Use of glucocorticoids in patients with adrenal insufficiency and COVID-19 infection

Isidori, Andrea M.; Pofi, Riccardo; Hasenmajer, Valeria; Lenzi, Andrea; Pivonello, Rosario

doi:10.1016/s2213-8587(20)30149-2

Cited by 49 publications

(65 citation statements)

References 10 publications

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“…In critically ill patients, uncontrolled viral propagation induces cytotoxicity and hyperactivation of immune cells, leading to increased vascular inflammation, clotting, and thromboembolism complications [2]. Reports of hypothalamicpituitary-adrenal (HPA) axis dysfunction have emerged in the literature but the detailed pathophysiology of immune response and the potential damages affecting especially the adrenal gland are still unclear [3].…”

Section: Introductionmentioning

confidence: 99%

Acute adrenal infarction as an incidental CT finding and a potential prognosis factor in severe SARS-CoV-2 infection: a retrospective cohort analysis on 219 patients

et al. 2020

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Objectives To retrospectively investigate the incidence of acute adrenal infarction (AAI) in patients who underwent chest CT for severe SARS-CoV-2 infection and to correlate findings with prognosis. Methods The local ethics committee approved this retrospective study and waived the need of informed consent. From March 9 to April 10, 2020, all patients referred to our institution for a clinical suspicion of COVID-19 with moderate to severe symptoms underwent a chest CT for triage. Patients with a/parenchymal lesion characteristics of COVID-19 involving at least 50% of lung parenchyma and b/positive RT-PCR for SARS-CoV-2 were retrospectively included. Adrenal glands were reviewed by two independent readers to look for AAI. Additional demographics and potential biological markers of adrenal insufficiency were obtained. Correlations with ICU stay and mortality were sought. Results Out of the 219 patients with critical (n = 52) and severe lung (n = 167) parenchyma lesions, 51 (23%) had CT scan signs of AAI, which was bilateral in 45 patients (88%). Four patients had an acute biological adrenal gland insufficiency (8%). Univariate analysis in AAI+ patients demonstrated a higher rate of ICU stay (67% vs. 45%, p < 0.05) and a longer stay (more than 15 days for 31% for AAI+ vs. 19%, p < 0.05) compared with AAI− patients. Mortality rate was similar (27%, p = 0.92). Conclusions Acute adrenal infarction on initial chest evaluation of severe COVID-19 is frequent (51/219, 23%) and might be a sign of poorer prognosis. Key Points • Acute adrenal infarction on initial chest CT evaluation of severe COVID-19 is frequent (51/219). • AAI might be a factor of poorer prognosis, with increased rate of ICU hospitalization and length of stay.

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Section: Introductionmentioning

confidence: 99%

Acute adrenal infarction as an incidental CT finding and a potential prognosis factor in severe SARS-CoV-2 infection: a retrospective cohort analysis on 219 patients

et al. 2020

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“…In the course of COVID-19 outbreak, GCs have been extensively introduced in the management of patients affected by Sars-Cov-2. Steroid administration in this contest is justified by increasing evidences suggesting that an abnormal immune reactivity, maybe more than uncontrolled viral replication, could be responsible for lung damage and progression to severe respiratory failure, causing in turn disease-dependent lethality [7]. A similar mechanism was recognized in SARS [8].…”

Section: Risk Of Adrenal Insufficiency In Patients With Covid-19mentioning

confidence: 98%

What we have to know about corticosteroids use during Sars-Cov-2 infection

Ferraú

Ceccato

Cannavò

et al. 2020

J Endocrinol Invest

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Purpose Glucocorticoids (GCs), alone or associated to other drugs, were widely used in the management of patients affected by severe acute respiratory syndrome caused by SARS-CoV-2 infection, during the recent COVID-19 outbreak. This review summarizes the available data on HPA axis impairment in GC-treated SARS-CoV-2 patients, focusing on the risk of adrenal insufficiency and on potential drug interactions during concomitant treatments. Methods Literature on the impact of GCs therapy on HPA axis and on the consequences of coadministration of GCs and other drugs in SARS-CoV-2 patients has been reviewed. Results GC treatment can cause symptoms of hypercortisolism, especially in patients with individual hypersensibility, or hypoadrenalism after drug withdrawal, due to hypothalamic-pituitary-adrenal (HPA) axis suppression, with consequences in terms of increased morbidity and mortality risk. On the other hand, in SARS-CoV-2-infected patient's cortisol secretion could be insufficient also due to critical illness-related corticosteroid insufficiency (CIRCI). In addition, in this clinical context, the co-administration of antiretroviral drugs and corticosteroids may trigger drug-drug interaction and enhance the exposure to the latter ones, metabolized through the CYP450 CYP3A pathway, severely impacting on HPA axis. Conclusion Physicians involved in the management of patients affected by COVID-19 should be aware of the need of an appropriate GC dose tapering, and of potential interaction of GCs with antiviral therapy and drugs used to treat associated co-morbidities.

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“…Glucocorticoids have both immune-stimulatory and -inhibitory effects [141]. During the initial phase of viral infection, glucocorticoids prime the immune response to counteract foreign antigens.…”

Section: Hypothalamic-pituitary-adrenal Axismentioning

confidence: 99%

“…During the initial phase of viral infection, glucocorticoids prime the immune response to counteract foreign antigens. However, in the advanced phase of viral infection, blunting of the hypothalamic-pituitary-adrenal axis activation may occur that may lead to glucocorticoid insufficiency in the critical illness setting [141]. Given the widespread use of glucocorticoids and the possible risk to patients with adrenal insufficiency (AI), the Society for Endocrinology released an advisory statement conveying the lack of evidence to support a higher risk for contracting COVID-19 in patients with AI (▶ Table 2).…”

Section: Hypothalamic-pituitary-adrenal Axismentioning

confidence: 99%

“…Those with AI who contract COVID-19 and require mechanical ventilation or are severely ill, should be dosed according to acute stress dosing guidelines (▶Table 2) [145]. Additionally, the use of venous thromboembolism prophylaxis with heparin in patients receiving glucocorticoids is recommended, given the increased risk of thrombotic events in COVID-19 [141]. Furthermore, an increased risk to those with posterior pituitary deficits and electrolyte abnormalities has been logically speculated and the need to stock reasonable supplies emphasized [143].…”

Section: Hypothalamic-pituitary-adrenal Axismentioning

confidence: 99%

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Endocrine Conditions and COVID-19

et al. 2020

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COVID-19 was declared a global pandemic by the WHO and has affected millions of patients around the world. COVID-19 disproportionately affects persons with endocrine conditions, thus putting them at an increased risk for severe disease. We discuss the mechanisms that place persons with endocrine conditions at an additional risk for severe COVID-19 and review the evidence. We also suggest precautions and management of endocrine conditions in the setting of global curfews being imposed and offer practical tips for uninterrupted endocrine care.

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Use of glucocorticoids in patients with adrenal insufficiency and COVID-19 infection

Cited by 49 publications

References 10 publications

Acute adrenal infarction as an incidental CT finding and a potential prognosis factor in severe SARS-CoV-2 infection: a retrospective cohort analysis on 219 patients

Acute adrenal infarction as an incidental CT finding and a potential prognosis factor in severe SARS-CoV-2 infection: a retrospective cohort analysis on 219 patients

What we have to know about corticosteroids use during Sars-Cov-2 infection

Endocrine Conditions and COVID-19

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