title: Adrenal suppression in patients taking inhaled glucocorticoids is highly prevalent and management can be guided by morning cortisol.
abstract: BACKGROUND
  Up to 3% of US and UK populations are prescribed glucocorticoids (GC). Suppression of the hypothalamo-pituitary-adrenal axis with the potential risk of adrenal crisis is a recognized complication of therapy. The 250 μg short Synacthen stimulation test (SST) is the most commonly used dynamic assessment to diagnose adrenal insufficiency. There are challenges to the use of the SST in routine clinical practice, including both the staff and time constraints and a significant recent increase in Synacthen cost.
  
  
  METHODS
  We performed a retrospective analysis to determine the prevalence of adrenal suppression due to prescribed GCs and the utility of a morning serum cortisol for rapid assessment of adrenal reserve in the routine clinical setting.
  
  
  RESULTS
  In total, 2773 patients underwent 3603 SSTs in a large secondary/tertiary centre between 2008 and 2013 and 17.9% (n=496) failed the SST. Of 404 patients taking oral, topical, intranasal or inhaled GC therapy for non-endocrine conditions, 33.2% (n=134) had a subnormal SST response. In patients taking inhaled GCs without additional GC therapy, 20.5% (34/166) failed an SST and suppression of adrenal function increased in a dose-dependent fashion. Using receiver operating characteristic curve analysis in patients currently taking inhaled GCs, a basal cortisol ≥348 nmol/l provided 100% specificity for passing the SST; a cortisol value <34 nmol/l had 100% sensitivity for SST failure. Using these cut-offs, 50% (n=83) of SSTs performed on patients prescribed inhaled GCs were unnecessary.
  
  
  CONCLUSIONS
  Adrenal suppression due to GC treatment, particularly inhaled GCs, is common. A basal serum cortisol concentration has utility in helping determine which patients should undergo dynamic assessment of adrenal function.
authors: Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK.
authors: Conor P
authors: CP
authors: Woods
authors: Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK.
authors: Nicola
authors: N
authors: Argese
authors: Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK.
authors: Matthew
authors: M
authors: Chapman
authors: Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK.
authors: Christopher
authors: C
authors: Boot
authors: Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK.
authors: Rachel
authors: R
authors: Webster
authors: Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK.
authors: Vijay
authors: V
authors: Dabhi
authors: Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK.
authors: Ashley B
authors: AB
authors: Grossman
authors: Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK.
authors: Andrew A
authors: AA
authors: Toogood
authors: Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK.
authors: Wiebke
authors: W
authors: Arlt
authors: Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK.
authors: Paul M
authors: PM
authors: Stewart
authors: Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK.
authors: Rachel K
authors: RK
authors: Crowley
authors: Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK jeremy.tomlinson@ocdem.ox.ac.uk.
authors: Jeremy W
authors: JW
authors: Tomlinson
mesh_terms: D000280:Administration, Inhalation; D000309:Adrenal Insufficiency / Q000097:blood / Q000139:chemically induced* / Q000175:diagnosis* / Q000453:epidemiology; D000328:Adult; D003366:Cosyntropin; D005938:Glucocorticoids / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D007030:Hypothalamo-Hypophyseal System / Q000187:drug effects; D010913:Pituitary-Adrenal System / Q000187:drug effects; D015995:Prevalence; D012189:Retrospective Studies; D006113:United Kingdom / Q000453:epidemiology
chemical_list: D005938:Glucocorticoids; D003366:Cosyntropin; D006854:Hydrocortisone