[Assessment of the hypothalamic-hypophyseal-adrenal axis in patients with chronic obstructive lung disease. Comparison of inhalant with systemic glucocorticoid therapy]. / Evaluation der hypothalamo-hypophysär-adrenalen Hormon-Achse bei Patienten mit chronisch-obstruktiver Atemwegserkrankung. Vergleich einer inhalativen mit einer systemischen Glucocorticoidtherapie.

OBJECTIVE: The action of inhalation and systemic treatment of chronic obstructive pulmonary disease by suppressing the hypothalamo-hypophyseal-adrenal axis was compared in patients with chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: Adrenocorticotropic hormone (ACTH) and cortisol concentrations were evaluated after a corticotropin-releasing-hormone (CRH)-test in 50 patients (aged 43 +/- 14 years) with chronic obstructive pulmonary disease (COPD) receiving inhalant glucocorticoid treatment (IGC), 61 patients (aged 54 +/- 11 years) with COPD on systemic glucocorticoid treatment (SGC) and 50 healthy volunteers (32 +/- 4 years). RESULTS: All 50 patients on IGC had normal CRH test results. 30 of 61 patients with SGC had decreased cortisol response (12 patients had no and 18 a reduced rise in cortisol). ACTH concentration was lower in patients on IGC than in the control group (basal ACTH 15.6 pg/ml and 24.5 pg/ml, respectively; after stimulation 40.3 vs 54.4 pg/ml, respectively). But systemic glucocorticoid treatment clearly caused suppression of basal (12.1 pg/ml) and stimulated (27.4 pg/ml) ACTH levels with correspondingly decreased cortisol levels (basal: 75.1 and 118.7 ng/ml [IGC], respectively, and after stimulation 128.5 and 225.9 ng/ml). CONCLUSIONS: Patients with COPD on inhalant glucocorticoid treatment have a clearly lower risk of adrenal cortical insufficiency than those on oral glucocorticoid treatment. But some suppression of ACTH secretion is demonstrable even in the former. Clinical significance of these findings seems unlikely. Development of adrenal cortical insufficiency need not be feared in patients treated with inhalant glucocorticoids.

The effect of long-term glucocorticoid therapy on pituitary-adrenal responses to exogenous corticotropin-releasing hormone.

BACKGROUND: Suppression of pituitary-adrenal function is a well-known consequence of glucocorticoid therapy, manifested principally by decreased corticotropin secretion. To determine the degree of suppression of pituitary-adrenal function in patients treated with different doses of synthetic glucocorticoid medication for different periods, we measured the pituitary-adrenal response to the administration of exogenous human corticotropin-releasing hormone (CRH). METHODS: We studied 279 patients who were receiving daily therapy with 5 to 30 mg of prednisone or its equivalent to treat various chronic diseases, principally collagen vascular disorders, and 50 normal subjects. Therapy ranged in duration from 1 week to 15 years. Stimulation tests using 100 micrograms of CRH as a bolus injection were performed in the morning, 24 hours after the most recent dose of glucocorticoids. In 61 patients an insulin hypoglycemia test, thought by many to be the reference standard, was also performed to assess the reliability of the CRH results. RESULTS: After the administration of CRH, 43 patients had no increase in plasma concentrations of corticotropin and cortisol. The response was blunted in 133 patients and normal in 103. There was poor correlation between the plasma cortisol response after the administration of CRH and the dose or duration of therapy or the basal plasma cortisol concentration. Although plasma cortisol concentrations after stimulation with CRH were generally lower than those after insulin administration, there was a significant correlation between the plasma cortisol responses to the two stimuli (r = 0.82). CONCLUSIONS: Pituitary-adrenal function in patients treated with synthetic glucocorticoids cannot be reliably estimated from the dose of glucocorticoid, the duration of therapy, or the basal plasma cortisol concentration. In such patients, testing with CRH is nearly as useful as insulin hypoglycemia testing in the assessment of pituitary-adrenal function.