Effects of testosterone treatment on bone mineral density in hypogonadal men receiving intrathecal opioids

Background Opioid induced depression of sex hormones is a common finding in chronic pain patients receiving long-term opioids by oral, parenteral and even intrathecal routes of administration. The hypothalamic suppression by opioids leads to a hypogonadal state with low testosterone levels in males and subsequent low bone mineral density (BMD). Methods We have studied the effects of intrathecally administered opioids on BMD in a group of male chronic pain patients. In addition, we have studied the effects of supplementary testosterone on bone metabolism to see if the adverse effects of intrathecal opioids can be reversed. Results Eleven of the 27 patients were on supplementary testosterone having previously been diagnosed as hypogonadal with low serum testosterone. Duration of testosterone supplementation was greater than 2 years in all 11 patients. Both serum total and free testosterone levels were higher in patients on supplementary testosterone than in patients who did not receive this treatment. Of the 16 patients not on testosterone supplement, 14 (87%) had low serum testosterone levels (<10 nmol/L) and 11 (69%) had low or osteoporotic T scores. Within this group, low free testosterone was associated with low BMD scores, and this persisted after correcting for age. Eight of the patients on testosterone supplement had normal BMDT scores and three (27%) had low or osteoporotic T scores. T and age-corrected BMDZ scores were significantly greater in the 11 patients on testosterone supplements than BMD scores in the other 16 patients. Conclusion Testosterone supplementation was found to largely correct the effects of intrathecal opioids on testosterone levels and BMD

Glucocorticoid insufficiency, Achalasia, Alacrima with autonomic and motor neuropathy

We report the case of a patient with adrenal disease with achalasia and alacrima, which appear to be part of a widespread defect in adrenal and nervous system function. A 21-year-old white woman at age 6 had had hypoglycaemia, hyperpigmentation, low plasma cortisol level (30 nmol/L; normal, 200 to 600), and a lack of cortisol response to cosyntropin. Alacrima had been noted since infancy but there were no other abnormal neurologic features. A roentgenogram of the chest at age 9 showed bilateral pulmonary opacities presumed due to aspiration; these have persisted. Nocturnal cough, vomiting of undigested food, and recurrent chest..