Adrenal insufficiency from steroid-containing complementary therapy: importance of detailed history

Abstract

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. Learning points: The likelihood of complementary and alternative medicines (CAMs) in medication-induced secondary adrenal insufficiency should be considered in any patient presenting with potential symptoms of adrenal insufficiency. If the contents of CAM preparation cannot be ascertained, toxicology screening should be considered. Patients should be advised to stop taking CAM preparation when it contains steroids and hydrocortisone replacement therapy commenced, with periodic reassessment of adrenal function, and then if indicated weaned accordingly. Patients should be informed about the contents of CAM therapies, so they can make a truly informed choice regarding the risks and benefits. This case also highlights a need to increase regulatory processes over CAM therapies, given their propensity to contain a number of undisclosed medications and potent steroids.

A Case of Iatrogenic Cushing’s Syndrome following Use of an Over-the-Counter Arthritis Supplement

“…Lastly, and relevant to this case, Cushing's syndrome can be caused by unwitting ingestion of substances not known to the user to contain glucocorticoids. Numerous reports exist of Cushing's syndrome caused by over-the-counter or herbal/alternative medicines used to treat various conditions [3,9].…”

Exogenous Cushing Syndrome Caused by a “Herbal” Supplement

“…Itraconazole and ritonavir, which inhibit the CYP3A4 metabolism of glucocorticoids, can delay the clearance of some glucocorticoids and cause Cushing's syndrome even with exposure to lower dose glucocorticoids (9,10). Surreptitious and occult glucocorticoid use have been reported as well (11)(12)(13).…”

A case of iatrogenic Cushing syndrome and subsequent adrenal insufficiency from a hidden ingredient in the supplement Artri Ajo King

“…This case highlights the importance of complementary and alternative medicines when obtaining a full history from patients. 12 The FDA is aware of the physiologic effects of AK and has appropriately issued warning to various distributors of these products, but as with our patient, the supplement may be still available from other sources or outside of the United States. 4 The impact of physician language concordance and cultural norms with medical outcomes is also a paramount point of discussion in this case report.…”