• Florica Sandru Department of Dermatology, ”Carol Davila” University of Medicine and Pharmacy, Bucharest
  • Bianca Maria Petrescu 2. Department of Dermatovenerology, Elias University Emergency Hospital, Bucharest, Romania
  • Alexandru Florin Florescu Endocrinology Department, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania & Endocrinology Department, "Sf. Spiridon" Emergency County Clinical Hospital, Iasi, Romania
  • Anda Dumitrascu Department of Radiology and Medical Imaging, “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania
  • Mara Carsote Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania & Department V of Clinical Endocrinology, “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania
  • Oana Claudia Sima Department V of Clinical Endocrinology, “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania & PhD Doctoral School, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
  • Anca Pati Cucu PhD Doctoral School, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania & Thoracic Surgery Department, “Dr. Carol Davila” Central Military Emergency University Hospital, Bucharest, Romania
  • Claudiu Nistor Thoracic Surgery Department, “Dr. Carol Davila” Central Military Emergency University Hospital, Bucharest, Romania & Department 4 - Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
Keywords: Cushing’s syndrome,, osteoporosis, fracture, DXA, surgery, dexamethasone


Chronic use of glucocorticoids, either as medical recommendation or as self-administration for bone and joint long-standing pain, might cause negative effects such as inducing Cushing’s syndrome that embraces a large panel of clinical manifestations and bone impact might be one of themWe aim to introduce an adult male case who developed Cushing’s syndrome following the daily use of oral dexamethasone for chronic spine pain after undergoing spine surgery. Additionally, he developed vertebral fractures requiring neurosurgery, but continued to voluntarily use the drug. However, DXA (Dual-Energy X-Ray Absorptiometry) assessment was non usable for lumbar spine evaluation and proved no lowering of the bone mineral density at non-lumbar sites. Despite discordances between DXA results and prevalent fractures, a difficult decision amid specific medication against osteoporosis was taken, including the acumen of following the expected improvement of bone status over the time.  Prolonged self-administration of corticoids for persistent post-operatory pain might bring negative bone effects in terms of multiple fractures requiring second time surgery that add to the already present component of persistent back pain. However, the tools we currently have to assess glucocorticoids-induced osteoporosis such as DXA and trabecular bone score might not be applicable in certain cases, thus the decision of medication against osteoporosis is based on the clinical panel (exogenous Cushing’s syndrome) and suppressed serum bone turnover markers. Poor compliance to glucocorticoids withdrawal as well as adherence to medication against osteoporosis represented another issue in this instance.


1. R. M. Paragliola, G. Papi, A. Pontecorvi, S. M. Corsello, "Treatment with Synthetic Glucocorticoids and the Hypothalamus-Pituitary-Adrenal Axis," Int J Mol Sci., vol. 18, no. 10, pp. 2201, 2017.
2. A. Güven, "Different Potent Glucocorticoids, Different Routes of Exposure but the Same Result: Iatrogenic Cushing’s Syndrome and Adrenal Insufficiency," J Clin Res Pediatr Endocrinol., vol. 12, no. 4, pp. 383-392, 2020.
3. J. M. Busillo, J. A. Cidlowski, "The five Rs of glucocorticoid action during inflammation: ready, reinforce, repress, resolve, and restore," Trends Endocrinol Metab., vol. 24, no. 3, pp. 109-119, 2013.
4. M. Carsote, D. N. Paduraru, A. E. Nica, A. Valea, "Parathyroidectomy: is vitamin D a player for a good outcome?" J Med Life., vol. 9, no. 4, pp. 348-352, 2016.
5. F. Sandru, M. Carsote, S. E. Albu, A. Valea, A. Petca, M. C. Dumitrascu, "Glucagonoma: From skin lesions to the neuroendocrine component (Review)," Exp Ther Med., vol. 20, no. 4, pp. 3389-93, 2020, doi:10.3892/etm.2020.8966.
6. D. W. Cain, J. A. Cidlowski, "Immune regulation by glucocorticoids," Nat Rev Immunol., vol. 17, no. 4, pp. 233-247, 2017.
7. M. R. Laurent, S. Goemaere, C. Verroken, P. Bergmann, J. J. Body, O. Bruyère, E. Cavalier, S. Rozenberg, B. Lapauw, E. Gielen, "Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club," Front Endocrinol (Lausanne), vol. 13, pp. 908727, 2022.
8. M. A. Amiche, J. M. Albaum, M. Tadrous, P. Pechlivanoglou, L. E. Lévesque, J. D. Adachi, S. M. Cadarette, "Fracture risk in oral glucocorticoid users: a Bayesian meta-regression leveraging control arms of osteoporosis clinical trials," Osteoporos Int., vol. 27, no. 5, pp. 1709-18, 2016.
9. J. Compston, "Glucocorticoid-induced osteoporosis: an update," Endocrine., vol. 61, no. 1, pp. 7-16, 2018.
10. T. P. Van Staa, H. G. Leufkens, L. Abenhaim, B. Zhang, C. Cooper, "Use of oral corticosteroids and risk of fractures," J Bone Miner Res., vol. 15, no. 6, pp. 993-1000, 2000.
11. S. S. Jha, "Glucocorticoid-Induced Osteoporosis (GIOP)," Indian J Orthop., vol. 57, no. Suppl 1, pp. 181-191, 2023, doi:10.1007/s43465-023-01037-8.
12. D. Sanchez-Rodriguez, P. Bergmann, J. J. Body, E. Cavalier, E. Gielen, S. Goemaere, B. Lapauw, M. R. Laurent, S. Rozenberg, G. Honvo, C. Beaudart, O. Bruyère, "The Belgian Bone Club 2020 guidelines for the management of osteoporosis in postmenopausal women," Maturitas., vol. 139, pp. 69-89, 2020.
13. T. Gazitt, J. Feld, D. Zisman, "Implementation of Calcium and Vitamin D Supplementation in Glucocorticosteroid-Induced Osteoporosis Prevention Guidelines-Insights from Rheumatologists," Rambam Maimonides Med J., vol. 14, no. 2, pp. e0010, 2023.
14. L. H. Broersen, A. M. Pereira, J. O. Jørgensen, O. M. Dekkers, "Adrenal Insufficiency in Corticosteroids Use: Systematic Review and Meta-Analysis," J Clin Endocrinol Metab., vol. 100, no. 6, pp. 2171-80, 2015.
15. M. C. Dumitrascu, F. Sandru, M. Carsote, R. C. Petca, A. A. Gheorghisan-Galateanu, A. Petca, A. Valea, "Anorexia nervosa: COVID-19 pandemic period (Review)," Exp Ther Med., vol. 22, no. 2, pp. 804, 2021.
16. E. Charmandari, N. C. Nicolaides, G. P. Chrousos, "Adrenal insufficiency," The Lancet., vol. 383, no. 9935, pp. 2152-2167, 2014.
17. G. Patti, C. Guzzeti, N. Di Iorgi, A. E. M. Allegri, F. Napoli, S. Loche, M. Maghnie, "Central adrenal insufficiency in children and adolescents," Best Practice & Research Clinical Endocrinology & Metabolism., vol. 32, no. 4, pp. 425-444, 2018.
18. S. W. Borresen, M. Klose, D. Glintborg, T. Watt, M. S. Andersen, U. Feldt-Rasmussen, "Approach to the Patient With Glucocorticoid-induced Adrenal Insufficiency," J Clin Endocrinol Metab., vol. 107, no. 7, pp. 2065-2076, 2022, doi:10.1210/clinem/dgac151.
19. V. Guarnotta, R. Amodei, C. Giordano, "Metabolic comorbidities of adrenal insufficiency: Focus on steroid replacement therapy and chronopharmacology," Curr Opin Pharmacol., vol. 60, pp. 123-132, 2021, doi:10.1016/j.coph.2021.07.003.
20. A. Prete and I. Bancos, "Glucocorticoid induced adrenal insufficiency," BMJ, vol. 374, pp. n1380, 2021, doi:10.1136/bmj.n1380.
21. A. H. K. Karangizi, M. Al-Shaghana, S. Logan, S. Criseno, R. Webster, K. Boelaert, P. Hewins, L. Harper, "Glucocorticoid induced adrenal insufficiency is common in steroid treated glomerular diseases - proposed strategy for screening and management," BMC Nephrol., vol. 20, no. 1, pp. 154, 2019, doi:10.1186/s12882-019-1354-6.
22. F. Guerrero Pérez, A. P. Marengo, and C. Villabona Artero, "The unresolved riddle of glucocorticoid withdrawal," J Endocrinol Invest., vol. 40, no. 11, pp. 1175-1181, 2017, doi:10.1007/s40618-017-0691-1.
23. R. L. Rushworth, G. L. Chrisp, and D. J. Torpy, "GLUCOCORTICOID-INDUCED ADRENAL INSUFFICIENCY: A STUDY OF THE INCIDENCE IN HOSPITAL PATIENTS AND A REVIEW OF PERI-OPERATIVE MANAGEMENT," Endocr Pract., vol. 24, no. 5, pp. 437-445, 2018, doi:10.4158/EP-2017-0117.
24. S. Dinsen, B. Baslund, M. Klose, A. K. Rasmussen, L. Friis-Hansen, L. Hilsted, and U. Feldt-Rasmussen, "Why glucocorticoid withdrawal may sometimes be as dangerous as the treatment itself," Eur J Intern Med., vol. 24, no. 8, pp. 714-720, 2013, doi:10.1016/j.ejim.2013.05.014.
25. L. Cianferotti, C. Cipriani, S. Corbetta, G. Corona, G. Defeudis, A. G. Lania, C. Messina, N. Napoli, and G. Mazziotti, "Bone quality in endocrine diseases: determinants and clinical relevance," J Endocrinol Invest., vol. 46, no. 7, pp. 1283-1304, 2023, doi:10.1007/s40618-023-02056-w.
26. T. Palomo, P. Muszkat, F. G. Weiler, P. Dreyer, C. M. A. Brandão, and B. C. Silva, "Update on trabecular bone score," Arch Endocrinol Metab., vol. 66, no. 5, pp. 694-706, 2022, doi:10.20945/2359-3997000000559.
27. E. Shevroja, O. Lamy, L. Kohlmeier, F. Koromani, F. Rivadeneira, and D. Hans, "Use of Trabecular Bone Score (TBS) as a Complementary Approach to Dual-energy X-ray Absorptiometry (DXA) for Fracture Risk Assessment in Clinical Practice," J Clin Densitom., vol. 20, no. 3, pp. 334-345, 2017, doi:10.1016/j.jocd.2017.06.019.
28. D. Hans, E. Šteňová, and O. Lamy, "The Trabecular Bone Score (TBS) Complements DXA and the FRAX as a Fracture Risk Assessment Tool in Routine Clinical Practice," Curr Osteoporos Rep., vol. 15, no. 6, pp. 521-531, 2017, doi:10.1007/s11914-017-0410-z.
29. Y. Omichi, N. Mima, K. Wada, R. Okada, Y. Tamaki, D. Hamada, T. Goto, M. Morimoto, T. Enomoto, H. Hayashi, K. Sairyo, "Can TBS reference values be a valid indicator for clinical vertebral fracture? A cross-sectional study," J Bone Miner Metab., 2023, doi:10.1007/s00774-023-01476-1.
30. J. Carballido-Gamio, "Imaging techniques to study diabetic bone disease," Curr Opin Endocrinol Diabetes Obes., vol. 29, no. 4, pp. 350-360, 2022.
31. J. I. Martínez-Montoro, B. García-Fontana, C. García-Fontana, and M. Muñoz-Torres, "Evaluation of Quality and Bone Microstructure Alterations in Patients with Type 2 Diabetes: A Narrative Review," J Clin Med., vol. 11, no. 8, pp. 2206, 2022, doi:10.3390/jcm11082206.
How to Cite
Sandru, F., Petrescu, B., Florescu, A., Dumitrascu, A., Carsote, M., Sima, O., Cucu, A., & Nistor, C. (2024). EXOGENOUS CUSHING’S SYNDROME, ADDICTION TO ORAL DEXAMETHASONE AS PAIN KILLER: PITFALLS OF SKELETON EFFECTS AND DECISION MAKING. Romanian Journal of Clinical Research, 6(2). https://doi.org/10.33695/rjcr.v6i2.210