Secondary Adrenocortical Insufficiency as a Result of Chronic Fentanyl Treatment: A Case Report

Abstract

Hypothalamus-Pituitary-Adrenal (HPA) may be disturbed by drugs, including opioids. In fact, opioids are a well-recognized cause of hypogonadotropic hypogonadism due to its effects in the hypothalamic-pituitary-gonads axis. Nevertheless, these results are not observed in all the studies and there are numerous contradictions in the literature. Receptor binding selectivity, doses, species used, and administration pathways of opioid derivates may contribute to these different results.A 36-years-old caucasian man was referred to our hospital with asthenia, facial and distal lower extremity swelling with pitting edema, and vinous red striaes on abdomen for one month. A hormone study was requested finding low levels of cortisol at 8 AM and Adrenocorticotropic Hormone (ACTH) levels. An ACTH stimulation test was performed observing an increase of cortisol levels. With the diagnosis of secondary adrenal insufficiency AI, transdermal Fentanyl 100 mcg per day treatment because of a chronic back pain was suspected as a causal agent. We gradually reduced the fentanyl dosage from 100 to 50 mcg per day and we introduce hydrocortisone 20 mg every 12 h as a treatment. After 10 days, HPA axis was recovered.Attending to the large number of patients treated with opioids, may be more common than is recognised. The mechanism involved in this disease is not well understood yet, however, there are several contradictions in the modulatory activity of opioids on the HPA axis. According to the possibility of the increase of the prevalence of this pathology, an awareness of this endocrinopathy is essential to the diagnosis and to apply the appropriate treatment with glucocorticoid replacement.