ESPE Yearbook of Paediatric Endocrinology

J Pediatr Endocrinol Metab. 2020; 33: 1257–1263. https://pubmed.ncbi.nlm.nih.gov/32845867/

This retrospective study evaluated the prevalence of adrenal insufficiency after a single intra-articular corticosteroid injection (IACI) in 60 children with chronic arthritis. Adrenal insufficiency was diagnosed in 30% (18/60) and was associated with higher doses of injected corticosteroid. Median duration of adrenal insufficiency was 181 days, among the nine patients who were followed up to the resolution of adrenal insufficiency. Four patients developed symptoms that were suggestive of adrenal insufficiency (fatigue, nausea and/or abdominal pain).

It is well known that non-systemic steroid formulations are able to inhibit the hypothalamic-pituitary adrenal (HPA) axis and cause iatrogenic central adrenal insufficiency. Adrenal insufficiency after IACI has long been demonstrated in adults (2) but there are very few data in children. As a meta-analysis (1) on the subject stated: 1) Adrenal insufficiency after discontinuation of glucocorticoid occurs frequently; 2) there is no administration form, dosing, treatment duration, or underlying disease for which adrenal insufficiency can be excluded with certainty, although higher dose and longer use give the highest risk; 3) the threshold to test corticosteroid users for adrenal insufficiency should be low in clinical practice, especially for those patients with nonspecific symptoms after cessation.

In this study, children were screened by measuring a morning cortisol about 2 weeks after IACI. Those with cortisol < 500 nmol/l (Siemens assay) or < 375 nmol/l (Roche assay), underwent a low dose ACTH stimulation test (ACTH 1 μg intravenously, with cortisol measurements at time 0 and 30 min). Adrenal insufficiency was diagnosed as: morning cortisol <50 nmol/l; peak cortisol at ACTH stimulation test < 375 nmol/l (Roche) or <500 nmol/l (Siemens); or AI diagnosis by a pediatric endocrinologist based on clinical judgment plus a low morning cortisol value (but >50 nmol/l). distribution of adiposity,

The topic of this study deserves the attention of all clinicians who prescribe steroids, not only endocrinologists, because adrenal insufficiency is a potentially life-threatening complication. Possible study limitations are its retrospective design, which limited the evaluation of signs and symptoms suggestive of adrenal insufficiency and its estimated duration; the questionable definition of adrenal insufficiency, although diagnostic criteria are still controversial (3); finally, the relatively small sample size, including patients treated with different types of corticosteroid drugs.

Reference: 1. Broersen LH, Pereira AM, Jørgensen JO, Dekkers OM. Adrenal Insufficiency in Corticosteroids Use: Systematic Review and Meta-Analysis. J Clin Endocrinol Metab. 2015; 100: 2171–80.2. Shuster S, Williams IA. Adrenal suppression due to intra-articular corticosteroid therapy. Lancet 1961; 278: 171–2.3. Ospina NS, Al Nofal A, Bancos I, Javed A, Benkhadra K, Kapoor E, Lteif AN, Natt N, Murad MH. ACTH Stimulation Tests for the Diagnosis of Adrenal Insufficiency: Systematic Review and Meta-Analysis. J Clin Endocrinol Metab. 2016; 101: 427–34.