R038

Opioid-induced ACTH deficiency or anterior panyhypopituitarism.

S.Qureshi, K.Darzy

Abstract:

Opioids are prescribed for all age groups with acute or chronic pain.¹ The high prevalence (21% to 86%) of opioid induced hypogonadotrophic hypogonadism is under recognised and under treated.^2,3,4 Opioids modulate their endogenous and exogenous effect by acting on opioid receptors in hypothalamus or direct effect on pituitary gland. To our knowledge opioid-induced ACTH deficiency or anterior panyhypopituitarism have not been reported before. We present 2 cases of opioid-induced hypopituitarism.

Case 1

A 57-year old man, with a past medical history of whiplash injury more then 12 years ago with chronic cervical pain treated with regular oral opioids.  Further assessment revealed secondary hypogonadism (LH was 1 IU/l (normal range 1.5-9.3 IU/l), FSH 1.0 IU/l (2-20 IU/l), testosterone 4.1 nmol/l (8.4-18.7 nmol/l). An ITT also confirmed the presence of severe ACTH and GH deficiency.

Case 2

A 54-year old man, followed up in our clinic, with generalized aches and pain, tiredness, depression erectile dysfunction. His testosterone level dropped from low normal many years ago to frankly subnormal levels with inappropriately low gonadotrophins (LH 1 IU/l (normal range 2-10 IU/l), FSH 8 IU/l (1.5-33 IU/l), testosterone 3.4 nmol/l (8.4-18.7 nmol/l) and prolactin 486 pmol/l (123-1271 pmol/l).

Learning Points:

• Patients on chronic opiate therapy should routinely be screened for possible functional hypopituitarism, which may compound the clinical picture and symptomatology.

• For those who cannot avoid opioids, hormone replacement therapy should be offered as appropriate to relieve symptoms and prevent the long term consequences like osteoporosis.

• Opioid-induced hypopituitarism is assumed to be functional in nature. However, we are not aware of any studies addressing the reversibility of this complication following withdrawal of opioid therapy.