Citation Information :
Srinivasagopalane B, Somasundaram K, Thoppalan B. Clinical and Biochemical Pertinence of Glucocorticoid-induced Adrenal Insufficiency in Glomerular Disease Conditions. World J Endoc Surg 2023; 15 (1):1-5.
The cardinal treatment modality for any glomerular disease is glucocorticoids. The glucocorticoids cause an imbalance in the hypothalamus–pituitary–adrenal axis by altering the endogenous cortisol levels. The low levels of cortisol result in a clinical syndrome called adrenal insufficiency (AI). The occurrence of iatrogenic AI by the glucocorticoids among glomerular disease is evaluated in this study by both biochemical cortisol assay and clinical evaluation, and also, the value of salivary cortisol over serum cortisol is correlated.
Materials and methods: This cross-sectional study was done on 30 biopsy-proven glomerular disease patients on glucocorticoid treatment. Clinical implications were noted using a detailed questionnaire, and serum and salivary cortisol assays were analyzed by enzyme-linked immunosorbent assay (ELISA) technique.
Results: On clinical evaluation, 78% of the study population did not show signs of AI. However, 15% of the patients exhibited cushingoid symptoms. Biochemical assay with serum cortisol showed 45% with low serum cortisol levels, suggesting AI and only 3% of the study population had low salivary cortisol levels. There was no linear correlation between serum and salivary cortisol levels.
Conclusion: The evidence of AI among glucocorticoid-treated glomerular disease patients is established with serum cortisol assay. The value of salivary cortisol is not marked as the other confounding factors, such as drugs and cross-reactivity with antibodies, could alter the assay values. Overall, the suppression of the hypothalamic–pituitary–adrenal (HPA) axis is evident in our study, and a monitored glucocorticoid therapy is vital so as to prevent the tendency of AI and its complications.
Karangizi AHK, Al-Shaghana M, Logan S, et al. Glucocorticoid induced adrenal insufficiency is common in steroid treated glomerular diseases - proposed strategy for screening and management. BMC Nephrol 2019;20(1):154. DOI: 10.1186/s12882-019-1354-6
Vining RF, McGinley RA, Maksvytis JJ, et al. Salivary cortisol: a better measure of adrenal cortical function than serum cortisol. Ann Clin Biochem 1983;20(6):329–335. DOI: 10.1177/000456328302000601
Joseph RM, Ray DW, Keevil B, et al. Low salivary cortisol levels in patients with rheumatoid arthritis exposed to oral glucocorticoids: a cross-sectional study set within UK electronic health records. RMD Open 2018;4(2):e000700–e000700. DOI: 10.1136/rmdopen-2018-000700
Broersen LH, Pereira AM, Jørgensen JO, et al. Adrenal insufficiency in corticosteroids use: systematic review and meta-analysis. J Clin Endocrinol Metab 2015;100(6):2171–2180. DOI: 10.1210/jc.2015-1218
Wallace I, Cunningham S, Lindsay J. The diagnosis and investigation of adrenal insufficiency in adults. Ann Clin Biochem 2009;46(5):351–367. DOI: 10.1258/acb.2009.009101
Nicolaides NC, Chrousos GP, Charmandari E. Adrenal insufficiency. 2015.
Laugesen K, Petersen I, Sørensen HT, et al. Clinical indicators of adrenal insufficiency following discontinuation of oral glucocorticoid therapy: a Danish population-based self-controlled case series analysis. PLoS One 2019;14(2):e0212259–e0212259. DOI: 10.1371/journal.pone.0212259
Sakihara S, Kageyama K, Oki Y, et al. Evaluation of plasma, salivary, and urinary cortisol levels for diagnosis of Cushing's syndrome. Endocr J 2010;57(4):331–337. DOI: 10.1507/endocrj.k09e-340
Gatti R, Antonelli G, Prearo M, et al. Cortisol assays and diagnostic laboratory procedures in human biological fluids. Clin Biochem 2009;42(12):1205–1217. DOI: 10.1016/j.clinbiochem.2009.04.011
Joseph RM, Hunter AL, Ray DW, et al. Systemic glucocorticoid therapy and adrenal insufficiency in adults: a systematic review. Semin Arthritis Rheum 2016;46(1):133–141. DOI: 10.1016/j.semarthrit.2016.03.001
Lipworth BJ. Systemic adverse effects of inhaled corticosteroid therapy: a systematic review and meta-analysis. Arch Intern Med 1999;159(9):941–955. DOI: 10.1001/archinte.159.9.941
Sorkness CA, LaForce C, Storms W, et al. Effects of the inhaled corticosteroids fluticasone propionate, triamcinolone acetonide, and flunisolide and oral prednisone on the hypothalamic-pituitary-adrenal axis in adult patients with asthma. Clin Ther 1999;21(2):353–367. DOI: 10.1016/S0149-2918(00)88292-2
Restituto P, Galofre JC, Gil MJ, et al. Advantage of salivary cortisol measurements in the diagnosis of glucocorticoid related disorders. Clin Biochem 2008;41(9):688–692. DOI: 10.1016/j.clinbiochem.2008.01.015
Raff H. Utility of salivary cortisol measurements in Cushing's syndrome and adrenal insufficiency. J Clin Endocrinol Metab 2009;94(10):3647–3655. DOI: 10.1210/jc.2009-1166
Törnhage CJ. Salivary cortisol for assessment of hypothalamic-pituitary-adrenal axis function. Neuroimmunomodulation 2009;16(5):284–289. DOI: 10.1159/000216186
Granger DA, Hibel LC, Fortunato CK, et al. Medication effects on salivary cortisol: Tactics and strategy to minimize impact in behavioral and developmental science. Psychoneuroendocrinology 2009;34(10):1437–1448. DOI: 10.1016/j.psyneuen.2009.06.017