Systemic Agents for the Treatment of Atopic Dermatitis
Donald Rudikoff, Steven R. Cohen, Noah Scheinfeld in Atopic Dermatitis and Eczematous Disorders, 2014
In children, a short course of oral corticosteroids at a dosage of 1 mg/kg body weight of prednisone or equivalent dose of prednisolone can be used in those whose disorder cannot be controlled by topical therapy, but long-term use should be avoided (Akdis et al. 2006). In cases in whom more prolonged courses of corticosteroids have been used, three critical clinical situations may occur: adrenal suppression, steroid withdrawal syndrome, and relapse/flare of the disease for which steroids were originally prescribed (Alves et al. 2008). Patients with adrenal insufficiency may display nonspecific symptoms such as anorexia, nausea, vomiting, weakness, malaise, myalgia, arthralgia, weight loss, postural hypotension, and depression, and may progress to adrenal crisis with cardiovascular collapse (Shulman et al. 2007). Steroid withdrawal syndrome manifests with physical or psychological symptoms, including many of the nonspecific symptoms previously mentioned and also emotional lability, mood swings, and sometimes delirium and psychotic states (Alves et al. 2008). A well-known pediatric dermatologist has written: There is no magic formula for corticosteroid use in children, except to say that it is safest to use the smallest possible dose for the shortest period of time (Lucky 1984).
Complications of Laparoscopic Adrenal Surgery
Kevin R. Loughlin in Complications of Urologic Surgery and Practice, 2007
Bilateral and, depending upon the indication, unilateral adrenalectomy can lead to adrenal insufficiency which must be addressed. Patients undergoing adrenalectomy for adenomas were found by Daitch et al. to require a mean length of steroid replacement therapy of 16.8 months prior to patients recovering their hypothalamic-pituitary-adrenal axis, permitting cessation of replacement. Of the patients 53.9% required replacement for over 24 months (43). There is a potential for requiring lifelong replacement therapy in up to 25% of patients (43). Addisonian crises requiring hospital admission occur in up to 32% of patients undergoing bilateral adrenalectomies (58). Symptoms can include anorexia, fatigue, and weight loss as well as a diminished health-related quality of life. There is a potential for an adrenal crisis, presenting with acute abdominal pain, vomiting, severe hypotension, or hypovolemic shock. Glycemic control can also worsen. Glucocorticoid, mineralocorticoid, and possibly dehydroepianrosterone replacement therapy are all important postoperative adjuncts (59). In some situations, Addisonian crises and other sequelae of adrenal insufficiency can potentially be avoided by doing a partial adrenalectomy when acceptable as a surgical option (16).
Non-Respiratory Tuberculosis
Peter D O Davies, Stephen B Gordon, Geraint Davies in Clinical Tuberculosis, 2014
Tuberculosis is now an uncommon cause of hypoadrenalism in developed countries, with autoimmune adrenalitis being the cause in the majority of cases [185]. Adrenal tuberculosis is more common in developing countries but is seldom an isolated site [186] and is often associated with other extrapulmonary tuberculosis, which may be undiagnosed until autopsy [187]. Rifampicin, which is included in all short-course chemotherapy regimens, can unmask subclinical adrenal involvement, causing adrenal crisis some two to four weeks after the commencement of treatment [188]. As a potent inducer of hepatic microsomal enzymes, the plasma half-life of corticosteroids is significantly reduced by rifampicin [189]. Adrenal crisis may thus be precipitated in those persons just producing enough cortisol under maximum stress to maintain minimum blood levels. This phenomenon is offered as an explanation for unexplained deaths soon after starting antituberculosis medication [190].
Prolonged adrenal insufficiency after high-dose glucocorticoid in infants with leukemia
Published in Pediatric Hematology and Oncology, 2018
Kyoko Moritani, Hisamichi Tauchi, Fumihiro Ochi, Sachiko Yonezawa, Koji Takemoto, Minenori Eguchi-Ishimae, Mariko Eguchi, Eiichi Ishii, Kozo Nagai
Each suffered from prolonged adrenal insufficiency during or after treatment. Adrenal insufficiency was evaluated by dose-modified ITT; dysfunction of HPA was defined as a low peak value of intrinsic cortisol with <18 μg/dL. Symptoms of adrenal crisis in these patients are summarized in Table 1. In Patient 1, after methylprednisone pulse for the treatment of chronic GVHD, oral corticosteroid was gradually tapered for 6 months and hydrocortisone replacement therapy was started due to a high cumulative dose of steroids. However, two days after onset of viral enteritis, the patient was somnolent and had hypoglycemia (blood sugar, less than 30 mg/dL). Drip infusion of glucose and hydrocortisone immediately relieved these symptoms. Hydrocortisone dose was increased in order to avoid a further adrenal crisis event, but nausea and hypoglycemia appeared again after respiratory infection. Insulin tolerance test (insulin, 0.05 U/kg) revealed significant adrenal suppression: intrinsic cortisol, 0.6 μg/dL and ACTH, 5.2 pg/mL at peak value (Figure 1). The patient has been in remission, and intrinsic cortisol levels have remained low with daily hydrocortisone for more than 18 months after initiation of replacement therapy.
Bilateral adrenal haemorrhage after a high energetic trauma: a case report and review of current literature
Published in Acta Chirurgica Belgica, 2020
N. Jimidar, D. Ysebaert, M. Twickler, M. Spinhoven, K. Dams, P. G. Jorens
The therapy in case of acute adrenal insufficiency consists of high dose (intravenously) hydrocortisone replacement. Due to the introduction of cortisol in the circulation, endothelial nitric oxide is generated with a subsequent arterial vasodilation with a subsequent need of aggressive fluid resuscitation. Initial electrolyte disturbances will often be reversible after the start of hydrocortisone treatment and subsequently they need no additional correction. As high dose of hydrocortisone may initiate psychiatric symptoms, patients with artificial ventilation and/or inability to express should be carefully monitored. Longer term use of high dose steroids could also result in a higher incidence of venous thrombosis indicating optimal prophylaxis. In selected cases such as ongoing active bleeding, embolization could be an option in the management of adrenal haemorrhage [2,6,7]. In our case, corticosteroids were adequately given before any disastrous adrenal crisis could occur stressing the importance of rapid diagnosis.
Burden of acromegaly in the United States: increased health services utilization, location of care, and costs of care
Published in Journal of Medical Economics, 2021
Antonio Ribeiro-Oliveira, Richard A. Brook, Kathryn A. Munoz, Ian A. Beren, John D. Whalen, Nathan L. Kleinman, Kevin C. J. Yuen
Patients with hypopituitarism and concurrent secondary adrenal insufficiency may be at a greater risk of developing episodes of adrenal crisis. This may prompt visits to the ED, which then subsequently drive up the ED costs30. However, we found that the ED costs for patients with acromegaly and hypopituitarism were not higher than for those without hypopituitarism. A possible explanation for this finding is that the patients with acromegaly and hypopituitarism may have a low prevalence of adrenal insufficiency, as the recovery of the hypothalamic–pituitary–adrenal axis is more frequent in these patients than patients with non-functioning adenoma after surgery31, and thus not needing to present to the ED as frequently as anticipated for possible episodes of adrenal crisis.
Related Knowledge Centers
- Hormone
- Cortisol
- ADDison'S Disease
- Waterhouse–Friderichsen Syndrome
- Congenital Adrenal Hyperplasia
- Psychosis
- Lethargy
- NON-Epileptic Seizure
- Fever
- Hyperkalemia