Undisclosed Glucocorticoids in Over-the-Counter Arthritis Supplements Linked to Adrenal Dysfunction and Cushing Syndrome

Core Concepts

Use of over-the-counter arthritis supplements containing undisclosed glucocorticoids can lead to iatrogenic adrenal dysfunction, Cushing syndrome, and adrenal insufficiency, requiring slow tapering with corticosteroid replacement to avoid life-threatening adrenal crisis.

Abstract

The article presents a case series of 12 patients who developed adrenal dysfunction and Cushing syndrome after prolonged use of over-the-counter (OTC) arthritis supplements containing undisclosed glucocorticoids. The specific supplements involved were Artri King, Ardosons, and Ajo Rey, which were found to contain ingredients like diclofenac and dexamethasone not listed on the product labels.
The patients, with a median age of 52 and a third being women, had started using the supplements for joint pain, with a median duration of about 6 months prior to cessation. They presented with symptoms like nausea, vomiting, fatigue, abdominal pain, and dizziness, along with physical exam findings of moon facies, central adiposity, abdominal striae, dorsocervical fat pad, and bruising. Cortisol testing revealed adrenal insufficiency in some patients, while others had indeterminate results requiring further cosyntropin-stimulation testing.
Ten of the 12 patients were prescribed glucocorticoid tapering replacements, such as twice-daily hydrocortisone, to avoid precipitating adrenal crisis. Eight of these patients continued to take the replacement steroids 1-2 years later. The article emphasizes the importance of healthcare providers asking patients to show their supplements and being vigilant about undisclosed ingredients, as these can lead to unexpected and potentially life-threatening adrenal suppression.

Stats

Median age of patients: 52 years
One-third of patients were women
Median duration of supplement use prior to cessation: 6 months
Presenting symptoms: nausea/vomiting (42%), fatigue (42%), abdominal pain (33%), dizziness (17%)
Physical exam findings: moon facies (66%), central adiposity (66%), abdominal striae (50%), dorsocervical fat pad (33%), bruising (33%)
3 patients required intensive care admission
Cortisol testing: normal (≥ 16 mcg/dL) in 1 patient, adrenal insufficiency (≤ 3 mcg/dL) in 3 patients, indeterminate results in 7 patients
10 out of 12 patients were prescribed glucocorticoid tapering replacements, and 8 of them continued the replacement steroids 1-2 years later

Quotes

"We found that quite a lot of patients after they've been on the Artri King or some other over the counter arthritis supplement, started developing these cushingoid features seen in the physical exam, such as rounded facial features or stretch marks of their abdomen."
"If they get an infection they can die because they can't mount a cortisol response."

Key Insights Distilled From

Over-the-Counter Arthritis Supplements Pose Adrenal Danger

by Miriam E. Tu... at www.medscape.com 06-06-2024

https://www.medscape.com/viewarticle/over-counter-arthritis-supplements-pose-adrenal-danger-2024a1000amy

Deeper Inquiries

What regulatory measures could be implemented to ensure better transparency and safety of over-the-counter supplements?

To enhance transparency and safety of over-the-counter supplements, regulatory measures such as stricter labeling requirements could be implemented. This includes mandating that all ingredients, including active and inactive components, are clearly listed on the product label. Additionally, regular testing and monitoring of these supplements by regulatory bodies can help ensure that they meet safety standards and do not contain undisclosed or harmful substances. Implementing penalties for companies that fail to comply with regulations can also serve as a deterrent against deceptive practices.

How can healthcare providers effectively educate patients about the potential risks of using unregulated supplements, especially those containing undisclosed ingredients?

Healthcare providers can play a crucial role in educating patients about the risks associated with unregulated supplements. This can be achieved through proactive discussions during patient visits, where providers inquire about supplement use and provide information on potential dangers. Utilizing educational materials, such as brochures or online resources, can also help reinforce key messages about the importance of consulting healthcare professionals before starting any new supplement. Furthermore, promoting awareness campaigns in healthcare settings and community settings can help reach a wider audience and emphasize the significance of informed supplement choices.

What research is needed to better understand the long-term consequences of adrenal suppression caused by prolonged use of these contaminated supplements?

Further research is essential to comprehensively understand the long-term consequences of adrenal suppression resulting from prolonged use of contaminated supplements. Longitudinal studies tracking individuals who have experienced adrenal dysfunction due to these supplements can provide insights into the persistence of symptoms and potential complications over time. Investigating the mechanisms underlying adrenal suppression and its impact on the hypothalamic-pituitary-adrenal axis can offer valuable information for developing targeted interventions and treatment strategies. Additionally, exploring the prevalence of such cases in different populations and regions can help identify at-risk groups and inform preventive measures to mitigate the adverse effects of these supplements on adrenal function.