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Glukokortikoidinducerad binjurebarkssvikt är ett underdiagnostiserat tillstånd som troligen bidrar till ökad mortalitet bland patienter med pågående eller nyligen avslutad kortisonbehandling. Konsensus om handläggning av glukokortikoidinducerad binjurebarkssvikt hos patienter med kortisonbehandling har tidigare saknats, men internationella riktlinjer har nyligen publicerats och sammanfattas i stora drag i denna ABC-artikel. Dessutom presenteras ett nytt svenskt kortisonkort som är avsett att delas ut till patienter som sätts in på prednisolon >5 mg dagligen eller motsvarande i >3–4 veckor, för att informera patient och vårdpersonal om risken för potentiellt livshotande binjurebarkssvikt.

Glucocorticoid-induced adrenal insufficiency is an underdiagnosed condition that possibly contributes to increased mortality. Consensus regarding management of glucocorticoid-induced adrenal insufficiency in patients receiving glucocorticoid therapy has previously been lacking, but the European Society of Endocrinology and the Endocrine Society have recently published joint international guidelines on the diagnosis and treatment, summarized in this article. To further support patients and healthcare professionals, and to prevent a potentially fatal adrenal crisis, a national blue corticosteroid treatment card has been introduced. The card is intended to be provided to patients treated with prednisolone >5 mg daily (or equivalent) for >3-4 weeks.

Hyperinsulinemic hypoglycemias resulting from variants in the insulin receptor (INSR) gene are rare but clinically important disorders. We present a male patient in his 30s, experiencing recurrent postprandial hypoglycemic events. Endocrine evaluation revealed an elevated insulin-to-C-peptide ratio. A hypoglycemia gene panel, using next-generation sequencing, identified a heterozygous nonsense variant in the INSR gene (NM_000208.4) c.3079C > T, p.(Arg1027*). Initial treatment with diazoxide reduced hypoglycemic symptoms and led to weight loss and decreased hemoglobin A1c due to reduced compensatory carbohydrate intake. However, limiting side effects on diazoxide prompted a treatment switch to lanreotide with maintained absence of hypoglycemic events. This case highlights the importance of considering variants in the INSR gene as a differential diagnosis in hyperinsulinemic hypoglycemia cases, even in adults.

Frozen saliva samples are often used for later determination of salivary glucocorticoids in research studies on stress and endocrine disorders. We studied the stability of cortisol and cortisone in saliva after six years of storage at −80 °C by repeated analysis of 153 stored aliquots, collected with Salivette®, using liquid chromatography tandem mass spectrometry. We found a very high agreement between the first and the repeated measurement after six years at −80 °C, for both cortisol and cortisone concentrations (rs= 0.96 and rs= 0.98, respectively). Passing-Bablok regression equations were y = 0.02 + 1.00x and y = 0.02 + 1.14x for cortisol and cortisone, respectively. We conclude that salivary cortisol and cortisone concentrations remain essentially unaltered after six years of storage at −80 °C.

Objective: To determine the effects of liquorice consumption, topical hydrocortisone, and blood contamination on salivary cortisol and cortisone concentrations.

Design and methods: Thirty healthy volunteers were randomized to a low, medium, or high dose of liquorice. Late-night saliva samples were collected using a Salivette® collection device at baseline, during 1 week of daily liquorice consumption, and during 4 weeks' washout. Saliva sampling was also performed before and after the application of topical hydrocortisone on the skin. Furthermore, in a subgroup (n  = 16), saliva and venous blood were collected from each individual and mixed to achieve graded blood contamination in saliva. Salivary cortisol and cortisone were analyzed with liquid chromatography-tandem mass spectrometry.

Results: Significant increases in salivary cortisol concentrations were observed during medium- (+49%) and high-dose (+97%) liquorice intake, which returned to baseline 4 days after liquorice withdrawal. Topical hydrocortisone on fingers holding the collection swab increased salivary cortisol concentrations >1000-fold with concomitant pronounced elevation of the cortisol:cortisone ratio. Salivary cortisol increased significantly after contamination with blood ≥0.5%. Visual examination could safely detect these samples. Salivary cortisone concentrations were unaffected by liquorice consumption and blood contamination, and only marginally affected by topical hydrocortisone.

Conclusion: Liquorice, topical hydrocortisone, and blood contamination may all cause elevated salivary cortisol concentrations. Improved sampling instructions and visual examination of the sample may minimize these risks. Salivary cortisone is essentially unaffected by the different preanalytical confounders and may be used as a first-line screening test for Cushing's syndrome.