Why glucocorticoid withdrawal may sometimes be as dangerous as the treatment itself

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• 作者：Stina Dinsen ; Bo Baslund ; Marianne Klose ; Aase Krogh Rasmussen ; Lennart Friis-Hansen ; Linda Hilsted ; Ulla Feldt-Rasmussen
• 关键词：Glucocorticoid-induced adrenal insufficiency ; Glucocorticoid withdrawal ; Adrenal insufficiency ; Glucocorticoids
• 刊名：European Journal of Internal Medicine
• 出版年：December, 2013
• 年：2013
• 卷：24
• 期：8
• 页码：714-720
• 全文大小：409 K

文摘

Glucocorticoid therapy is widely used, but withdrawal from glucocorticoids comes with a potential life-threatening risk of adrenal insufficiency. Recent case reports document that adrenal crisis after glucocorticoid withdrawal remains a serious problem in clinical practice. Partly due to difficulties in inter-study comparison the true prevalence of glucocorticoid-induced adrenal insufficiency is unknown, but it might be somewhere between 46 and 100% 24 h after glucocorticoid withdrawal, 26-49% after approximately one week, and some patients show prolonged suppression lasting months to years. Adrenal insufficiency might therefore be underdiagnosed in clinical practice.

Clinical data do not permit accurate estimates of a lower limit of glucocorticoid dose and duration of treatment, where adrenal insufficiency will not occur. Due to individual variation, neither the glucocorticoid dose nor the duration of treatment can be used reliably to predict adrenal function after glucocorticoid withdrawal. Also the recovery rate of the adrenal glands shows individual variation, which may be why there is currently insufficient evidence to prove the efficacy and safety of different withdrawal regimens.

Whether a patient with an insufficient response to an adrenal stimulating test develops clinically significant adrenal insufficiency depends on the presence of stress and resulting glucocorticoid demand and it is thus totally unpredictable and can change relative fast. Adrenal insufficiency should therefore always be taken seriously. Individual variation in hypothalamic-pituitary-adrenal axis function might be due to differences in glucocorticoid sensitivity and might be genetic.

Further awareness of the potential side effect of withdrawal of glucocorticoid and further research are urgently needed.