The effect of alpha adrenergic manipulation on the 24 hour pattern of cortisol secretion in man

Clinical Review#: The diagnosis and management of central hypoadrenalism

CONTEXT

Adrenal failure secondary to hypothalamo-pituitary disease is a common clinical problem which has serious repercussions. It is essential to perform validated diagnostic procedures and manage such patients with clear objectives and based on well-established replacement programs.

EVIDENCE ACQUISITION

PubMed was searched for all data reflecting pituitary hypoadrenalism dating back to 1960 in order to establish a published database.

EVIDENCE SYNTHESIS

The results from published studies were assessed in the light of the author's extensive personal experience dating back some 30 yr in clinical endocrinology, in an attempt to provide clear diagnostic and management advice.

CONCLUSIONS

While much of the physiology of the hypothalamo-pituitary-adrenal axis is well understood, its clinical assessment and diagnostic procedures to establish the need for replacement are still far from perfect, and to a certain extent clinical judgement is still vital. In terms of replacement therapies, these are still far from optimal in terms of quality of life and mortality, although they are increasingly being based on objective evidence rather than established practice. However, it is anticipated that newer replacement protocols will improve a situation that has previously changed little for many years.

Relationships between beta- and alpha2-adrenoceptors and G coupling proteins in the human brain: effects of age and suicide

Interactions between brain alpha2- and beta-adrenoceptors are of interest in physiological (aging) and pathological (major depression) processes involving both receptors. In this study, total beta-adrenoceptors and beta1/2-subtypes were quantitated in postmortem human brains to investigate their relationships with alpha2A-adrenoceptors and specific G proteins during the process of aging and in brains of suicide victims. Analysis of [3H]CGP12177 binding, in the presence of CGP20712A (beta1-antagonist), indicated that the predominant beta-adrenoceptor in the frontal cortex is the beta1-subtype (65-75%). The density of total beta- (r=-0.60, n=44) or beta1-adrenoceptors (r=-0.78, n=22), but not the beta2-subtype, declined with aging (3-80 years). The density of total beta- or beta1-adrenoceptors, but not the beta2-subtype, correlated with the number of alpha2-adrenoceptors quantitated in the same brains with the agonist [3H]UK14304 (r=0.71-0.81) or the antagonist [3H]RX821002 (r=0.61-0.66). Interestingly, the ratios alpha2/beta- or alpha2/beta1-adrenoceptors did not correlate with the age of the subject at death, indicating that the proportion of alpha2/beta-adrenoceptors in brain remains rather constant during the process of aging. The density of beta-adrenoceptors correlated with the immunodensity of G(alpha)s (r=0.55) and Gbeta (r=0.61) proteins, and that of alpha2-adrenoceptors with those of G(alpha)i1/2 (r=0.88) and Gbeta (r=0.65). In brains of suicides, compared to controls, the ratio between alpha2- and beta- or beta1-adrenoceptors (alpha2-full agonist sites/beta-sites) was greater (1.3- to 2.0-fold; P<0.05). The results demonstrate a close interdependence between brain alpha2- and beta-adrenoceptors during aging, and in brains of suicides. The quantitation of the alpha2A/beta-adrenoceptor ratio could represent a relevant neurochemical index in the study of brain pathologies in which both receptors are involved.

High-dose naloxone (1.0 mg/kg): psychological and endocrine effects in normal male subjects pretreated with one milligram of dexamethasone

The possible participation of the endogenous opioid system (EOS) in the negative feedback of the hypothalamic-pituitary-adrenal axis (HPA-a) activated by low doses (1 mg) of dexamethasone (Dex) was investigated. Ten male healthy subjects (mean age 31.5 +/- 1.9 SEM) were studied on 2 separate days, in a double-blind, cross-over and placebo-controlled design. All subjects were pretreated with 1.0 mg Dex orally the night (2300 h) before both test days. On the study days, subjects were admitted at 0700 h for cannula insertion; the administration of an i.v. bolus of either naloxone (Nal) (1.0 mg/kg) or saline solution (Sal) i.v. was started at 0900 h. Before and following each infusion, mood was measured by a Visual Analogue Scales (VAS) and by the Affective Quality Scale (AQS) every 30 min and blood samples were taken at 15-min intervals. Blood pressure and heart rate were also monitored. Before Dex administration, plasma cortisol levels were within the normal range in all subjects (210.4 +/- 13 ng/ml), while after 9 h after Dex cortisol levels showed the expected significant (p < 0.01) decrease (11.5 +/- 1.9 and 15.04 +/- 0.7 ng/ml for Sal and Nal test days respectively). There were no detectable increases in plasma cortisol levels following either Nal nor Sal administration. However, there was a Nal-induced significant increase in LH (p < 0.01) thus indicating that an effective opioid blockade at the level of the hypothalamic-pituitary unit occurred. There were also a mild and selective Dex + Nal-induced dysphoric (mood factors related to subjects perception of their cognition) and bradycardic effects (p < 0.05). These results suggest that the EOS is not directly involved in the negative feedback triggered by low doses of Dex of the HPA-a, and that there might be a possible glucocorticoid-opioid interaction for the modulation of some aspects of mood.

Psychological and endocrine abnormalities in refugees from East Germany: Part II. Serum levels of cortisol, prolactin, luteinizing hormone, follicle stimulating hormone, and testosterone

We investigated afternoon serum levels of cortisol, prolactin, luteinizing hormone (LH), follicle stimulating hormone (FSH), and testosterone in a group of 84 refugees who had fled from East to West Germany and suffered from psychiatric disorders within 6 weeks of their arrival in West Berlin. The mean hormone levels were compared with those of healthy control subjects. Cortisol levels were lower and LH levels were higher in the patients than in the control subjects, but only at trend levels of significance. No differences were found between the prolactin, FSH, or testosterone concentrations of the two groups. The patients with major depressive disorder (MDD) had a significantly higher mean cortisol level than the mean levels in the subgroups in whom posttraumatic stress disorder, dysthymia, and adjustment disorder were diagnosed. It can be concluded that the hypothalamic-pituitary-adrenal axis may "adapt" during severe long-term psychological stress and that long-term stress may be only one of the neurochemical mechanisms underlying the hypercortisolemia in patients with MDD.

Influence of partial sleep deprivation on the secretion of thyrotropin, thyroid hormones, growth hormone, prolactin, luteinizing hormone, follicle stimulating hormone, and estradiol in healthy young women

The influence of partial sleep deprivation during the second half of the night on the secretion of thyroid stimulating hormone (TSH), thyroxin (T4), free T4 (fT4), triiodothyronine (T3), prolactin (PRL), growth hormone (GH), luteinizing hormone (LH), follicle stimulating hormone (FSH), and estradiol (E2) was investigated in 10 healthy young women. Blood samples were drawn at hourly intervals over a 64-hour period (i.e., 3 consecutive days and nights). During night 2, all subjects were awakened at 1:30 a.m. During partial sleep deprivation, TSH concentrations increased significantly and remained elevated throughout the following day. Levels of T4, fT4, and T3 were enhanced during the partial sleep deprivation hours only, and changes in these hormones seemed to be independent of TSH. PRL levels decreased, LH and E2 concentrations increased, and GH and FSH secretion remained unchanged during partial sleep deprivation. This pattern of change of different endocrine axes during partial sleep deprivation resembles those seen after total sleep deprivation, suggesting that similar neurochemical changes are induced by both forms of antidepressant therapy. The late evening GH peak occurred almost exclusively before the onset of sleep. Partial sleep deprivation did not influence the chronobiological profiles of any of the hormones investigated. The chemical changes underlying these alterations are speculated to involve enhancement of central norepinephrine and dopamine activity with a concomitant increase in the activity of the sympathetic nervous system.

Adrenergic control of the secretion of anterior pituitary hormones

The hypothalamic hypophysiotrophic neurones are densely innervated by adrenergic and noradrenergic nerve terminals. Activation of alpha 1-adrenoceptors located in the brain stimulates the secretion of ACTH, prolactin and TSH. The effects of the alpha 1-adrenoceptors seem to be exerted on hypothalamic neurones that secrete vasopressin, CRH-41 and TRH. These mechanisms are important in the physiological control of the secretion of ACTH and TSH in humans. alpha 2-Adrenoceptors are not involved in the control of secretion of these hormones under basal conditions in humans. However, alpha 2-adrenoceptors exert an inhibitory effect that acts as a negative feedback mechanism, limiting excessive secretion of these hormones. There is no convincing evidence for the involvement of beta-adrenoceptors in the control of the secretion of these three hormones in humans. Studies on cultured anterior pituitary cells suggested that adrenaline and noradrenaline may influence the secretion of ACTH, prolactin and TSH directly at the level of the pituitary. However, these effects are not demonstrable in humans, and are likely to be due to alterations in the pituitary adrenoceptors during culture. In the case of growth hormone, activation of alpha 2-adrenoceptors located in the brain stimulates secretion of this hormone both by increasing the secretion of GHRH and by inhibiting the secretion of somatostatin. Activation of beta-adrenoceptors inhibits the secretion of growth hormone via an increase in the secretion of somatostatin. The effects of the central alpha 2- and beta-adrenoceptors are important in the physiological control of growth hormone secretion in humans. A considerable amount of evidence implicates brain alpha 1-adrenoceptors in the control of secretion of the gonadotrophins in experimental animals, but, despite intensive study, no convincing evidence has been found in humans of reproductive age.

Beta-adrenergic receptor binding in human and rat hypothalamus

Quantitative autoradiographic analysis of beta-adrenergic binding sites was conducted in human postmortem hypothalamus using the radioligand 125I-pindolol. The focus was on the hypothalamic nuclei most clearly involved in corticotropin-releasing hormone (CRH) release, the PVN and SON. For comparison, the distribution of hypothalamic beta-adrenergic receptors was evaluated in the rat. A high level of beta-adrenergic receptor binding was found in the human paraventricular nucleus (PVN) and supraoptic nucleus (SON), but not in the rat. The majority of the beta-adrenergic receptors found in the human hypothalamus were of the beta 2-subtype. In contrast, in the rat hypothalamus, the majority of receptors were of the beta 1-subtype. These results show that the anatomical loci exist for direct beta-adrenergic influence on hypothalamic neuroendocrine function in the human and that the topography of beta-adrenergic receptors is markedly different in the rat and human hypothalamus.

Central noradrenergic lesion impairs the adrenocorticotrophin response to release of endogenous catecholamines

Activation of hypothalamic α(1) -adrenoceptors stimulates the secretion of corticotrophin-releasing factors which in turn stimulate pituitary adrenocorticotrophin (ACTH). This mechanism is important in the physiological control of ACTH secretion. This study assesses the feasibility of using the ACTH response to release of endogenous catecholamines as a means of detecting a hypothalamic noradrenergic lesion in vivo. Intracerebroventricular infusion of the catecholamine neurotoxin, 6-hydroxydopamine, was used to destroy noradrenergic nerve endings in rats, with the purpose of producing a model that could be used to study alterations in ACTH responses that may result from a lesion involving central noradrenergic neurons. 6-Hydroxydopamine (250 μg icv) significantly reduced hypothalamic noradrenaline content, indicating damage to noradrenergic nerve endings, without affecting postsynaptic receptor function, as judged by preservation of the effect of a selective α(1) -adrenergic agonist. Pharmacological release of endogenous catecholamines, effected by combined administration of a catecholamine precursor and an α(2) -adrenergic antagonist, stimulated the secretion of ACTH in control, but not in 6-hydroxydopamine-treated rats. Degeneration of hypothalamic noradrenergic nerve endings is not followed by denervation hypersensitivity, and is therefore accompanied by impairment of the ACTH response to release of endogenous catecholamines.

Epinephrine augments cortisol secretion from isolated perfused adrenal glands of guinea pigs

To determine direct effects of epinephrine on adrenal cortisol secretion, bilateral adrenal glands were isolated from guinea pigs, together with bilateral kidneys, aorta, and inferior caval vein for influent and effluent routes. The preparation was perfused with oxygenated Krebs-Ringer bicarbonate solution (pH 7.4) containing 10 mM glucose, 0.2% bovine serum albumin, and 4.6% dextran. The perfusate cortisol level was elevated by the addition of epinephrine in a dose-dependent manner at concentrations greater than 100 pg/ml and increased eightfold as high as the basal level at 1 micrograms/ml epinephrine. The stimulatory effect of epinephrine on cortisol secretion was completely abolished by phentolamine, an alpha-adrenergic antagonist but was not affected by propranolol, a beta-adrenergic antagonist. These results demonstrate that epinephrine has a direct stimulatory effect on adrenal cortisol secretion via an alpha-adrenergic mechanism and also suggest that not only adrenocorticotropin but also epinephrine is a most important factor for the regulation of cortisol secretion.

Metabolic regulation by alpha 1- and alpha 2-adrenoceptors

The role of alpha-adrenoceptors in the mediation of autonomic function, particularly in the control of the cardiovascular system, is widely known. However, alpha-adrenoceptors are also important in the regulation of a variety of metabolic processes that occur in the body either through direct action or by stimulation of the release of other mediators that control metabolic function. Thus, alpha 2-adrenoceptor activation by circulating or neuronally released catecholamines inhibits the release of insulin from pancreatic islet beta-cells and, by inhibiting this response, alpha 2-adrenoceptor antagonists have been shown to have an antihyperglycemic effect. The alpha-adrenoceptor-mediated regulation of the release of pituitary hormones is indirect, with alpha-adrenoceptors being located on peptidergic neurons in the hypothalamus that secrete releasing hormones into the hypophysial portal system to regulate the secretion of hormones from the anterior pituitary gland. Thus, the increase in cortisol secretion from the adrenal glands following a meal is produced, at least in part, by an alpha 1-adrenoceptor-mediated increase in vasopressin and CRF-41 secretion from neurons on the hypothalamus that stimulate the release of adrenocorticotrophic hormone secretion from the pituitary gland, which subsequently stimulates the synthesis and release of cortisol from the adrenal medulla. In addition to metabolic regulation by alpha 1- and alpha 2-adrenoceptors within the endocrine system, alpha-adrenoceptors are also a component of the system that regulates certain aspects of metabolism within autonomic effector cells, such as the control of smooth muscle cell division and growth during periods of continued alpha-adrenoceptor activation as a result of activation of second messenger systems.

Neuroendocrinological investigations during sleep deprivation in depression. II. Longitudinal measurement of thyrotropin, TH, cortisol, prolactin, GH, and LH during sleep and sleep deprivation

Thyrotropin (TSH), thyroxin (T4), triiodothyronine (T3), free T3 (fT3), cortisol, prolactin, and human growth hormone (HGH) were measured every 2 hr during a night of sleep, the following day, and a night of sleep deprivation (SD) in 14 patients with major depressive disorder. In subgroups fT4 (n = 5), reverse T3 (rT3), and luteinizing hormone (LH) (n = 6) were also investigated. Significant increases in TSH, T4, fT4, T3, fT3, rT3, and cortisol and decreases in prolactin levels occurred during the night of SD, compared to the pattern during the night of sleep. The pre-SD T4 and T3 levels of the responders to SD were already higher than in the nonresponders, and increased less during SD. The cortisol and HGH concentrations of the responders rose higher during SD than those of the nonresponders. Changes in TSH and prolactin were not correlated to clinical response. Analysis of possible neurochemical mechanisms underlying this "pattern" of changes in different endocrine profiles suggests that enhanced noradrenergic activity might play a role in the changes in TSH, cortisol, thyroid hormones, and possibly HGH secretion during SD, and increased dopaminergic tone probably induced the decline in prolactin levels. Additional effects of the serotonergic system cannot be excluded at present. In conclusion, the data suggest that enhanced noradrenergic activity of the locus coeruleus stimulates alpha and/or beta adrenergic receptors in depressed patients during SD. This mechanism could well be involved in the antidepressant effect of this therapy.

24-hour pulsatile and circadian patterns of cortisol secretion in alcoholic men

Pulsatile and circadian patterns of cortisol secretion during acute (3 to 16 days) and chronic (29 to 39 days) abstinence were examined in alcoholic men with no clinical or laboratory evidence of hepatic dysfunction or nutritional deficiencies. Mean and integrated 24-hour serum concentrations of cortisol determined by sampling the blood every 20 minutes over a 24-hour period were increased in six out of 10 alcoholic subjects during acute abstinence when compared with normal controls. Sustained abstinence in seven subjects with follow-up studies caused significant decreases in the mean maximal cortisol peak amplitude (13 +/- 1.0 SEM acutely vs. 10.3 +/- 0.52 micrograms/dl follow-up; P = 0.01), mean 24-hour serum cortisol concentrations (10.9 micrograms/dl +/- 1.2 vs. 8.5 micrograms/dl +/- 0.26; P = 0.047), interpulse valley mean (9.3 micrograms/dl +/- 0.88 vs. 6.5 micrograms/dl +/- 0.34; P = 0.007), and valley nadir (7.9 micrograms/dl +/- 0.69 vs. 5.4 micrograms/dl +/- 0.30; P = 0.0036) concentrations. Cortisol pulse frequency was normal. Although circadian cortisol rhythmicity was maintained in alcoholics, the timing of the circadian acrophase was delayed significantly (P = 0.006) during acute abstinence (1022 [clocktime] +/- 34 min) as compared with normal controls (0743 [clocktime] +/- 34 min), and the amplitude of circadian cortisol rhythms exceeded normal in five of 10 alcoholics. Analysis of data in one alcoholic subject by a new multiparameter deconvolution method demonstrated increases in secretory burst amplitude (0.64 microgram/dl +/- 0.08 SD), mass of cortisol released per burst (9.8 micrograms/dl +/- 1.2 SD), and daily endogenous cortisol production rate (22 mg +/- 2.4 SD) during acute abstinence. These values were statistically different when compared with seven normal controls and the subjects' values during sustained abstinence (P less than 0.02). In conclusion, the results of the present study suggest increased daily production of cortisol as a possible mechanism underlying the elevated serum cortisol concentrations in chronic alcoholics during acute abstinence. This abnormality is shown to be reversible with sustained abstinence from alcohol.

Modulation of the actions of tyrosine by alpha 2-adrenoceptor blockade

1. Eight normal subjects were given, in double-blind, random order L-tyrosine 50, 250 and 500 mg kg-1 and placebo orally. Plasma tyrosine concentrations rose in a dose-dependent manner, without affecting the concentrations of the other large neutral amino acids. Tyrosine stimulated the secretion of prolactin and thyrotrophin (TSH) but had no effect on the plasma concentrations of adrenocorticotrophic hormone (ACTH), cortisol, growth hormone or the gonadotrophins. 2. The lack of a stimulant effect of tyrosine on ACTH secretion was presumed to be due to activation of one of the negative feedback mechanisms that control the rate of synthesis and release of the catecholamines, and this hypothesis was tested by examining the effects of the alpha 2-adrenoceptor antagonist idazoxan on the actions of tyrosine. 3. Seven normal males were given on 6 separate occasions tyrosine 250 and 500 mg kg-1 and placebo orally following pretreatment with saline and idazoxan (0.1 mg kg-1 i.v.). Following pretreatment with idazoxan, tyrosine stimulated the secretion of ACTH and noradrenaline in a dose-dependent manner, although neither tyrosine nor idazoxan on their own had any effect on the secretion of either substance. 4. The lack of effect of tyrosine when given on its own appears to be due, to partly, to activation of alpha 2-adrenoceptors, which inhibit the release of noradrenaline. Idazoxan caused a small increase in systolic blood pressure, both when given on its own and in combination with tyrosine. Neither tyrosine nor idazoxan had any significant effect on the state of behavioural arousal, as measured by visual analogue scales, or on the secretion of growth hormone or the gonadotrophins.

Effects of catecholamines on secretion of adrenocorticotrophic hormone (ACTH) in man

The hypothalamus receives a rich supply of adrenergic and noradrenergic nerve fibres from the brain stem, terminating in many hypothalamic regions, including the paraventricular nucleus, which is the site of the cell bodies of corticotrophin releasing factor (CRF) neurones in man. Experimental evidence has shown that an alpha 1 adrenoceptor mechanism stimulates adrenocorticotrophic hormone (ACTH) secretion in man. The site of action of this mechanism seems to be within the blood brain barrier, presumably modulating the secretion of the CRF complex. This mechanism is important in the control of ACTH secretion in some physiological conditions in healthy subjects.

Thymoxamine: lack of antihistaminic effects in clinical doses in man

The purpose of this study was to investigate whether the alpha 1-adrenoceptor antagonist thymoxamine possesses antihistaminic activity in clinical doses in man, as has been reported on the guinea pig ileum in vitro. Five normal subjects were given on three separate occasions intravenous infusions of thymoxamine (0.15 mg kg-1 loading dose followed by 0.15 mg kg-1 h-1), chlorpheniramine (1.5 mg loading dose followed by 1.5 mg h-1) and normal saline (placebo). Intravenous bolus doses of histamine (1 and 2 micrograms kg-1) were given after pretreatment with propranolol 10 mg to block the beta-adrenoceptor agonist effects of the catecholamines released by the histamine injections. Histamine caused a dose-dependent reduction of FEV1 and FVC that was antagonised by chlorpheniramine but not by thymoxamine, suggesting that thymoxamine has no antihistaminic activity in the doses used in man. Thymoxamine caused a small enhancement of the bronchoconstrictor effect of the lower dose of histamine. The relatively selective action of thymoxamine makes it a suitable agent for the investigation of alpha 1-adrenoceptors.

Stress and the pituitary-adrenal axis

The hypothalamo-pituitary-adrenal axis is controlled by complex regulatory mechanisms. Numerous factors such as CRF, vasopressin, oxytocin, angiotensin II and conceivably other hormones--all controlled by various substances acting on central locations--stimulate the release of the stress hormone ACTH. On the other hand, glucocorticoids inhibit the secretion of ACTH by acting at the hypothalamic and/or pituitary level. The release of ACTH is therefore the final outcome of the interactions between the hypothalamus, the adrenal gland and possibly other organs. The multimolecular nature of the factors responsible for the control of the pituitary-adrenal axis is an attractive hypothesis because of the great variety of stress stimuli. The various factors could have specific roles in various stress situations. They provide a highly sensitive mechanism regulating very finely the stress hormone in response to a whole variety of endogenous and exogenous stimuli. Depending on the type of stress, they may therefore singly or in combination affect the amount and duration of ACTH and steroid secretion. The released glucocorticoids may then produce their numerous effects on inflammatory and immunological processes, carbohydrate metabolism, shock and water balance. It has been postulated that these effects may be important in order to prevent host responses from over-reacting to stress and threatening homeostasis. However, proof of the necessity of the glucocorticoid hypersecretion in response to stress remains elusive.

Food-induced cortisol secretion is mediated by central alpha-1 adrenoceptor modulation of pituitary ACTH secretion

Food ingestion stimulates cortisol secretion in man, but the mechanism of this effect is unknown. We have investigated the possible role of adrenoceptors in the mediation of this effect. Six normal males were given continuous 3 h i.v. infusions of normal saline, methoxamine (alpha-1 adrenoceptor agonist) and thymoxamine (alpha-1 adrenoceptor antagonist). Methoxamine enhanced and thymoxamine attenuated the ACTH and cortisol responses to a standard meal given 60 min after commencement of the infusion. The drugs had no effect on nutrient absorption. Four patients with recent onset of pituitary ACTH deficiency and normally responsive adrenal glands showed no ACTH or cortisol rises after the standard meal, demonstrating that postprandial cortisol secretion is mediated by pituitary rather than gut ACTH. Our previous investigations have demonstrated that alpha-1 adrenoceptors stimulate pituitary ACTH secretion in man by an action within the blood brain barrier. We therefore conclude that postprandial cortisol secretion is mediated by central stimulant alpha-1 adrenoceptors modulating pituitary ACTH secretion.