Review for 10.1186/1471-230X-14-51 (2014)

Reviewer's report
Title:Screening for adrenal suppression in children with inflammatory bowel
disease discontinuing glucocorticoid therapy
Version:1Date:18 February 2014
Reviewer: JACQUES WEILL
Reviewer's report:
Review of the manuscript ‘’Adrenal Suppression in Paediatric IBD’’
from K Kolho and M Sidoroff
Assessment of the work
Question 1 : Relevance of the question : The subject of the paper iswelldefined
and responds to aneed, since few publications have been dedicated in
paediatrics to the weaningfromglucocorticoidtherapy in
inflammatoryboweldiseases.
Question 2 : Appropriateness of the data : Data are perfectlysound and
wellidentified
Question 3 : Interpretation of the data : Interpretation of the resultsfitswith the
data and lie on a supporting argumentation.
Question 4 : Validity of the methods : Globally, the methods are correct, but the
statistical tests shouldbedevelopped
Question 5 :Strenghts and weaknesses of the methods : See the commentary
Question 6 : Improvements : Writings (excepted few minor spelling errors),
organization, tables and figures are correctly conceived and do not need to be
improved.
Question 7 : Ethical aspects : The studydoes not raiseanyethicaldifficulty, sinceit
has been approvedbeforehand by a local ethicalcommittee and sincethereis no
deviationfrom the ordinary care procedure.
Commentary :
The presentpaperaddresses to an audience of paediatricgastroenterologists,
whose attention is to becalled on the possibility of corticotropindeficiency in
childrentreated for IBD by syntheticglucocorticoids. Not many publications have
been devoted to thisspecifictopic.This deficiencydepends on manyfactors :
glucocorticoidtherapy doses and duration, patient’s compliance, as wellexposed
in thispaper, but also intestinal absorption, whichmaybedisturbed in smallbowel
affections, and individualglucocorticoidsensitivity on a genetic basis (see : Quax
RA et al.Glucocorticoidsensitivity in health and disease. Nat RevEndocrinol.2013
Nov;9(11): 670-686). The consequences of this observation
shouldbedevelopped, ie a replacement therapywith hydrocortisone, sothat
practical guidelinesshouldbedesigned in case of adrenalsecondarydeficiency. As
underlined by the authors, silentadrenaldeficiency, detectable by corticotropin
test, maycoexistwith the overtform, which would need transiently an appropriate
(withincreased doses) hydrocortisone treatment.
The tempo of prednisolonetapering off shouldbeprecised. It appearsthatsome
patients did no more receiveanyprednisolone( dose of < 5 mg/day) ;
thiswaningperiod, source of heterogeneity in the data, does not appear in table 1
and its duration shouldbementioned. This classification shouldbeextended to
prednisolone doses inferior to the doses
suppressinghypothalamo-pituitary-adrenal axis, as wellcharacterized in
congenitaladrenal hyperplasia (cf : Hughes IA, Read GF. Control in
congenitaladrenal hyperplasiamonitored by frequent saliva 17OH-progesterone
measurements.HormRes. 1984;19(2):77-85).
The statistical tests have to berefined (for instance :
multiparametriccorrelationssuch as mixed model : cortisolaemia vs type of IBD +
prednisolone dose + prednisolonetreatment duration or ROC curve of
cortisolaemia<threshold vs prednisolone dose).
Spellingerrors : p 4, 9th line : patients
,, , 19th ,, : cushingoid