Manipulation of hydrocortisone tablets leads to iatrogenic cushing syndrome in a 6-year-old girl with CAH

Heba Al-Rayess, Kristin Fleissner, Mutaz Jaber, Richard C. Brundage, Kyriakie Sarafoglou

Research output: Contribution to journalArticlepeer-review

Abstract

Currently there are no commercially available hydrocortisone formulations for the treatment of children with congenital adrenal hyperplasia (CAH) that allow for smaller doses (0.1-1.25 mg) and incremental adjustments needed to control excess androgen production and avoid the negative effects of overtreatment. This lack of availability has led physicians to recommend dividing hydrocortisone 5-mg tablets into 4 to 6 pieces, compounding capsules or hydrocortisone suspension, or crushing 5- or 10-mg tablets in 5 or 10 mL of water. We report a case of iatrogenic Cushing syndrome in a 6-year 11-month-old girl with salt-wasting CAH treated with hydrocortisone tablets that were administered after crushing and dispersing into water to obtain the prescribed dose. She presented with poor growth, increasing body mass index (BMI), excess downy hair, round facies, and gastric ulcers. Her hydrocortisone dose was 8.1 mg/m2/day. Results for all adrenal steroid concentrations were undetectable at 8 am, 12 hours after her last dose. The year prior to presentation her parents began dissolving 10 mg of hydrocortisone in 10 mL of water and using this preparation over the course of 24 hours, which coincided with rapid increase of BMI. We switched her to a pharmacy-compounded alcohol-free hydrocortisone suspension with total daily doses ranging from 6.5 to 8.2 mg/m2/day, which resulted in resolution of her cushingoid features, a decrease in BMI, and catch-up growth. Our case highlights that manipulation of hydrocortisone tablets by parents can result in great variability in dosing and the need for commercially available pediatric formulations allowing for smaller dosing required in young children.

Original languageEnglish (US)
Article numberbvaa091
JournalJournal of the Endocrine Society
Volume4
Issue number8
DOIs
StatePublished - Aug 1 2020

Bibliographical note

Funding Information:
This work was supported in part by the Office of Orphan Products Development of the Food and Drug Administration (award number R01FDR0006100). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the FDA or FDA's Office of Orphan Products Development.

Funding Information:
Financial Support: This work was supported in part by the Office of Orphan Products Development of the Food and Drug Administration (award number R01FDR0006100). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the FDA or FDA’s Office of Orphan Products Development.

Keywords

  • Congenital adrenal hyperplasia
  • Cushing syndrome
  • Hydrocortisone
  • Pharmacokinetics

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