Endocrine Abstracts

JOINT1900

Introduction: Adrenal insufficiency can result from a variety of causes, including primary adrenal disorders, secondary causes such as adrenocorticotropic hormone (ACTH) deficiency, or suppression of the Hypothalamic-Pituitary-Adrenal (HPA) axis by medications. Long-term use of codeine is a recognized but underdiagnosed cause of opioid-induced adrenal insufficiency (OIAI), resulting from HPA axis suppression. It is important to note that Hydrochlorothiazide, a thiazide diuretic, is well-documented to cause hyponatremia. We present a case of a 67-year-old woman with codeine-induced secondary adrenal insufficiency and moderate hyponatremia exacerbated by Hydrochlorothiazide, highlighting the diagnostic and therapeutic challenges in managing such a complex condition.

Case report: A 69-year-old female, with a history of hypertension and osteoporosis, presented in June 2024 to the emergency department with hypotension, hyponatremia, and normal kalemia. She had been undergoing long-term treatment with codeine and paracetamol for bone pain. Upon arrival, she showed signs of hypotension. Her laboratory findings revealed moderate hyponatremia, along with low cortisol and ACTH levels confirming secondary adrenal insufficiency (SAI). Kidney function and complete blood count were within normal ranges. Hydrocortisone therapy was initiated, leading to an improvement in cortisol levels. Head CT, abdominal and thyroid ultrasound were normal, excluding other causes of situation. She was prescribed hydrocortisone (20 mg morning, 5 mg at noon, 5 mg evening), fludrocortisones 0.1 mg in addition to the previous treatment with antihypertensive (Irbesartan, Hydrochlorothiazide, Amlodipine, Metoprolol). After two weeks, her sodium levels improved to normal, while potassium remained stable. She discharged in a stable situation but six months later, the patient presented again to the emergency department with a hypertensive crisis (200/110 mmHg), hyponatremia and a 12 kg weight gain. The cortisol and ACTH levels were low. After workup it was concluded as

Final Diagnosis: Secondary adrenal insufficiency due to long -term codeine use, with hyponatremia exacerbated by hydrochlorothiazide. The synacten stimulation test resulted positive. After that, it was stopped Fludrocortisones and Hydrochlorothiazide and decreased gradually the dose of Hydrocortisone and Codeine (with monitoring by the toxicologist to prevent withdrawal syndrome). Follow-up tests confirmed stable electrolytes and cortisol levels.

Conclusion: This case highlights the critical importance of accurate diagnosis and tailored treatment in patients with secondary adrenal insufficiency induced by medication. It underscores the need for awareness of the potential for opioid-induced adrenal insufficiency and the exacerbating effects of thiazide diuretics, necessitating careful management and timely intervention to prevent complications.