Q: All of the following drugs can cause adrenal inhibition in ICU except? 

 A) ketoconazole 
B) metyrapone 
C) fluconazole 
D) etomidate 
E) hydrocortisone


Answer: E

All of the above choices except choice E (hydrocortisone) are adrenal enzyme inhibitors involved in endogenous cortisol making. In fact they are used as treatment in hypercorticolism 1,2, 3. Objective of above question is to highlight other drugs beside etomidate, which has already earned enough bad name in this regard! Fluconazole is widely and many times inappropriately used in ICU and should be suspected in such clinical scenarios 4, 5

Hydrocortisone is the treatment for adrenal insufficiency in ICU.


References:

1. Jeffcoate WJ, Rees LH, Tomlin S, et al. Metyrapone in long-term management of Cushing's disease. Br Med J 1977; 2:215.

2. Loli P, Berselli ME, Tagliaferri M. Use of ketoconazole in the treatment of Cushing's syndrome. J Clin Endocrinol Metab 1986; 63:1365. Schulte HM, Benker G, Reinwein D, et al.

3. Infusion of low dose etomidate: correction of hypercortisolemia in patients with Cushing's syndrome and dose-response relationship in normal subjects. J Clin Endocrinol Metab 1990; 70:1426.

4. Gordon J D, Sepkowitz D V. Fluconazole associated acute adrenal insufficiency. Postgrad Med J 1991671084–1085.1085

5. Michaelis G, Zeiler D, Biscoping J. et al Function of the adrenal cortex during therapy with fluconazole in intensive care patients. Mycoses 199336117–123.123