Glucocorticoid replacement therapy: are patients over treated and does it matter?
OBJECTIVE
Adequate assessment of patients on glucocorticoid replacement therapy is of great importance to avoid the consequences of under or over treatment, but no simple test is available for this. The aims of this study were (1) to assess adequacy of glucocorticoid replacement in hypoadrenal patients, (2) to correlate serum cortisol levels (cortisol day curve) with 24-hour urine free cortisol excretion and (3) to assess the impact of glucocorticoid dose optimization on markers of bone formation and bone resorption.


METHODS
Cross-sectional study of current replacement therapy and a prospective study of the effect of dose alteration on bone turnover markers.


METHODS
Thirty-two consecutive patients on replacement glucocorticoid therapy (12 Addison's disease, 20 hypopituitarism) from a University teaching hospital out-patient department.


METHODS
Serum and urinary cortisol, osteocalcin, N-telopeptide of type I collagen (NTX) and bone mineral density.


RESULTS
28/32 (88%) patients required a change of therapy; 24/32 (75%) a total reduction in dose, 18/32 (56%) a change in replacement therapy regimen or drug and 14/32 (44%) both changes. The mean daily dose of hydrocortisone was reduced from 29.5 +/- 1.2 to 20.8 +/- 1.0 mg. A significant correlation was found between peak cortisol and 24-hour urine free cortisol/ creatinine (Spearman correlation r = 0.60, P < 0.0001; n = 51). Following hydrocortisone dose reduction, median osteocalcin increased from 16.7 micrograms/l (range 8.2-65.7) to 19.9 micrograms/l (8.2-56.3); P < 0.01, with no change in the NTX/creatinine ratio.


CONCLUSIONS
A high proportion of patients on conventional corticosteroid replacement therapy are over treated or on inappropriate replacement regimens. To reduce the long term risk of osteoporosis, corticosteroid replacement therapy should be individually assessed and over replacement avoided.
Peacey
S R
SR
University Department of Medicine, Northern General Hospital, Sheffield, UK.
Guo
C Y
CY
Robinson
A M
AM
Price
A
A
Giles
M A
MA
Eastell
R
R
Weetman
A P
AP
D000224:Addison Disease / Q000097:blood / Q000188:drug therapy / Q000652:urine; D000307:Adrenal Gland Diseases / Q000097:blood / Q000188:drug therapy* / Q000652:urine; D000328:Adult; D000368:Aged; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage* / Q000378:metabolism / Q000627:therapeutic use; D015415:Biomarkers / Q000097:blood; D015519:Bone Density / Q000187:drug effects; D016723:Bone Remodeling / Q000187:drug effects*; D003094:Collagen / Q000097:blood; D024042:Collagen Type I; D003348:Cortisone / Q000008:administration & dosage / Q000378:metabolism / Q000627:therapeutic use; D003404:Creatinine / Q000652:urine; D003430:Cross-Sectional Studies; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000008:administration & dosage* / Q000378:metabolism / Q000627:therapeutic use; D007018:Hypopituitarism / Q000097:blood / Q000188:drug therapy / Q000652:urine; D008297:Male; D008875:Middle Aged; D015675:Osteocalcin / Q000097:blood; D010455:Peptides / Q000097:blood; D011446:Prospective Studies
D000893:Anti-Inflammatory Agents; D015415:Biomarkers; D024042:Collagen Type I; D010455:Peptides; C052929:collagen type I trimeric cross-linked peptide; D015675:Osteocalcin; D003094:Collagen; D003404:Creatinine; D003348:Cortisone; D006854:Hydrocortisone