Adrenal Insufficiency

Rohan Henry, MD, MS, on Screening for Secondary Adrenal Insufficiency

02/07/2022

In this podcast, Rohan Henry, MD, MS, speaks about how health care providers can screen for secondary adrenal insufficiency and treatment options for secondary adrenal insufficiency in patients with pituitary deficiency.

Additional Resource:

Rohan Henry, MD, MS, is a pediatric endocrinologist and an attending physician at Nationwide Children’s Hospital. He’s also a faculty member at the Ohio State University College of Medicine in Columbus, Ohio.

TRANSCRIPTION:

Jessica Bard: Hello everyone and welcome to another installment of "Podcast360," your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.

Secondary adrenal insufficiency occurs more frequently than primary adrenal insufficiency. Its estimated prevalence is 150 to 280 per million and is more common in women compared with men.

Dr Rohan Henry is here to speak with us about screening and treatment options for secondary AI in patients with pituitary deficiency. Dr Henry is a pediatric endocrinologist and an attending physician at Nationwide Children's Hospital. He's also a faculty member at the Ohio State University College of Medicine in Columbus, Ohio.

Thank you for joining us today, Dr Henry. How can healthcare providers, say pediatricians or primary care providers, screen for secondary adrenal insufficiency?

Dr Rohan Henry: It's a great question, Jessica. The screening for primary and secondary adrenal insufficiency are the same. We screened for the disorders by doing a morning cortisol.

We have to bear in mind that because secondary adrenal insufficiency is so rare there has to be a heightened index of suspicion as to this existing in a particular patient.

One of the things that we look for is a history which is in keeping with the fact that you'd expect some hormonal insufficiency. If we have a patient who have had trauma to the pituitary gland or radiation to the pituitary gland, then you'd expect that the secondary adrenal insufficiency could exist as a part about multiple hormonal insufficiencies.

Morning cortisol is a pretty good screening test. Most of the cortisol which is produced by the body is produced between 4:00 and 7:00 AM in the morning. However, as you can imagine, no lab is open between 4:00 and 7:00 AM in the morning.

As a surrogate, we usually tell our patients to do cortisol and most of our lab is commercially open at 8:30. I instruct the patients to do lab as close as possible to when your local lab opens, in our clinic setting, between 8:30 and 9:30 AM.

We have said in the past that morning cortisol have a value of 10 micrograms per deciliter was pretty a robust cortisol. However, this value is subject to debate at this point in time, because machines over the years have gotten very sensitive.

We talk about the assays have become more sensitive. With the new assays, values of maybe 6.5 or 7 may be equivalent to those values in previous years which are about 10. There're ongoing studies now as to proving which value is predictive of adrenal sufficiency at that time of the morning.

Jessica: What are some treatment options for secondary AI in patients with pituitary deficiency?

Dr Henry: All right, the treatment options for secondary AI is to replace the glucocorticoid part of the axis. It's really to replace hydrocortisone. Hydrocortisone replacement is given by suspension or tablets.

I will tell you though in the pediatric population, we try and give him the tablets as much as possible because it's a case where if you have a suspension, if the suspension isn't vigorously agitated before giving it to the patient, there could be settling of the active ingredients to the bottom.

It's as best as possible we tried to give tablets, the lowest tablet were like 5-mg where you could divide it into four equal segments of 1.25, when you have like a pill cutter.

However, this is very recent, within the past year, there has been a company which has actually developed some sprinkles. I'm obviously not employed to this company. [laughs] It's called Alkindi Sprinkles. That has proved useful in this population where you can get on even to 1-mg of hydrocortisone, so ease of administration where you can simply put it into the food which the patient is using.

The options that are really as I said, hydrocortisone tablets, preferable. You may see people giving it as twice daily, however, it doesn't last the full 12 hours, it usually lasts for like up to 8 hours, so 3 times daily may be optimal.

Some persons in a research setting have also used pumps, just like you have insulin pumps for your patients with type 1 diabetes. You may have hydrocortisone pumps, but this is not used in the mainstream medical therapy at this point in time.

Jessica: In your opinion, are the current treatment guidelines sufficient?

Dr Henry: That's a very great question. Secondary adrenal insufficiency is a very uncommon disorder, like I had said because the prevalence is about 150 to 280 per million. I haven't come across treatment guidelines per se for secondary adrenal insufficiency in terms of established treatment guidelines.

We have different organizations which govern the practice of endocrinology both in the US and in Europe. Our society in pediatrics is the Pediatric Endocrine Society, and for the adults, they have the Endocrine Society, and they have come up with guidelines for primary adrenal insufficiency.

I haven't seen any guidelines per se for secondary adrenal insufficiency because the prevalence is so rare that I haven't seen any guidelines. However, the principles are that you should replace the hormone which the person is missing, which in this case would be missing cortisol. We replace it with hydrocortisone.

Jessica: Is there anything else that you'd like to add that you think is important today?

Dr Henry: Very good question. Adrenal insufficiency, as most of us know, is a life‑threatening disorder. It's very important that apart from the hormone replacements, these persons definitely should wear a medical alert bracelet.

I cannot overemphasize that too much because if it's a case where the person has had an alteration of consciousness or totally unconscious, somebody who's coming across this patient, if they have seen that the person has adrenal insufficiency, they can actually get this life‑threatening hormone to them, this intramuscular hydrocortisone.

That means save lives. That's akin to give Narcan in somebody who has opioid toxicity. That is very important that the person should wear a medical alert bracelet.

Jessica: Thank you for joining us on the podcast today. We appreciate your time.

Dr Henry: Thanks for having me again, Jessica