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Abstract
An 18-year-old woman with a history of hollow visceral myopathy presented with a small-bowel obstruction. High-dose opioid analgesia was required subsequently during hospital admission. She suffered two episodes of documented fasting hypoglycaemia, despite adjustment of parenteral carbohydrate administration. Investigations for non-insulin-mediated hypoglycaemia revealed a low morning cortisol of 109 nmol/L and an inappropriately low Adrenocorticotropic hormone (ACTH) level of 2.2 pmol/L. A diagnosis of secondary adrenal insufficiency was confirmed on repeat cortisol and ACTH testing. The 250 µg short Synacthen test cortisol response was normal, suggestive of acute rather than chronic ACTH deficiency. This pattern was consistent after further opioid exposure. Adrenal recovery occurred shortly after opioid cessation. Opioid-induced hypoadrenalism is likely an under-recognised clinical entity with potentially serious adverse patient outcomes. There are reported cases involving commonly prescribed opioids including fentanyl and tramadol. However, we believe this is the first reported clinical case of acute transient opioid-induced secondary hypoadrenalism associated with fasting hypoglycaemia.
- drugs: endocrine system
- adrenal disorders
- unwanted effects/adverse reactions
- pituitary disorders
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Footnotes
Twitter @antieclarke
Contributors EJT was the clinician primarily involved in reviewing the patient clinically during her hospital admission and subsequent outpatient investigations and follow-up phone calls. EJT was primarily responsible for collating the clinical history, performing physical examinations and writing and presenting the case in the form of oral presentation to colleagues at RPA Hospital. He was also closely involved in drafting the final manuscript and literature review for which he was closely assisted by AJC. AJC obtained patient consent, performed a literature review and subsequently wrote the discussion section of the manuscript. AJC also undertook all suggested revisions and edits of the manuscript. SMT was the senior clinician consulted by the admitting surgical team to review the patient during her admission with respect to her adrenal insufficiency. SMT was instrumental in supervising the case and providing supervision and support for EJT who was an Endocrinology Advanced Trainee at the time of the patient’s presentation. SMT has been a senior author on another publication on opioid-induced hypoadrenalism and therefore has some clinical experience which helped to recognise this rare but important diagnosis. SMT has overseen the preparation of the case in oral format as presented by EJT. All authors contributed to and revised the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.