Endocrine Abstracts

We report the management of a 49-year-old woman with classic congenital adrenal hyperplasia (CAH) with background of multiple sclerosis. She was treated for many years with twice-daily hydrocortisone and fludrocortisone. Despite good adherence, she experienced persistent biochemical hyperandrogenism (elevated testosterone, ACTH and 17-hydroxyprogesterone), hirsutism, menstrual disturbance, and periods of fatigue. Attempts to increase hydrocortisone to three daily doses achieved partial biochemical control but led to adverse effects, including recurrent episodes of raised intraocular pressure. To improve disease control while minimising side effects, therapy was switched to prednisolone, initially given as a split dose (4 mg morning, 1 mg evening). This regimen resulted in significant biochemical improvement, with normalisation of testosterone, androstenedione, and ACTH levels, along with resumption of menstrual periods and reduction in hirsutism. Bone density remained normal on serial DEXA scans. However, occasional lapses in adherence to the evening dose were associated with biochemical relapse, highlighting the importance of dose timing and compliance. Clinical discussions also considered lifestyle factors, working hours, and symptom control when individualising her regimen. This case highlights the importance of fine-tuning glucocorticoid therapy in CAH. Splitting prednisolone dosing achieved a balance between androgen suppression and avoidance of steroid-related complications, with meaningful improvements in clinical and biochemical outcomes. Individualised treatment, patient education on compliance, and regular biochemical monitoring are essential for long-term optimisation of therapy.