Treatment-related adrenal insufficiency in patients with autoimmune blistering diseases

Treatment-related adrenal insufficiency in patients with autoimmune blistering diseasesTo the Editor: Systemic corticosteroids are the backbone in the treatment of autoimmune blistering diseases, but its use is associated with metabolic comorbidities including adrenal insufficiency. 1 The prevalence of treatment related adrenal insufficiency in autoimmune blistering diseases patients is rarely reported. 2,3e routinely assessed autoimmune blistering diseases patients for adrenal insufficiency when they are in clinical remission on #5 mg prednisolone, prior to treatment cessation (Fig 1).Patients who declined testing were monitored for adrenal insufficiency clinically during the prednisolone taper.We conducted an audit of those patients seen between Jan 2010 and September 2023 in Changi General Hospital who underwent a short Synacthen test.Cases were identified from the hospital's electronic database using ICD codes for bullous pemphigoid, pemphigoid, pemphigus, pemphigus vulgaris, and pemphigus foliaceus.We excluded patients who had an existing diagnosis of adrenal insufficiency or had missing data regarding the prednisolone treatment doses and duration.Masked demographic and treatment data were extracted in those cases who underwent the short Synacthen test.Data were analyzed using nonparametric Wilcoxon Rank Sum test with SPSS (version 29.0.2.0) (IBM).Twenty-three patients were included (Table I).Bullous pemphigoid accounted for 65% of the cohort (15 patients).The median age was 78 years.The median duration of their skin disease was 48 months.The median initiating dose of prednisolone was 20 mg and the median cumulative prednisolone dose was 5502 mg.Eighteen patients (78%) also required the use of steroid-sparing agents.Short Synacthen test was performed electively for 15 patients per department protocol, while 6 patients were tested because of hyponatremia (1 patient), hypotension or incidental postural hypotension (5 patients).The reasons for testing were not available in the electronic records for 2 patients.Eight patients (34%, Table I) were diagnosed with adrenal insufficiency and were managed by the endocrinologist with oral hydrocortisone replace-