The Journal of clinical endocrinology and metabolism | 2021
Selective Glucocorticoid Replacement Following Unilateral Adrenalectomy for Hypercortisolism and Primary Aldosteronism.
Abstract
BACKGROUND\nAn institutional study previously demonstrated that cosyntropin stimulation testing on postoperative day 1 (POD1-CST) identified patients at risk for adrenal insufficiency (AI) following unilateral adrenalectomy (UA) for adrenal-dependent hypercortisolism (HC) and primary aldosteronism (PA), allowing for selective glucocorticoid replacement (GR). This study reevaluates the need for GR following UA for patients with HC and PA in a larger cohort.\n\n\nMETHODS\nA prospective database identified 108 patients who underwent UA for mild autonomous cortisol excess (MACE) (n=47), overt hypercortisolism (OH) (n=27), PA (n=22), and concurrent PA/HC (n=12) from 9/2014-10/2020; all underwent preoperative evaluation for HC. MACE was defined as 1mg dexamethasone suppression test (DST) cortisol >1.8 (μg/dL), with ≥5 defined as OH. GR was initiated for basal cortisol ≤5 or stimulated cortisol ≤14 (≤18 prior to 4/2017) on POD1-CST.\n\n\nRESULTS\nFifty-one (47%) patients had an abnormal POD1-CST; 54 (50%) were discharged on GR (27 MACE, 20 OH, 1 PA, 6 PA/HC). Median duration of GR was OH: 6.0 months, MACE: 2.1 months, PA: 1 month, PA/HC: 0.8 months. Overall, 26% (n=7) of OH patients and 43% (n=20) of MACE patients did not require GR. Two (2%) OH patients had normal POD1-CST but developed AI several weeks postoperatively requiring GR. None experienced life-threatening AI.\n\n\nCONCLUSION\nPOD1-CST identifies HC patients at risk for AI after UA, allowing for selective GR. One-quarter of OH patients and nearly half of MACE patients can forego GR after UA. PA patients do not require evaluation for AI if concurrent HC has been excluded preoperatively.