Endocrine Abstracts

JOINT2270

Introduction: Glucocorticoid-induced adrenal insufficiency (GC-induced AI) remains a common although under-recognised cause of morbidity in patients on chronic steroid therapy for a wide array of therapeutic indications.

Objectives: This systematic review of literature was carried out to evaluate prevalence of GC-induced AI by dose, duration and route of administration. An approach to screen and manage such patients (which can was be adapted to clinical practice) was critically appraised.

Methods: A systematic review of literature published between 2015 and 2024 was carried out using PubMed, Cochrane, Embase, Google Scholar, and EBSCOhost databases. Studies with strong evidence, including systematic reviews, randomized controlled trials, and observational studies, were included. Case reports and studies without full texts were excluded. Data were extracted on GC dose, duration, route, and diagnostic tests.

Results: Twenty-one studies met the inclusion criteria, reporting AI prevalence ranging from 7.8% for inhaled GCs to 63% for oral high dose GCs used on short-term. Oral prednisolone doses ≥15 mg/day for >3 months carried the highest risk of developing iatrogenic AI. Inhaled fluticasone >800 mcg/day and super-potent topical clobetasol >50 g/week posed significant clinical risks. Diagnostic tests included early morning cortisol and Short Synacthen Test (SST), with SST providing the most reliable results. Measurement of salivary cortisol in outpatient settings remains a useful non-invasive test (with sensitivity 97%, specificity 97%) to assess ACTH-cortisol axis function. The results of this systematic review were compared to the recent European guidelines which were published in May 2024. This review provided more granular dose-specific data, evidence on short term risk compared to recent European guidelines.

Conclusions: GC-induced AI remains a clinically under-recognised condition associated with significant morbidity. Patients at high-risk of developing AI (based on potency, route and duration of steroid therapy) need to be closely monitored using 0900 h cortisol +/− SST. Salivary cortisol measurement can be used to improve diagnostic accuracy. It is important to educate patients at risk of developing iatrogenic AI regarding sick day rules and given back-up support (e.g. sign post to self-help groups, steroid alert card and hydrocortisone emergency use kit).