Usage of continuous glucose monitoring (CGM) for detecting an unrecognized hypoglycemia and management of glucocorticoid replacement therapy in adult patients with central hypoadrenalism

Abstract

Patients with adrenal insufficiency require appropriate glucocorticoid replacement therapy; however, reliable biological parameters for optimizing glucocorticoid supplementation are limited. The physician has to rely primarily on clinical judgment, carefully taking into account signs and symptoms potentially suggestive of over- or under-replacement. We have found that some patients who are viewed as receiving sufficient doses of glucocorticoids occasionally exhibit morning headache or morning discomfort, which may be caused by unrecognized nocturnal hypoglycemia. Our aim in this study was to evaluate the usefulness of continuous glucose monitoring (CGM) for detecting unrecognized hypoglycemia and optimizing glucocorticoid replacement therapy in adult patients with central hypoadrenalism. Six patients with central hypoadrenalism of various etiologies were included in this study. All patients exhibited occasional morning headache or discomfort. We performed CGM to measure plasma glucose levels in all patients, and CGM identified unrecognized hypoglycemia episodes at midnight and early in the morning in five patients (83%). The CGM findings were used to fine-tune the dosing and regimens of glucocorticoid replacement and to re-evaluate glucose levels to avoid further unrecognized hypoglycemic events. This optimization of hydrocortisone supplementation prevented additional nocturnal hypoglycemia incidences in all cases. The addition of L-thyroxine with hydrocortisone continued to provide favorable glycemic control. Occasional symptoms also improved after maintenance in all patients. These findings demonstrated that CGM may represent a powerful tool for identifying unrecognized hypoglycemia and for optimizing supplementary hormones in patients with central hypoadrenalism, thereby improving their quality of life.

Flash glucose monitoring system was applied to cortisol treatment for a patient with congenital adrenal hyperplasia and 17α-hydroxylase deficiency

“…A previous research has investigated cortisol dose adjustment using continuous glucose monitoring in patients with secondary hypoadrenalism [ 11 ]. CAH with 17α-hydroxylase deficiency leads to adrenal insufficiency; however, incomplete cortisol deficiency was the distinguishing feature of our patient.…”

<p>A Single Episode of Hypoglycemia as a Possible Early Warning Sign of Adrenal Insufficiency</p>

“…10,11 Nevertheless, a recent study using a continuous glucose monitoring system reported a number of cases of nocturnal hypoglycemia in adult patients with adrenal insufficiency despite glucocorticoid replacement. [12][13][14] In Islamic culture, patients with adrenal insufficiency can suffer from hypoglycemia during Ramadan fasting, despite the continuance of glucocorticoid replacement therapy. 15 These reports indicate adrenalinsufficient adults are also prone to hypoglycemia, especially during fasting, and that the frequency may have been underestimated.…”

Continuous glucose monitoring for hypoglycaemia in children: Perspectives in 2020

“…Hypoglycaemia is considered a rare problem for adults with adrenal insufficiency (AI) 52 . However, in those with morning headache or discomfort, overnight CGM revealed hypoglycaemia in 5 out of 6 patients who had all demonstrated normal morning fingerprick glucose testing 53 . Increasing hydrocortisone dosing not only prevented overnight hypoglycaemia but also resulted in resolution of symptoms 53 .…”