Screening for adrenal insufficiency prior to withdrawal of corticosteroid treatment for renal conditions: an audit cycle at a tertiary centre
A. Karangizi, M. Al-Shaghana, S. Logan, L. Harper, P. Hewins
Renal Medicine, Queen Elizabeth Hospital, Birmingham, United Kingdom
Introduction: Corticosteroids are a common and effective treatment for a variety of inflammatory renal disorders. However, due to a considerable number of significant adverse effects maintenance doses should be kept as low as possible and cessation considered in patients with stable remission. Clinical practice in many centres is to taper prednisolone gradually and discontinue without formally testing for adrenal insufficiency but our experience indicated that a proportion of patients on low dose Prednisolone exhibited biochemical adrenal insufficiency but were not symptomatic.
Objectives: For the past few years, we have routinely undertaken Short Synacthen Tests (SST) prior to stopping steroid treatment >3 months. In an initial audit in 2014 we demonstrated that 46% (19/41) of patients had adrenal insufficiency. To facilitate safe withdrawal we made the recommendation to involve Endocrinology in those identified to have adrenal insufficiency and carried out this re-audit 2 years later.
Methods: We studied all patients on Prednisolone therapy for renal conditions who had an initial SST conducted between 1st September 2015 and 31st August 2016. Data was collected retrospectively using our electronic system.
Results: 46 (27 females, 19 males) SSTs were conducted. The average patient age was 54 years (range 22-83). Patients were on corticosteroids for a variety of conditions including vasculitis (21/46), lupus nephritis (12/46) and glomerulonephritis (10/46). The average duration, where available, of corticosteroid use was 30.3 months (range 4–181). The majority of patients were on Prednisolone 5mg daily at the time of testing (39/46). Fifty-six percent (26/46) of patients failed the SST (30 minute cortisol <450 nmol/l ). 21 of 26 patients were referred to Endocrinology. Of those who were not referred 4/5 had indications to continue on Prednisolone. 16/26 patients that failed the test were switched to Hydrocortisone. Baseline cortisol ranged from <20 to 643 nmol/l (Median 211 nmol/l). The positive predictive value of passing the SST with a baseline >350 nmol/l was 100% making it legitimate to use this as a cut-off for 9am cortisol testing. Standard of care is to repeat SST at 6-12 months from conversion to hydrocortisone. To date, 7 patients have been re-tested of which 3 have passed and stopped steroids. 16 of the 20 patients that passed the SST stopped taking steroids at once rather than through conventional tapering.
Conclusion: We have confirmed that biochemical adrenal insufficiency is common in this cohort of patients. Identification is relevant as it aims to protect patients from adrenal crisis when subjected to stress. Endocrinology involvement has facilitated safe withdrawal through conversion to hydrocortisone, scheduled re-testing and patient education of dose adjustment during intercurrent illness.
Disclosure of Interest: None Declared
Keywords: Audit, Clinical quality improvement, Corticosteroids