Iatrogenic adrenal insufficiency – a single centre response to increasing awareness and instituting management in non-endocrine specialities

Sally Tollerfield; Abigail Atterbury-Todd; Hannah Wadey; Claire Edmondson; Nicola Moodey; Stacey Morris; Noelle Enright; Audrey Soo; Hoong-Wei Gan; Rakesh Amin; Meera Shaunak; Mehul Dattani; Steve Hoskins; Harshini Katugampola

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ESPE Abstracts (2024) 98 P2-11

ESPE2024 Poster Category 2 Adrenals and HPA Axis (25 abstracts)

Iatrogenic adrenal insufficiency – a single centre response to increasing awareness and instituting management in non-endocrine specialities.

Sally Tollerfield ¹ , Abigail Atterbury-Todd ¹ , Hannah Wadey ¹ , Claire Edmondson ¹ , Nicola Moodey ¹ , Stacey Morris ¹ , Noelle Enright ¹ , Audrey Soo ¹ , Hoong-Wei Gan ¹ , Rakesh Amin ¹ , Meera Shaunak ^1,2 , Mehul Dattani ^1,2 , Steve Hoskins ¹ & Harshini Katugampola ^1,2

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¹Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom. ²UCL Great Ormond Street Institute of Child Health, London, United Kingdom

Introduction: Supra-physiological doses of steroids are frequently used in the management of non-endocrine conditions, including chronic respiratory disease and epilepsy. Long-term use risks iatrogenic adrenal insufficiency (AI), necessitating professional and family education on management of intercurrent illness and adrenal crisis.

Aims: To design and implement a Trust-wide pathway for steroid prescribers on the management of iatrogenic adrenal insufficiency at Great Ormond Street Hospital.

Methods: We produced an innovative pathway for non-endocrine specialities to ensure the safe management of their patient cohort on steroid treatment. Speciality teams responsible for the most steroid prescriptions were identified using hospital electronic records. These teams were approached to pilot the pathway. The Paediatric Endocrine Clinical Nurse Specialist (CNS) team provided formal training prior to implementation.

Results: Two speciality teams are participating in this ongoing pilot: The Respiratory team have begun testing high-risk patients e.g. children on high-dose inhaled corticosteroids (ICS)). 47 patients on high-dose ICS have been identified from their patient databases. To date 15 have undergone a Synacthen test, and of these 4 patients currently require maintenance hydrocortisone and 3 require “sick-day" only cover. The Neurology team reviewed their steroid weaning plan for patients with infantile spasms (IS). Over the last year, they reviewed 17 patients with IS within 2 weeks of starting prednisolone. 7 patients had an early morning cortisol blood test (41.2%) – 5 (71%) had an abnormal result (cortisol <250 nmol/L) and 1 (14%) additionally had symptoms of AI. All 6 patients commenced hydrocortisone for a variable duration (3 weeks to >9 months). This pathway is being rolled out across the Trust and has been shared via local and national networks. It has influenced guidance at a regional level (North Star Guidelines for the treatment of boys with Duchenne Muscular Dystrophy) and a national level (British Society of Paediatric Endocrinology - management of children with AI).

Conclusion: This guideline has increased awareness of AI, and facilitated identification of patients with AI who were previously under-recognised and under-treated. It provides a uniform approach for non-endocrine teams to safely manage their patients on steroid treatment at times of sickness, and to assess the hypothalamo-pituitary-adrenal axis in those in whom steroid therapy is discontinued.