ESPE Abstracts

Background: Steroid therapy has been used as a therapeutic strategy in the management of Paediatric Multisystem Inflammatory Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS) with good effect. However, as always, exogenous steroid administration carries with it a risk of iatrogenic adrenal insufficiency.

Aim: We characterise steroid therapy use in PIMS-TS and consider implications for hypothalamic-pituitary-adrenal (HPA) axis function.

Methods: We conducted a retrospective review of children (<18 years) admitted to a tertiary paediatric centre with PIMS-TS during the first wave of the COVID-19 pandemic (1^st April 2020 to 10^th May 2020). We collected data on duration, type, and dosing of steroid therapy used as part of PIMS-TS management. Median total steroid dose is expressed as mg/m²/day, hydrocortisone equivalent. Data are presented as median (interquartile range (IQR)).

Results: A total of 36 patients were included in this study with a median age of 9.5 years (IQR 8.0-13.4) and a median body surface area of 1.20m² (IQR 0.82-1.43). The majority of patients were admitted to the Paediatric Intensive Care Unit (97.2%, n = 35) for a median length of stay of 2.8 days (IQR 1.0-5.9). Steroid therapy was commenced in most children (75.0%, n = 27). Median total steroid dose was 237mg/m²/day (IQR 122-425) and treatment length was 26 days (IQR 23-35). Dosing regimens predominantly involved a short course of high-dose pulsed methylprednisolone followed by oral prednisone tapered over several weeks. There were no baseline cortisol nor ACTH concentrations available for any patient. Three patients (8.3%, n = 3) were referred to endocrinology for advice on steroid management. One of these three patients underwent dynamic testing of the HPA axis (short Synacthen test) which demonstrated iatrogenic adrenal insufficiency. This patient later recovered endogenous adrenal axis function during paediatric endocrinology follow-up.

Conclusion: Prolonged steroid therapy at supraphysiological doses is often used in the management of PIMS-TS. Patients with PIMS-TS represent a clinical cohort vulnerable to iatrogenic adrenal insufficiency secondary to HPA axis suppression. Steroid therapy should be withdrawn gradually, maintaining a high index of suspicion for adrenal compromise and a low threshold for discussion with paediatric endocrinology teams. If concerns arise at any point during or after the steroid taper, the dose should not be further reduced and dynamic testing of the HPA axis should be arranged. There is a need for advice on steroid management to be incorporated into national and international PIMS-TS guidance.