‘Inherent’ risks of prolonged use of OTC supplements seen in case study

Woman develops Cushing's syndrome from arthritis supplement Artri King

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by Andrea Lobo |

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The risk of consuming supplements was recently highlighted in a case of a woman with Cushing’s syndrome caused by prolonged use of an over-the-counter arthritis product containing a glucocorticoid.

The patient was ultimately diagnosed with Cushing’s based on her typical disease features together with her long exposure to the Artri King supplement, which is known to contain the glucocorticoid dexamethasone.

“This case highlights the risks inherent in the use of herbal and supplemental therapies which are largely not subject to the same strict regulatory framework as traditional medicines,” researchers wrote.

The report, “A Case of Iatrogenic Cushing’s Syndrome following Use of an Over-the-Counter Arthritis Supplement,” was published in the journal Case Reports in Endocrinology.

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Cushing’s syndrome most commonly caused by excessive glucocorticoid use

Cushing’s syndrome is characterized by excessive levels of the stress hormone cortisol, which is produced by the adrenal glands located atop the kidneys.

In rare cases, the excessive cortisol levels that characterize Cushing’s are driven by the body’s own overproduction of specific hormones, including adrenocorticotropic hormone (ACTH). From all these forms of endogenous (having an internal cause or origin) Cushing’s syndrome, Cushing’s disease is the most common.

Cushing’s syndrome is most commonly caused by the excessive and prolonged use of glucocorticoids to treat autoimmune or inflammatory conditions. This form of the disease is caused by the use of certain medications and is sometimes referred to as iatrogenic Cushing’s syndrome.

In this report, researchers described the case of a 35-year-old Hispanic woman with iatrogenic Cushing’s syndrome caused by glucocorticoids found in an over-the-counter arthritis supplement.

The patient, whose previous medical history included rheumatoid arthritis and a pulmonary embolism (a blood clot in the lungs that blocks blood flow), visited the emergency department with complaints of shortness of breath and upper abdominal pain.

This case highlights the risks inherent in the use of herbal and supplemental therapies which are largely not subject to the same strict regulatory framework as traditional medicines.

She had gained 7 kg (around 15 lbs) in the last three years and displayed several characteristics of Cushing’s syndrome, including a rounded face, central obesity, fat accumulation behind the shoulders, easy bruising, non-healing wounds, and infrequent menstrual periods.

She was originally admitted to the hospital for severe anemia requiring a blood transfusion. The cause of her anemia was identified as a bleeding stomach ulcer attributed to infection by the bacteria Helicobacter pylori and heavy use of non-steroidal anti-inflammatory medications. She was ultimately discharged with treatment for H. pylori and iron supplements.

A review of the patient’s home medications revealed she was taking an over-the-counter supplement from Mexico, called Artri King, for the past three years to alleviate her joint pain. This supplement is known to the U.S. Food and Drug Administration to contain unspecified and undeclared amounts of the glucocorticoid dexamethasone.

Other cases have previously been reported of Cushing’s syndrome being caused by unintentional ingestion of glucocorticoids found in the same supplement.

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Tests show low hormone levels consistent with secondary adrenal insufficiency

Further tests were conducted to assess her capacity to produce cortisol following stimulation with cosyntropin, a man-made form of the hormone ACTH that stimulates the adrenal glands to produce cortisol. Her cortisol levels remained low after the test and her basal ACTH levels were also low, consistent with secondary adrenal insufficiency. This is a common complication of glucocorticoid use and occurs when the adrenal glands fail to produce enough cortisol due to the lack of ACTH production by the brain’s pituitary gland.

Based on these findings, the patient was advised to stop taking Artri King and was started on hydrocortisone replacement therapy, with a follow-up plan at an endocrinology outpatient service. She was eventually lost to follow-up for some time but later, she showed no signs of glucocorticoid withdrawal after being seen in the clinic.

“It is therefore important that patients at risk for glucocorticoid withdrawal undergo a careful taper when stopping steroids. In this case, given that her previous steroid dose was unknown, she was started on … hydrocortisone with a plan to attempt tapering from there,” the researchers wrote.

“This case reinforces the value of a thorough medication reconciliation to include over-the-counter and complementary and alternative medications,” they noted.