6665 A Case of Exogenous Cushing Syndrome and Acute Adrenal Insufficiency from Usage and Subsequent Withdrawal of Unregulated Glucocorticoid Supplement Ardosons

Abstract Disclosure: A. Rao: None. A.F. Ishola: None. D. Desai: None. D.E. Sellmeyer: None. Introduction: Exogenous Cushing’s syndrome is a frequent complication of therapeutic glucocorticoids. Rare cases of exogenous hypercortisolism from supplements have been reported. We report the first case of exogenous Cushing’s syndrome due to an unregulated anti-inflammatory supplement called Ardosons. Clinical Case: A 47-year-old male with medical history of ankylosing spondylitis, obstructive sleep apnea, and hypertension presented to the hospital with several weeks of generalized weakness. Five weeks prior to his admission, he was evaluated by Rheumatology and started on adalimumab for ankylosing spondylitis, and all previous medications were stopped.His medication history was notable for Ardosons, an unregulated supplement he obtained in Mexico for ankylosing spondylitis that contains 25 mg of indomethacin, 0.75 mg of oral betamethasone, and 215 mg of methocarbamol. He had been taking two tablets of Ardosons daily for the past ten years, and throughout this time had noted 160 lb weight gain, worsening hypertension, and development of obstructive sleep apnea.His symptoms on hospital presentation since stopping Ardosons included weakness, nausea, vomiting, and hypotension. Clinically, he appeared Cushingoid with violaceous striae, abdominal adiposity, prominent dorsoclavicular and supraclavicular fat pads, and scattered ecchymoses. Due to these exam findings, the medical team obtained a 1 mg dexamethasone suppression test which showed morning cortisol of 1.1 ug/dL reference range post-suppression 1.8 ug/dL. Endocrinology was consulted and due to clinical features of acute adrenal insufficiency, in the setting of abrupt withdrawal from systemic glucocorticoids, he was started on physiologic hydrocortisone with symptomatic improvement. At his subsequent endocrinology clinic visit five weeks later, he had lost 20 lbs, and striae were less prominent. His hypothalamic-pituitary-adrenal axis has been serially reassessed and shows continued impaired adrenal function, most recently with morning cortisol of 2.9 ug/dL reference range 6-18 ug/dL, and ACTH of 49.9 reference range 7-63 pg/mL. Clinical Lesson: This is the first case of exogenous Cushing syndrome resulting from usage of a medication called Ardosons, which contains a potent glucocorticoid. Abrupt withdrawal of agents like these can cause acute adrenal insufficiency and can present as a diagnostic challenge, as physical findings may paradoxically show evidence of cortisol excess. Thorough medication reconciliation and supplementation history is essential to identify potential hidden corticosteroids which can have severe and lasting systemic effects. Presentation: 6/2/2024