Poster Presentation ESA-SRB-APEG-NZSE 2022

Opioid-induced adrenal insufficiency - an under-recognised phenomenon in children and adolescents (#467)

Shane M Mc Kenna 1 , Farrah Rodrigues 1 2 , Michele A O'Connell 1 2 3
  1. Department of Endocrinology and Diabetes , The Royal Children's Hospital , Melbourne , Victoria , Australia
  2. Murdoch Children's Research Institute , Melbourne , Victoria , Australia
  3. Department of Paediatrics , University of Melbourne , Melbourne , Victoria , Australia

To report two cases of opioid-induced adrenal insufficiency(OIAI) in children and adolescents with opioid use.

Opioid-induced adrenal insufficiency (OIAI) is a well-documented cause of iatrogenic adrenal insufficiency in adults, arising as a result of hypothalamic-pituitary-adrenal(HPA) axis suppression(1). Here we report two paediatric cases of opioid-induced adrenal insufficiency(OIAI). De-identified clinical and biochemical data pertaining to 2 adolescents known to the authors were extracted from the electronic medical record for this report.

Case 1 had a history comprising acute lymphoblastic leukaemia(ALL) and multi-focal avascular-necrosis(AVN) which necessitated chronic opioid analgesia. Recovery of adrenal function post initial ALL-related prednisolone therapy had been documented one months later. Investigation of incidentally-noted hypoglycaemia revealed low ACTH and cortisol levels(Table1). Central nervous system ALL or alternative disease was suspected; however, excluded with investigation. Testing of other anterior pituitary hormonal axes and causes of hypoglycaemia were normal. Hydrocortisone replacement led to resolution of hypoglycaemia. She remains on opioid therapy due to persistent complex pain despite two doses of zoledronic acid for AVN. While OIAI is presumed responsible, this will only be confirmed when opioid is ceased. 

Case 2 presented with slipped-upper-femoral-epiphysis(SUFE) and received opioid therapy for analgesia. Investigation for possible hormonal causes of SUFE revealed low ACTH and cortisol levels(Table1). Thyroid function tests were normal. Opioid was ceased and stress hydrocortisone dosing advice provided. Recovery of the hypothalamic-pituitary-adrenal axis(HPA) was observed on repeat testing two weeks after opioid cessation.

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The prevalence of OIAI in adults on chronic opioids is estimated to range from 8.3% to 29%(2,3) but reports in children and adolescents are limited.  Our cases indicate OIAI can arise with both short and longer-term paediatric opioid use. Given its prevalence in adults, OIAI may be under-recognised in the paediatric population. Further research is necessary to identify the frequency and guide optimal management of OIAI in paediatric populations. 

 

 

 

  1. Tabet EJ, Clarke AJ, Twigg SM. Opioid-induced hypoadrenalism resulting in fasting hypoglycaemia. BMJ Case Reports. 2019 Dec 11; 12 (12).
  2. Lamprecht A et al. Secondary adrenal insufficiency and pituitary dysfunction in oral/transdermal opioid users with non-cancer pain. Eur J Endocrinol. 2018 Dec 1;179(6):353-62.
  3. Gibb FW et al. Adrenal insufficiency in patients on long-term opioid analgesia. Clin Endocrinol (Oxf). 2016 June;85(6):831-5.