MON-756 Adrenal Crisis Induced By Zoledronic Acid In Patients With Adrenal Insufficiency: Case Series

Abstract A.M. AlFaifi: None. W. AlMistehi: None. Introduction: Adrenal insufficiency (AI) is characterized by an inadequate production of steroid hormones, and may subject patients to having osteoporosis. Zoledronic acid is a commonly used bisphosphonate that is known to cause acute phase reactions (APRs). Few case reports have demonstrated a risk of developing adrenal crisis in patients with AI after zoledronic acid, and we report two cases with a similar observation. Case 1: A 60-year-old female with history of Sheehan's syndrome and receives hydrocortisone and levothyroxine replacement. She is also on rosuvastatin for dyslipidemia. She had severe osteoporosis (T-score of -3.9 at lumbar spine and -2.6 at femoral necks), and received zoledronic acid infusion with precautionary acetaminophen. She reported nausea, vomiting and diarrhea the following day, and was brought to the emergency department in a shock state. All potential triggers were excluded, and she was started on intravenous hydrocortisone and phenylephrine infusion. She improved the following day and was discharged in a stable condition. Case 2: A 52-year-old female with giant prolactinoma and a remote history of transsphenoidal surgery and radiation therapy. She is on hydrocortisone, levothyroxine, statin therapy for dyslipidemia, and perindopril and amlodipine for hypertension. She had osteoporosis (T-score -2.7 at the lumbar spine and -1.8 at femoral necks), and received zoledronic acid and acetaminophen. The following day she complained of flu-like symptoms, and the day after was taken to the emergency department with lethargy and loss of consciousness. Her vital signs remained stable, but she had severe hyponatremia. She was managed with intravenous hydrocortisone and hypertonic saline infusion. She improved within 24 hours and was discharged in a stable condition. Discussion: Several precautionary methods were proposed to mitigate the risk of APRs with zoledronic acid in the overall population, such as the use of acetaminophen and dexamethasone. Our patients used the former, and it would be worthwhile to examine the effect of dexamethasone in patients with AI. Moreso, statin therapy showed promising results in-vitro experiments, but has failed to show clinical benefit in several randomized trials. Both of our patients used statins for a prolonged period of time for dyslipidemia, which has not resulted in a substantial benefit to this regard. Our findings suggest that zoledronic acid may pose a risk for adrenal crisis in patients with AI. Although anecdotal evidence, it calls for careful patient selection and highlights the potential benefit of keeping AI patients under extended surveillance following the use of zoledronic acid. Monday, June 3, 2024