P77 What is the role of cortisol and short Synacthen testing in patients weaning off long term glucocorticoids?
Authors: Smith Ruth , Akil Mohammed 
Published: April 2020

Background

Many rheumatological conditions are treated with steroids. Patients on long-term steroids are known to be at risk of adrenal insufficiency especially when withdrawing them. Sheffield Teaching Hospital (STH) Endocrinologists advised the following protocol for patients reducing steroids to determine hypothalamic pituitary adrenal status and confirm safe onward withdrawal of steroids:- After 1 month on 3mg prednisolone measure 9am serum cortisol and ACTH (after 24 hours off steroid)- If cortisol &lt;150nmol/L or &lt; 200nmol/L and ACTH &lt;10pg/mL - refer Endocrinology- If cortisol 200-430nmol/L (or &gt; 150nmol/L and ACTH &gt;10pg/mL) arrange short Synacthen test (SST). If 30-minute cortisol &lt;430nmol/L - refer Endocrinology. If 30 minute cortisol &gt;430nmol/L - stop steroids and monitor for adrenal insufficiency (give hydrocortisone 20mg TDS to cover illness for 3 months after stopping prednisolone).

Methods

We performed a retrospective review of records of rheumatology patients having morning cortisol level checked July 2017-January 2019 to determine how many tests were abnormal and to what degree the results changed management.

Results

160 cortisol tests were performed. 36 were excluded from further analysis. Of the 124 cases reviewed: 80 females and 44 males. Age range 18-87; mean 64 years. Starting dose of prednisolone 5-60mg. Duration of steroid use 6 months to &gt; 10 years; modal duration 13-24 months (49 patients/40%). 59 patients/48% were taking other immunosuppressants. Prednisolone dose at cortisol testing 1-5mg; modal value 3mg (89 patients/72%). 12 patients/10% had a normal morning cortisol. 9 patients/7% fell into the group ‘cortisol &lt;150nmol/L refer Endocrinology.’ 103 patients/83% fell into the group requiring SST. 79 patients had an SST (out of an expected 112). 58/73% were normal. 17 patients/81% with abnormal SST were referred to Endocrinology. 11/65% were advised to wean prednisolone as per normal rheumatology practice of 1mg per month; 1/6% to continue prednisolone and repeat SST in 2-3 months; 3/18% to commence hydrocortisone. 2/12% had not yet been seen. Of the patients with abnormal SST: 8 females and 13 males. Age range 32-87; mean 67 years. Starting dose of prednisolone 5-40mg. Duration on steroids 6 months to &gt; 10 years; modal duration 13-24 months in 9 patients/43%. 12 patients/57% were on other forms of immunosuppression.

Conclusion

Endocrinology guidance changed the management of 3 patients/2% by the introduction of hydrocortisone compared with previous rheumatology standard practice of weaning prednisolone by 1mg per month or similar. No distinctive characteristics were identified in patients with abnormal SST, except for a greater proportion of men (35% of whole group: 62% of abnormal SST group). Given the limited impact of the investigations, and the shortage of Synacthen, a new protocol has been implemented: if morning cortisol &lt;300nmol/L, or 300-350nmol/L and symptoms - contact Endocrinology for SST; if 30 minute cortisol &lt;430nmol/L - refer Endocrinology; otherwise wean prednisolone as normal.

Disclosures

R. Smith None. M. Akil Honoraria; AbbVie, Actelion, Celgene, Astra Zenica, Lilly and UCB.