Adrenal insufficiency from steroid-containing complementary therapy: importance of detailed history
A 62-year-old Asian British female presented with increasing tiredness. She had multiple co-morbidities and was prescribed steroid inhalers for asthma. She had also received short courses of oral prednisolone for acute asthma exacerbations in the last 2 years. Unfortunately, the frequency and dose...
| Main Authors: | , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Bioscientifica
2019-07-01
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| Series: | Endocrinology, Diabetes & Metabolism Case Reports |
| Online Access: | https://edm.bioscientifica.com/view/journals/edm/2019/1/EDM19-0047.xml |
| Summary: | A 62-year-old Asian British female presented with increasing tiredness. She had multiple co-morbidities and was
prescribed steroid inhalers for asthma. She had also received short courses of oral prednisolone for acute asthma
exacerbations in the last 2 years. Unfortunately, the frequency and dose of steroids for asthma was unclear from history.
Her type 2 diabetes mellitus (DM) control had deteriorated over a short period of time (HbA1c: 48–85 mmol/mol). Blood
tests revealed undetectable cortisol and ACTH (<28 mmol/L, <5.0 ng/L). Renin, electrolytes and thyroid function were within
normal limits. A diagnosis of secondary adrenal insufficiency, likely due to long-term steroid inhaler and recurrent short
courses of oral steroids for asthma exacerbations was made. Patient was commenced on hydrocortisone 10 mg, 5 mg and
5 mg regimen. Steroid inhaler was discontinued following consultation with respiratory physicians. Despite discontinuation
of inhaled steroids, patient continued not to mount a response to Synacthen®. Upon further detailed history, patient
admitted taking a ‘herbal’ preparation for chronic osteoarthritic knee pain. Toxicology analysis showed presence of
dexamethasone, ciprofloxacin, paracetamol, diclofenac, ibuprofen and cimetidine in the herbal medication. Patient was
advised to discontinue her herbal preparation. We believe the cause of secondary adrenal insufficiency in our patient was
the herbal remedy containing dexamethasone, explaining persistent adrenal suppression despite discontinuation of all
prescribed steroids, further possibly contributing to obesity, hypertension and suboptimal control of DM. In conclusion,
a comprehensive drug history including herbal and over-the-counter preparations should be elucidated. Investigation for
the presence of steroids in these preparations should be considered when patients persist to have secondary adrenal
insufficiency despite discontinuation of prescribed steroid medications. |
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| ISSN: | 2052-0573 2052-0573 |