Single serum cortisol values at 09:00 h can be indices of adrenocortical function in children with Kawasaki disease treated with intravenous immunoglobulin plus prednisolone

Abstract

Combination treatment with intravenous immunoglobulin (IVIG) plus prednisolone is effective for prevention of cardiovascular complications in children with Kawasaki disease (KD). However, administration of prednisolone for approximately 20 d in this regimen causes adrenocortical suppression in a high proportion of treated children. To establish a simple method to screen for this suppression, we performed a prospective study on 72 children with KD treated with this regimen in our institution from February 2012 to March 2014. By performing ROC analysis of 21 initial patients treated between February and June 2012, a serum cortisol value at 09:00 h of 5 mcg/dL was established as a threshold for intact adrenocortical function, which is equivalent to a peak serum cortisol value of higher than 15 mcg/dL in the CRH stimulation test. Then, we applied this screening test to 51 subsequent patients treated between July 2012 and March 2014. Approximately 90% of the patients with morning serum cortisol values above 5 mcg/dL 2 to 6 mo after the cessation of initial prednisolone treatment had peak serum cortisol values exceeding 15 mcg/dL, suggesting the efficacy of this approach.

Efficacy of single serum cortisol reading obtained between 9 AM and 10 AM as an index of adrenal function in children treated with glucocorticoids or synthetic adrenocorticotropic hormone

“…Based on peak cortisol values from the CRH stimulation test, all subjects as well as those in primary disease groups (IBD, purpura, West syndrome, and others) were further divided into two subgroups. One group had insufficient adrenal function (peak cortisol values < 15 µg/dL) and the other with intact adrenal function (peak cortisol values > 15 µg/dL), in accordance with the definition applied in our previous study ( 8 ). Scatter diagrams were then constructed, and the overlap of the two subgroups was calculated.…”

“…1B, C, E ). This may be one reason why the degrees of AUC in these categories were not as high as that in subjects with West syndrome or Kawasaki disease ( 8 ). We could not get satisfactorily high degrees of AUC from ROC curves even when we divided our subjects (excluding patients with West syndrome) into subgroups according to the duration of initial treatment (data not shown).…”

“…Previously, we reported that single serum cortisol values obtained at 09:00 AM correlated significantly with peak cortisol values in a CRH stimulation test in children with Kawasaki disease treated with prednisolone for approximately 20 days ( 7 ). We also reported that a single cortisol value higher than 5 µg/dL obtained at 09:00 AM can be a practical index of intact adrenal function in these children ( 8 ).…”

Steroid-Induced Iatrogenic Adrenal Insufficiency in Children: A Literature Review

“…In an interventional study where a high-dose, short-term glucocorticoid (HDC 25 mg twice daily for five days) was administered to healthy adult subjects, the peak cortisol response to the ITT significantly decreased two days after PSL discontinuation but nearly returned to pretreatment levels five days after the intervention [72]. An observational study of childhood asthma found that adrenal function normalized in all 11 patients ten days after the completion of short-term PSL treatment [30], and another study of PSL treatment for Kawasaki disease in children reported recovery in more than half the patients within two months [67].…”

“…A reference value of plasma cortisol, which is equivalent to that of serum cortisol [63][64][65], ≤3 µg/dL (83 nmol/L), may indicate SIAI, while a value >19 µg/dL (525 nmol/L) can be used to exclude SIAI [66]. A cohort study suggested a serum cortisol level of 5 µg/dL at 9 a.m. in children as a cutoff value for SIAI screening following steroid administration for Kawasaki disease [67].…”