Session: SUN 50-71-HPA Axis
Poster Board SUN-65
Systemic and intra-articular corticosteroids are the gold standard treatment to relieve pain and inflammation associated to various articular disorders and orthopedic procedures. At the same time, HPA axis’ suppression is a major side effect associated to these therapies. We provide data of the first study assessing the magnitude and duration of HPA axis’ suppression following a single intra-bursal injection of two different steroids in a large, homogeneous cohort of patients, evaluated using new techniques for hormonal assays.
Materials and methods
Randomized, blind, case-control study. 40 patients affected by rotator cuff painful calcific tendonitis underwent percutaneous ultrasound-guided treatment (TPE). They were then randomly treated with an intra-bursal injection of 40 mg of metilprednisolone acetate (MA) (group A, 20 patients) or triamcinolone acetonide (TA) (group B, 20 patients). Exclusion criteria were steroid/ACTH treatment in the previous 3 months, pregnancy, lactation and severe concomitant diseases. In all patients, the morning before (T0) and 1 (T1), 7 (T2), 15 (T3), 30 (T4) and 45 (T5) days after treatment we evaluated plasmatic cortisol and ACTH (by RIA), urinary cortisol, urinary MA/TA (by LC-MS/MC).
Results: At baseline, levels of plasmatic cortisol and ACTH, and urinary cortisol were in the normal range and similar in both groups. Compared to T0, a significant (p<0.00001) and similar decrease in levels (mean ± SD, mean difference 95% CI) of plasmatic ACTH (Group A 9.1 ± 9.1 vs 23.77 ± 11.29; 15±7 pg/ml. Group B 5.49 ± 6.96 vs 29.2 ± 16.14; 24±8 pg/ml) and cortisol (Group A 45.94 ± 50.66 vs 182.55 ± 59.67; 136±36 ng/ml. Group B 36.97 ± 52.9 vs 179.71 ± 58.41; 143±35 ng/ml) and urinary cortisol (Group A 7.23±8.1 vs ±24±11; -16.77 ±5.57 µg/die. Group B 12.83±20.88 vs 24±9; -11.17 ±8.27 µg/die) was observed at T1 in both groups (mean hormonal levels under minimal reference value in >85% of patients). Compared to baseline, no significant differences (p>0.05) were found for mean ACTH levels after T2; cortisol levels were similar to baseline after T2 in group A, and after T3 in group B, whereas mean urinary cortisol levels were still significantly (p<0.001) lower up to T4 in group B (13.88±8.79; -10.12±5.79 mcg/die) and up to T5 in group A (14.01±10.15; -9.99±5.9 mcg/die). Drugs’ urinary levels decreased sharply from T1 to T2 (MA: 23.15±14.51 vs 5.37±4.38 ng/ml. TA: 12.33 ± 7.53 vs 4.56 ± 3.08 ng/ml) and then more gradually disappeared, being still detectable in ~10% of the patients at T5.
Conclusions: a single intra-bursal injection of 40 mg of MA/TA is sufficient to temporarily (up to 45 days) suppress HPA axis’ function, with no significant differences between the two drugs, and a trend of cortisol production converse but parallel to drug elimination. For this reason, treated patients deserve a particular attention and replacement therapy, especially under stress conditions.
Nothing to Disclose: FG, MB, EC, ML, DG, SG, FS, AS, EGGMG, EA
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