Secondary Adrenal Insufficiency due to Opiate Therapy – Another Differential Diagnosis Worth Consideration

Abstract

We report on a 64-year-old patient in whom fentanyl therapy was found to be responsible for the induction of secondary adrenal insufficiency as clearly demonstrated by re-exposure. We conclude that given the widespread use of opiates in chronic pain management physicians should raise their level of awareness for adrenal insufficiency and look for it generously. Opiates should be added to the list of differential diagnoses to be considered routinely in patients with newly diagnosed secondary adrenal insufficiency.

Key words

secondary adrenal insufficiency - partial anterior pituitary failure - opiate therapy - fentanyl

References

• 1 Abs R, Verhelst J, Maeyaert J. et al . Endocrine consequences of long-term intrathecal administration of opioids.  J Clin Endocrinol Metab. 2000;  85 2215-2222
• 2 Arafah BM. Hypothalamic pituitary adrenal function during critical illness: limitations of current assessment methods.  J Clin Endocrinol Metab. 2006;  91 3725-3745
• 3 Bianda T, Delli Carpini R. et al . Severe back pain, depression and psycho-organic syndrome.  Qjm. 2003;  96 950-951
• 4 Cooper MS, Stewart PM. Corticosteroid insufficiency in acutely ill patients.  N Engl J Med. 2003;  348 727-734
• 5 Delitala G, Grossman A, Besser M. Differential effects of opiate peptides and alkaloids on anterior pituitary hormone secretion.  Neuroendocrinology. 1983;  37 275-279
• 6 Grossman A. Brain opiates and neuroendocrine function.  Clin Endocrinol Metab. 1983;  12 725-746
• 7 Grossman A, Moult PJA, Cunnah D. et al . Different opioid mechanisms are involved in the modulation of ACTH and gonadotrophin release in man.  Neuroendocrinology. 1986;  42 357-360
• 8 Howlett TA, Rees LH. Endogenous opioid peptides and hypothalamo-pituitary function.  Annu Rev Physiol. 1986;  48 527-536
• 9 Morley JE. The endocrinology of the opiates and opioid peptides.  Metabolism. 1981;  30 195-209
• 10 Oltmanns KM, Fehm HL, Peters A. Chronic fentanyl application induces adrenocortical insufficiency.  J Intern Med. 2005;  257 478-480
• 11 Pende A, Musso NR, Montaldi ML. et al . Evaluation of the effects induced by four opiate drugs, with different affinities to opioid receptor subtypes, on anterior pituitary LH, TSH, PRL and GH secretion and on cortisol secretion in normal men.  Biomed Pharmacother. 1986;  40 178-182
• 12 Rothwell PM, Udwadia ZF, PG L. Cortisol response to corticotropin and survival in septic shock.  Lancet. 1991;  337 582-583
• 13 Schuetz P, Müller B. The hypothalamic-pituitary-adrenal axis in critical illness.  Endocrinol Metab Clin North Am. 2006;  35 823-838

Correspondence