Case: A 29-year-old gentleman with HIV was self-administering anabolic steroids. The abrupt discontinuation of the exogenous anabolic steroids resulted in fatigue and abdominal pain. A short synacthen test confirmed adrenal insufficiency.
His past medical history comprised of HIV which was stable on anti-retroviral therapy. He was commenced on Hydrocortisone 10 mg in twice daily.
Over 1 year he developed clinical Cushings. Discontinuation of hydrocortisone resulted in symptomatic improvement. CT scan confirmed atrophic adrenals. ACTH was <5 ng/l whilst on Hydrocortisone. His hydrocortisone replacement therapy was reduced from 10 mg twice daily to 5 mg twice daily to improve iatrogenic Cushing.
A Hydrocortisone Day Curve was performed to evaluate endogenous production and assess exogenous replacement therapy of 5mg twice daily.
Discussion: This gentleman was in adrenal insufficiency at presentation and developed iatrogenic Cushings on physiological replacement therapy of hydrocortisone 10 mg twice daily. A Hydrocortisone Day Curve following a dose reduction to 5 mg twice daily reveals no endogenous cortisol production and supra physiological levels lasting for 6 h. This is likely to be a result of his HIV therapy drugs inhibiting the metabolism of hydrocortisone.
|Time interval (min)||Serum cortisol (nmol/l)||Salivary cortisol (nmol/l)|
Conclusion: Treatment of adrenal deficiency with Hydrocortisone in patients with HIV therapy needs to be cautiously monitored. HIV therapy currently in place and their potency of inhibition of steroid metabolism will help guide initiation and dosing of hydrocortisone.