an underlying tumour, cancer treatments, nausea and pain. Cortisol deficiency is an important differential in the assessment of hyponatraemia, as it has an identical biochemical pattern to SIAD, and is easily treatable. This is particularly relevant with the increasing use of immune checkpoint inhibitors, which can cause hypophysitis and adrenalitis, leading to cortisol deficiency. Guidelines on the management of acute, symptomatic hyponatraemia recommend 100ml bolus of 3% saline with careful monitoring of the serum sodium to prevent overcorrection. In cases of chronic hyponatraemia, fluid restriction is recommended as first line treatment, however this is frequently not feasible in patients with cancer and has been shown to have limited efficacy. Vasopressin-2 receptor antagonists (vaptans), may be preferable, as they effectively increase sodium levels in SIAD and do not require fluid restriction. Active management of hyponatraemia is increasingly recognised as an important component of oncological management; correction of hyponatraemia is associated with shorter hospital stay and prolonged survival. The awareness of the impact of hyponatraemia, and the positive benefits of active restoration of normonatraemia, remain challenging in oncology.

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