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Introduction: Opioid treatment is common and useful in acute pain management, but long-term opioid treatment is not routinely recommended. Opioids influence the endocrine system by blunting the hypothalamic–pituitary–adrenal (HPA) axis: as ACTH is synthesized from the same precursor protein as beta-endorphins, opioids lower serum cortisol and supress cortisol response through a mechanism of negative feedback. In the same way, naloxone infusion leads to an increase in serum cortisol. Clinical Case: A forty-nine-year-old woman was sent to an endocrinology appointment due to altered serum cortisol measurements. She had a past history of Graves' disease currently in clinical and biochemical remission. Her history was also notable for chronic obstructive pulmonary disease under inhaled corticosteroids and previous toxicophilic habits under methadone replacement treatment. The patient was asymptomatic with a laboratory evaluation of the HPA axis suggestive of adrenal insufficiency –morning serum cortisol measurements persistently under 10μg/dL. Stimulation test with cosyntropin showed an insufficient response with a peak cortisol of 12 μg/dL, confirming adrenal insufficiency. As the patient had no clinical signs of adrenal insufficiency and was maintained under inhaled corticosteroid treatment, she was given an emergency glucocorticoid card and was instructed to take replacement treatment with hydrocortisone in stress situations. Conclusion: In this patient, the HPA axis suppression might have been multifactorial resulting from inhaled glucocorticoids and chronic opioid use. Opioids are very common drugs and adrenal insufficiency is probably more frequent than it is accounted for in this population, with unspecific symptoms but possible serious consequences. Therefore, patients under opioid treatment with suggestive symptoms might benefit from adrenal insufficiency exclusion. [ABSTRACT FROM AUTHOR]

Introduction: The novel antidiabetic therapies have been showing promising results in cardiovascular and renal protection besides diabetes treatment. GLP-1 receptor agonists (GLP-1RA) are well tolerated drugs with few side effects, but they are only approved for a glomerular filtration rate (GFR) higher than 15 mL/min. Anecdotal reports have been made of therapy with GLP-1RA in patients undergoing hemodialysis and intermittent hemodialysis with good results. Clinical Case: A sixty-five-year-old male patient with stage 4 chronic kidney disease in the setting of hypertensive and diabetic nephropathy is accompanied at our Endocrinology Department due to non-insulin treated type 2 diabetes. His past-history was notable for atrial fibrillation, obstructive sleep apnea and chronic obstructive pulmonary disease. In what diabetes is concerned, he was under empagliflozin 10mg daily and dulaglutide 1.5mg weekly with excellent glycemic control. Despite optimized treatment and Nephrology follow-up, GFR continued to decay, standing currently at 11 mL/min, without any acute insult, acidosis or hyperkalemia. The patient is starting preparation for hemodialysis with construction of an arteriovenous fistula. At last appointment, despite the lower GFR he maintained an excellent glycemic control with HbA1c of 6% without hypoglycemia and remained clinically asymptomatic without nausea, vomiting, or abdominal pain. A pharmacokinetics study revealed a similar exposure to semaglutide independent of renal function (including severe renal impairment [10 patients] and end-stage kidney disease [10 patients]) with the drug being well tolerated in both subgroups without the need for dose adjustments. In our case, the patient maintained the weekly treatment, without reported and/or documented hypoglycemia and possible advantageous cardiovascular profile. In the future, GLP1RA may be a treatment option independently of the patient renal function. [ABSTRACT FROM AUTHOR]