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

Abstract

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.

Adrenal insufficiency in pediatric kidney transplantation recipients

“…Nonetheless, this is concordant with Laulhé et al. 's findings, that delay between arrest of steroid treatment and time of ACTH stimulation testing did not predict adrenal function recovery 45 …”

“…Nonetheless, this is concordant with Laulhé et al's findings, that delay between arrest of steroid treatment and time of ACTH stimulation testing did not predict adrenal function recovery. 45 As proxies for medical complexity, number of medications [30][31][32][33][34] and rates of hospitalization [35][36][37] were both associated with a greater AI risk as reflected by lower MC level. Although causality cannot be inferred, the most likely explanation is that impaired cortisol responsiveness to stress contributes to a risk for more severe illness and sequelae.…”