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No Blood Testing in Relative Adrenal Insufficiency: Just Treat!

Ligtenberg and colleagues in their letter suggest that, in patients with septic shock, adrenal insufficiency is best diagnosed by the hemodynamic response to corticosteroids. This statement is incorrect for two primary reasons.

First, the cardiovascular effects of exogenous corticosteroids are not related to the adrenal function; intravenous administration of 50 mg of hydrocortisone enhanced pressure response to -agonists in healthy volunteers and septic shock patients regardless of adrenal status (1). The underlying mechanisms may include nongenomic and genomic effects (2). The very early (within 1 h) and transient (2 to 6 h) increase in pressure sensitivity to catecholamines is likely nongenomic and related to direct mobilization of intracellular calcium. Delayed and sustained effects are likely mediated through inhibition of nuclear factor-B–induced nitric oxide synthase and cyclooxygenase II. Thus, the decreased vasopressor dose associated with hydrocortisone infusion is not synonymous with adrenal insufficiency.

Second, recognizing adrenal insufficiency during critical illness helps to guide corticosteroid treatment. In our study, the prevalence of adrenal insufficiency as defined by the metyrapone test was 60% and not 83.5% (3). Given these findings, without endocrine testing, a substantial number of patients would receive unnecessary prolonged corticosteroid treatment. In addition, our results should prompt investigations to establish the cause of impaired adrenal function and whether it is reversible or requires chronic hormone replacement and long-term follow-up. It is paramount that physicians confirm the diagnosis of adrenal insufficiency when treating patients with septic shock with low-dose hydrocortisone.

Djillali Annane

Hôpital Raymond Poincaré (AP-HP), Université de Versailles SQY, Garches, France

FOOTNOTES

Conflict of Interest Statement: D.A. does not have a financial relationship with commercial entity that has an interest in the subject of this manuscript.

REFERENCES

1. Bellissant E, Annane D. Effect of hydrocortisone on phenylephrine: mean arterial pressure dose–response relationship in septic shock. Clin Pharmacol Ther 2000;68:293–303.[CrossRef][Medline]
2. Annane D. Glucocorticoids in the treatment of severe sepsis and septic shock. Curr Opin Crit Care 2005;11:449–453.[CrossRef][Medline]
3. Annane D, Maxime V, Ibrahim F, Alvarez JC, Abe E, Boudou P. Diagnosis of adrenal insufficiency in severe sepsis and septic shock. Am J Respir Crit Care Med 2006;174:1319–1326.[Abstract/Free Full Text]

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