Adrenalna insuficijencija i stres – kako postupiti s djetetom na kroničnoj glukokortikoidnoj terapiji
DOI:
https://doi.org/10.13112/pc.1142Ključne riječi:
Adrenalna insuficijencija; Glukokortikoidi; Hidrokortizon; Faktori rizikaSažetak
Adrenalna insuficijencija je često podcijenjen poremećaj koji, ako se ne prepozna, nosi rizik lošeg ishoda akutnih bolesti te dijagnostičkih i terapijskih zahvata. Rastuća incidencija kroničnih bolesti koje se često liječe glukokortikoidima čini jatrogeno uvjetovanu adrenalnu insuficijenciju značajnim problemom već u pedijatrijskoj populaciji.
Cilj ovog rada je naglasiti potrebu uvažavanja postojanja i pravovremenog prepoznavanja znakova adrenalne insuficijencije u djece, bilo da se radi o djeci koja su na kroničnoj supstitucijskoj terapiji hidrokortizonom zbog od ranije poznate adrenalne insuficijencije ili o djeci na kroničnoj glukokortikoidnoj terapiji, čija adrenalna insuficijencija može biti neprepoznata.
Sustavnim pregledom i analizom relevantnih znanstvenih radova, kliničkih smjernica i udžbenika nastojali smo dati pregled patofizioloških procesa koji vode razvoju adrenalne insuficijencije, njezinog prepoznavanja i liječenja, s posebnim osvrtom na adrenalnu insuficijenciju uzrokovanu kroničnom glukokortikoidnom terapijom. Sintezom brojnih preporuka i smjernica dali smo smjernice za prepoznavanje rizika za razvoj adrenalne insuficijencije te preporuke za postupanje u stanjima akutne bolesti i stresa, kao i preporuke za sigurno prekidanje kronične glukokortikoidne terapije.
Podizanje svijesti o riziku za razvoj jatrogene adrenalne insuficijencije u bolesnika na kroničnoj glukokortikoidnoj terapiji, uvažavanje činjenice da dijete s adrenalnom insuficijencijom ne može adekvatno odgovoriti na stres te edukacija liječnika i roditelja o pravodobnom reagiranju u hitnim situacijama, temelji su za smanjenje razvoja ozbiljnih komplikacija.
Reference
1. Buğrul F, Murat NÖ. Treatment and follow-up of non-stress adrenal insufficiency. J Clin Res Pediatr Endocrinol. 2025;17(Suppl 1):91–9.
2. Beuschlein F, Else T, Bancos I, Hahner S, Hamidi O, van Hulsteijn L, et al. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. Eur J Endocrinol 2024;190:G25–51.
3. El-Matary W, Carroll MW, Deslandres C, Griffiths AM, Kuenzig ME, Mack DR, et al. The 2023 impact of inflammatory bowel disease in Canada: Special populations-children and adolescents with IBD. J Can Assoc Gastroenterol 2023;6:S35–44.
4. Bansal N, Goyal A, Duong T, Patel S, Ishak A. A comprehensive overview of juvenile idiopathic arthritis: From pathophysiology to management. Autoimmun Rev. 2023;22:103337.
5. Holsboer F, Ising M. Stress hormone regulation: biological role and translation into therapy. Annu Rev Psychol. 2010;61:81–109, C1–11. doi:10.1146/annurev.psych.093008.100321.
6. McEwen BS, Bowles NP, Gray JD, Hill MN, Hunter RG, Karatsoreos IN, et al. Mechanisms of stress in the brain. Nat Neurosci. 2015;18:1353–63. doi:10.1038/nn.4086.
7. Leistner C, Menke A. Hypothalamic–pituitary–adrenal axis and stress. Handb Clin Neurol. 2020;175:55–64.
8. Tafet GE, Nemeroff CB. The links between stress and depression: psychoneuroendocrinological, genetic, and environmental interactions. J Neuropsychiatry Clin Neurosci. 2016;28:77–88.
9. Kilberg MJ, Vogiatzi MG. Adrenal Insufficiency in Children. In: Feingold KR, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2024.
10. Guyton AC, Hall JE. Textbook of Medical Physiology. 14th ed. Philadelphia: Elsevier; 2021. Chapter: The Adrenal Cortex and Adrenocortical Hormones.
11. Gallo-Payet N, Martinez A, Lacroix A. Editorial: ACTH action in the adrenal cortex: From molecular biology to pathophysiology. Front Endocrinol (Lausanne) 2017;8:101.
12. Webb TR, Chan L, Cooray SN, Cheetham ME, Chapple JP, Clark AJL. Distinct melanocortin 2 receptor accessory protein domains are required for melanocortin 2 receptor interaction and promotion of receptor trafficking. Endocrinology 2009;150:720–6.
13. Cay M, Ucar C, Senol D, Cevirgen F, Ozbag D, Altay Z, et al. Effect of increase in cortisol level due to stress in healthy young individuals on dynamic and static balance scores. North Clin Istanb 2018;5:295–301.
14. Krasner AS. Glucocorticoid-induced adrenal insufficiency. JAMA. 1999;282:671–6.
15. Nachawi N, Li D, Lansang MC. Glucocorticoid-induced adrenal insufficiency and glucocorticoid withdrawal syndrome. Cleve Clin J Med. 2024;91:245–55.
16. Bowden SA, Henry R. Pediatric adrenal insufficiency: diagnosis, management, and new therapies. Int J Pediatr. 2018;2018:1739831.
17. Bornstein SR, Allolio B, Arlt W, Barthel A, Don-Wauchope A, Hammer GD, et al. Diagnosis and treatment of primary adrenal insufficiency: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2016;101:364–89.
18. Krude H, Biebermann H, Luck W, Horn R, Brabant G, Grüters A. Severe early-onset obesity, adrenal insufficiency and red hair pigmentation caused by POMC mutations. Nat Genet. 1998;19:155–7.
19. Kamoi K, Tamura T, Tanaka K, Ishibashi M, Yamaji T. Hyponatremia and osmoregulation of thirst and vasopressin in adrenal insufficiency. J Clin Endocrinol Metab. 1993;77:1584–8.
20. Ahmet A, Rowan-Legg A, Pancer L. Adrenal suppression from exogenous glucocorticoids: Recognizing risk factors and preventing morbidity. Paediatr Child Health. 2021;11;26:242-54. doi: 10.1093/pch/pxab015.
21. Jonetz-Mentzel L, Wiedemann G. Establishment of reference ranges for cortisol in neonates, infants, children and adolescents. Clin Chem Lab Med. 1993;31:525–30.
22. Coshway LK, Indyk JA, Bowden SA. Repeating ACTH Stimulation Test Is Necessary to Diagnose ACTH Deficiency in Neonatal Hypopituitarism With Initial False Negative Result. Glob Pediatr Health. 2014;1:2333794X14563385. doi: 10.1177/2333794X14563385.
23. Bornstein SR, Allolio B, Arlt W, Barthel A, Don-Wauchope A, Hammer GD, et al. Diagnosis and treatment of primary adrenal insufficiency: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2016;101:364–89.
24. Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, et al. Congenital adrenal hyperplasia—current insights in pathophysiology, diagnostics, and management. Endocr Rev 2022;43:91–159. doi: 10.1210/endrev/bnab016.
25. Improda N, Chioma L, Capalbo D, Bizzarri C, Salerno M. Glucocorticoid treatment and adrenal suppression in children: current view and open issues. J Endocrinol Invest 2025;48:37–52.
26. Holterhus P-M, Kulle A, Till A-M, Stille C, Lamprecht T, Vieth S, et al. Pilot study shows suppression of mineralocorticoid precursors under high-dose glucocorticoid therapy in pediatric acute lymphoblastic leukemia. Endocr Connect 2023;12.
27. Miller BS, Spencer SP, Geffner ME, Gourgari E, Lahoti A, Kamboj MK, et al. Emergency management of adrenal insufficiency in children: advocating for treatment options in outpatient and field settings. J Investig Med 2020;68:16–25.
28. Bowden SA, Connolly AM, Kinnett K, Zeitler PS. Management of adrenal insufficiency risk after long-term systemic glucocorticoid therapy in Duchenne muscular dystrophy: Clinical practice recommendations. J Neuromuscul Dis 2019;6:31–41.
29. Maguire AM, Biesheuvel CJ, Ambler GR, Moore B, McLean M, Cowell CT. Evaluation of adrenal function using the human corticotrophin-releasing hormone test, low dose Synacthen test and 9am cortisol level in children and adolescents with central adrenal insufficiency. Clin Endocrinol (Oxf) 2008;68:683–91.
30. Mushtaq T, Ali SR, Boulos N, Boyle R, Cheetham T, Davies JH, et al. Emergency and perioperative management of adrenal insufficiency in children and young people: British Society for Paediatric Endocrinology and Diabetes consensus guidance. Arch Dis Child 2023;108:871–8.
31. Çamtosun E, Sangün Ö. Treatment and prevention of adrenal crisis and family education. J Clin Res Pediatr Endocrinol. 2025;17:80–92.
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Autorska prava (c) 2026 Anita Špehar Uroić, Lana Njavro
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