Adrenal insufficiency have non-specific symptom and sign, so it is difficult to diagnosis as early as possible. Besides, there was no definite diagnosis criteria in iatrogenic secondary adrenal insufficiency. Though this article couldn't answer this problem, it will clarify the percentage of iatrogenic adrenal insufficiency in each disease, drug, dose and route

1. Adrenal
insufficiency
Presenter: PGY Hsu Jin-Yi
Supervisor: VS Chen Hsiao-Lian

2. J Clin Endocrinol Metab. 2015 Apr 6

3. N Engl J Med 2005;353:1711-23.
Stress
Stress

4. N Engl J Med 2005;353:1711-23.
Inflammation ➡

5. N Engl J Med 2005;353:1711-23.
Inflammation ➡
Inflammtory
Malignancy
Transplantation

6. N Engl J Med 2005;353:1711-23.
Negative feedback

7. N Engl J Med 2005;353:1711-23.
Negative feedback
Adrenal insufficiency

8. Objective
Primary outcome
The percentage of patients that develops adrenal
insufficiency after the use of corticosteroids
Secondary outcome
Route of administration
Underlying disease
Treatment dose
Duration
J Clin Endocrinol Metab. 2015 Apr 6

9. Materials and Methods
Inclusion criteria
Insulin tolerance test (ITT)
ACTH stimulation tests (0.5 ︎g, 1 ︎g, or 250︎g)
CRH (corticotropin releasing hormone)
Metyrapone test
J Clin Endocrinol Metab. 2015 Apr 6

10. Materials and Methods
Exclusion criteria
Not at risk of adrenal insufficiency
No or insufficient data were presented to analyze
adrenal insufficiency
Pregnant women, intensive care patients and
patients receiving corticosteroids peri-operatively
J Clin Endocrinol Metab. 2015 Apr 6

11. Statistical analysis
Mainly random effects logistic regression
A fixed logistic regression model was used
when the number of studies in a particular
subgroup was ︎ 5
J Clin Endocrinol Metab. 2015 Apr 6

12. Statistical analysis
Treatment duration
Short term: < 1 month
Medium term: 1 month to 1 year
Long term use: ︎ 1 year
Treatment dose: by recommended dosage
Low dose
Medium dose
High dose
J Clin Endocrinol Metab. 2015 Apr 6

13. Results

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Autoimmune
Transplantation
Malignancy
Skin problem
Asthma

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Still at risk

19. Discussion
Administration form
4.2% for nasal corticosteroids
52.2% for intra-articular corticosteroids
Disease
6.8% for asthma patients with inhalation
corticosteroids only
60.0% for patients with hematological malignancies
J Clin Endocrinol Metab. 2015 Apr 6

20. Discussion
Treatment dose
2.4% ( low dose)
21.5% ( high dose)
Treatment duration in asthma patients
1.4% (28 days)
27.4% (︎1 year)
J Clin Endocrinol Metab. 2015 Apr 6

21. Administration Disease
Treatment dose
Treatment
duration
J Clin Endocrinol Metab. 2015 Apr 6

22. Administration Disease
Treatment dose
Treatment
duration
Heterogeneity
J Clin Endocrinol Metab. 2015 Apr 6

23. Administration Disease
Treatment dose
Treatment
duration
HeterogeneityPractically
J Clin Endocrinol Metab. 2015 Apr 6

24. Short term
Low dose
Inhaled
Long term
High dose
Intra-articular
Incidence rate
J Clin Endocrinol Metab. 2015 Apr 6

25. Discussion
Corticosteroids are used by at least 1% of the population
The risk of developing adrenal insufficiency in these
patients is 1.4 to 60.0%
Symptoms of mild to moderate adrenal insufficiency,
like fatigue and abdominal discomfort
There is insufficient evidence to prove any withdrawal
scheme after steroid use to be efficient or safe
In case of insufficient response, treatment should be
initiated with physiological doses of hydrocortisone
J Clin Endocrinol Metab. 2015 Apr 6

26. Conclusion
All patients using corticosteroid therapy are at risk for
adrenal insufficiency
This implicates that clinicians should
1. Inform patients about the risk and symptoms of
adrenal insufficiency
2. Consider testing patients after cessation of high dose
or long-term treatment with corticosteroids
3. Display a low threshold for testing especially in those
patients with nonspecific symptoms after cessation
J Clin Endocrinol Metab. 2015 Apr 6

27. Thanks for your attention!