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Han MM, Zhang JX, Liu ZA, Xu LX, Bai T, Xiang CY, Zhang J, Lv DQ, Liu YF, Wei YH, Wu BF, Zhang Y, Liu YF. Glucose metabolism profile recorded by flash glucose monitoring system in patients with hypopituitarism during prednisone replacement. World J Diabetes 2023; 14:1112-1125. [PMID: 37547590 PMCID: PMC10401453 DOI: 10.4239/wjd.v14.i7.1112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/17/2023] [Accepted: 05/30/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Commonly used glucocorticoids replacement regimens in patients with hypopituitarism have difficulty mimicking physiological cortisol rhythms and are usually accompanied by risks of over-treatment, with adverse effects on glucose metabolism. Disorders associated with glucose metabolism are established risk factors of cardiovascular events, one of the life-threatening ramifications.
AIM To investigate the glycometabolism profile in patients with hypopituitarism receiving prednisone (Pred) replacement, and to clarify the impacts of different Pred doses on glycometabolism and consequent adverse cardiovascular outcomes.
METHODS Twenty patients with hypopituitarism receiving Pred replacement [patient group (PG)] and 20 normal controls (NCs) were recruited. A flash glucose monitoring system was used to record continuous glucose levels during the day, which provided information on glucose-target-rate, glucose variability (GV), period glucose level, and hypoglycemia occurrence at certain periods. Islet β-cell function was also assessed. Based on the administered Pred dose per day, the PG was then regrouped into Pred > 5 mg/d and Pred ≤ 5 mg/d subgroups. Comparative analysis was carried out between the PG and NCs.
RESULTS Significantly altered glucose metabolism profiles were identified in the PG. This includes significant reductions in glucose-target-rate and nocturnal glucose level, along with elevations in GV, hypoglycemia occurrence and postprandial glucose level, when compared with those in NCs. Subgroup analysis indicated more significant glucose metabolism impairment in the Pred > 5 mg/d group, including significantly decreased glucose-target-rate and nocturnal glucose level, along with increased GV, hypoglycemia occurrence, and postprandial glucose level. With regard to islet β-cell function, PG showed significant difference in homeostasis model assessment (HOMA)-β compared with that of NCs; a notable difference in HOMA-β was identified in Pred > 5 mg/d group when compared with those of NCs; as for Pred ≤ 5 mg/d group, significant differences were found in HOMA-β, and fasting glucose/insulin ratio when compared with NCs.
CONCLUSION Our results demonstrated that Pred replacement disrupted glycometabolic homeostasis in patients with hypopituitarism. A Pred dose of > 5 mg/d seemed to cause more adverse effects on glycometabolism than a dose of ≤ 5 mg/d. Comprehensive and accurate evaluation is necessary to consider a suitable Pred replacement regimen, wherein, flash glucose monitoring system is a kind of promising and reliable assessment device. The present data allows us to thoroughly examine our modern treatment standards, especially in difficult cases such as hormonal replacement mimicking delicate natural cycles, in conditions such as diabetes mellitus that are rapidly growing in worldwide prevalence.
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Affiliation(s)
- Min-Min Han
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
- The First Clinical Medical College of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Jia-Xin Zhang
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
- The First Clinical Medical College of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Zi-Ang Liu
- Department of General Medicine, The Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan 030000, Shanxi Province, China
| | - Lin-Xin Xu
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Tao Bai
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Chen-Yu Xiang
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Jin Zhang
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Dong-Qing Lv
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Yan-Fang Liu
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Yan-Hong Wei
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Bao-Feng Wu
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
- The First Clinical Medical College of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Yi Zhang
- Department of Pharmacology, Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
| | - Yun-Feng Liu
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
- The First Clinical Medical College of Shanxi Medical University, Taiyuan 030000, Shanxi Province, China
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Abstract
Adrenal insufficiency (AI), first described by Thomas Addison in 1855, is characterised by inadequate hormonal production by the adrenal gland, which could either be primary, due to destruction of the adrenal cortex, or secondary/tertiary, due to lack of adrenocorticotropic hormone or its stimulation by corticotropin-releasing hormone. This was an invariably fatal condition in Addison's days with most patients dying within a few years of diagnosis. However, discovery of cortisone in the 1940s not only improved the life expectancy of these patients but also had a dramatic effect on their overall quality of life. The diagnosis, easily confirmed by demonstrating inappropriately low cortisol secretion, is often delayed by months, and many patients present with acute adrenal crisis. Sudden withdrawal from chronic glucocorticoid therapy is the most common cause of AI. Currently, there remains a wide variation in the management of this condition across Europe. As primary AI is a relatively rare condition, most medical specialists will only manage a handful of these patients in their career. Despite many advances in recent years, there is currently no curative option, and modern cortisol replacement regimens fail to adequately mimic physiological cortisol rhythm. A number of new approaches including allograft of adrenocortical tissue and stem cell therapy are being tried but remain largely experimental.
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Affiliation(s)
- Rajeev Kumar
- Diabetes and Endocrinology, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - W S Wassif
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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Zdrojowy-Wełna A, Halupczok-Żyła J, Słoka N, Syrycka J, Gojny Ł, Bolanowski M. Trabecular bone score and sclerostin concentrations in patients with primary adrenal insufficiency. Front Endocrinol (Lausanne) 2022; 13:996157. [PMID: 36407318 PMCID: PMC9666397 DOI: 10.3389/fendo.2022.996157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Patients with primary adrenal insufficiency need lifelong replacement therapy with glucocorticoids and mineralocorticoids, which may influence their bone quality. AIM The aim of the study was to evaluate densitometry parameters, trabecular bone score and sclerostin concentrations in patients with primary adrenal insufficiency in comparison to control group. MATERIALS AND METHODS We included 29 patients (62% females) with diagnose of autoimmune primary adrenal insufficiency (mean age 49.7 ± 11.7 years, mean duration of the disease 13.2± 13.6 years) and 33 healthy subjects (adjusted with age, sex and body mass index). Bone mineral density at the femoral neck, lumbar spine, total body and trabecular bone score were evaluated. Serum sclerostin concentrations were measured. RESULTS There were no significant differences in densitometry parameters (T-score, Z-score, bone mineral density in all locations) as well as in trabecular bone score in patients with adrenal insufficiency in comparison to control group. Mean serum sclerostin concentration was significantly higher in patients with adrenal insufficiency than in control group (44.7 ± 23.5 vs 30.7 ± 10.4 pmol/l, p=0.006). There was a negative correlation between trabecular bone score and the duration of adrenal insufficiency and age, also a negative correlation between femoral neck and total densitometry parameters and 24-hour urine cortisol as a marker of hydrocortisone daily dose in patients with adrenal insufficiency. CONCLUSIONS The bone status in patients with primary adrenal insufficiency was not impaired in comparison to control group, while sclerostin concentration was higher. The duration of the disease and higher hydrocortisone doses may affect negatively bone status.
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Affiliation(s)
- Aleksandra Zdrojowy-Wełna
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
- *Correspondence: Aleksandra Zdrojowy-Wełna,
| | - Jowita Halupczok-Żyła
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Natalia Słoka
- Laboratory of Molecular Endocrinology, Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Joanna Syrycka
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Łukasz Gojny
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
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Abstract
OPINION STATEMENT Corticosteroids have been essential in the management of brain tumor patients for decades, primarily for the treatment of peritumoral cerebral edema and its associated neurologic deficits. Dexamethasone is the drug of choice with standard practice being administration up to four times per day, however, because of its long biologic half-life and high potency, once or twice a day dosing is likely adequate in patients without elevated intracranial pressure. The length of corticosteroid treatment should be limited to the shortest period of time to minimize the risk of potential toxicities that can significantly affect quality of life, as well as to avoid a possible detrimental impact on survival in high-grade glioma patients and abrogation of the effect of immunotherapy. Agents such as bevacizumab should be considered in patients who are unable to wean completely off of steroids as well as those who have symptomatic edema and are on immunotherapy. Several other agents have been studied without much success. An increased understanding of the complex pathophysiology of peritumoral vasogenic edema is critically needed to discover new agents that are safer and more effective.
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Scherholz ML, Rao RT, Androulakis IP. Modeling inter-sex and inter-individual variability in response to chronopharmacological administration of synthetic glucocorticoids. Chronobiol Int 2019; 37:281-296. [PMID: 31797700 DOI: 10.1080/07420528.2019.1660357] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Endogenous glucocorticoids have diverse physiological effects and are important regulators of metabolism, immunity, cardiovascular function, musculoskeletal health and central nervous system activity. Synthetic glucocorticoids have received widespread attention for their potent anti-inflammatory activity and have become an important class of drugs used to augment endogenous glucocorticoid activity for the treatment of a host of chronic inflammatory conditions. Chronic use of synthetic glucocorticoids is associated with a number of adverse effects as a result of the persistent dysregulation of glucocorticoid sensitive pathways. A failure to consider the pronounced circadian rhythmicity of endogenous glucocorticoids can result in either supraphysiological glucocorticoid exposure or severe suppression of endogenous glucocorticoid secretion, and is thought be a causal factor in the incidence of adverse effects during chronic glucocorticoid therapy. Furthermore, given that synthetic glucocorticoids have potent feedback effects on the hypothalamic-pituitary-adrenal (HPA) axis, physiological factors which can give rise to individual variability in HPA axis activity such as sex, age, and disease state might also have substantial implications for therapy. We use a semi-mechanistic mathematical model of the rodent HPA axis to study how putative sex differences and individual variability in HPA axis regulation can influence the effects of long-term synthetic exposure on endogenous glucocorticoid circadian rhythms. Model simulations suggest that for the same drug exposure, simulated females exhibit less endogenous suppression than males considering differences in adrenal sensitivity and negative feedback to the hypothalamus and pituitary. Simulations reveal that homeostatic regulatory variability and chronic stress-induced regulatory adaptations in the HPA axis network can result in substantial differences in the effects of synthetic exposure on the circadian rhythm of endogenous glucocorticoids. In general, our results provide insight into how the dosage and exposure profile of synthetic glucocorticoids could be manipulated in a personalized manner to preserve the circadian dynamics of endogenous glucocorticoids during chronic therapy, thus potentially minimizing the incidence of adverse effects associated with long-term use of glucocorticoids.
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Affiliation(s)
- Megerle L Scherholz
- Department of Chemical and Biochemical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ
| | - Rohit T Rao
- Department of Chemical and Biochemical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ
| | - Ioannis P Androulakis
- Department of Chemical and Biochemical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ.,Department of Biomedical Engineering, Rutgers The State University of New Jersey, Piscataway, NJ.,Department of Surgery, Rutgers - Robert Wood Johnson Medical School, New Brusnwick, NJ
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Scherholz ML, Schlesinger N, Androulakis IP. Chronopharmacology of glucocorticoids. Adv Drug Deliv Rev 2019; 151-152:245-261. [PMID: 30797955 DOI: 10.1016/j.addr.2019.02.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 12/24/2018] [Accepted: 02/13/2019] [Indexed: 12/30/2022]
Abstract
Glucocorticoids influence a wide array of metabolic, anti-inflammatory, immunosuppressive, and cognitive signaling processes, playing an important role in homeostasis and preservation of normal organ function. Synthesis is regulated by the hypothalamic-pituitary-adrenal (HPA) axis of which cortisol is the primary glucocorticoid in humans. Synthetic glucocorticoids are important pharmacological agents that augment the anti-inflammatory and immunosuppressive properties of endogenous cortisol and are widely used for the treatment of asthma, Crohn's disease, and rheumatoid arthritis, amongst other chronic conditions. The homeostatic activity of cortisol is disrupted by the administration of synthetic glucocorticoids and so there is interest in developing treatment options that minimize HPA axis disturbance while maintaining the pharmacological effects. Studies suggest that optimizing drug administration time can achieve this goal. The present review provides an overview of endogenous glucocorticoid activity and recent advances in treatment options that have further improved patient safety and efficacy with an emphasis on chronopharmacology.
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Hsiao HY, Chen RLC, Chou CC, Cheng TJ. Hand-held Colorimetry Sensor Platform for Determining Salivary α-Amylase Activity and Its Applications for Stress Assessment. SENSORS 2019; 19:s19071571. [PMID: 30939788 PMCID: PMC6479482 DOI: 10.3390/s19071571] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/22/2019] [Accepted: 03/28/2019] [Indexed: 11/29/2022]
Abstract
This study develops a hand-held stress assessment meter with a chemically colorimetric strip for determining salivary α-amylase activity, using a 3,5 dinitrosalicylic acid (DNS) assay to quantify the reducing sugar released from soluble starch via α-amylase hydrolysis. The colorimetric reaction is produced by heating the strip with a mini polyester heater plate at boiling temperature to form a brick red colored product, which measured at 525 nm wavelength. This investigation describes in detail the design, construction, and performance evaluation of a hand-held α-amylase activity colorimeter with a light emitted diode (LED) and photo-detector with built-in filters. The dimensions and mass of the proposed prototype are only 120 × 60 × 60 mm3 and 200 g, respectively. This prototype has an excellent correlation coefficient (>0.995), comparable with a commercial ultraviolet–visible spectroscope, and has a measurable α-amylase activity range of 0.1–1.0 U mL−1. The hand-held device can measure the salivary α-amylase activity with only 5 μL of saliva within 12 min of testing. This sensor platform effectively demonstrates that the level of salivary α-amylase activity increases more significantly than serum cortisol, the other physiological stressor biomarker, under physiologically stressful exercise conditions. Thus, this work demonstrates that the hand-held α-amylase activity meter is an easy to use and cost-effective stress assessment tool for psychoneuroendocrinology research.
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Affiliation(s)
- Hsien-Yi Hsiao
- Department of Bio-industrial Mechatronics Engineering, College of Bio-Resources and Agriculture, National Taiwan University, Taipei 100617, Taiwan.
| | - Richie L C Chen
- Department of Bio-industrial Mechatronics Engineering, College of Bio-Resources and Agriculture, National Taiwan University, Taipei 100617, Taiwan.
| | - Chih-Chi Chou
- Department of Bio-industrial Mechatronics Engineering, College of Bio-Resources and Agriculture, National Taiwan University, Taipei 100617, Taiwan.
| | - Tzong-Jih Cheng
- Department of Bio-industrial Mechatronics Engineering, College of Bio-Resources and Agriculture, National Taiwan University, Taipei 100617, Taiwan.
- Department of Biomedical Engineering, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 10002, Taiwan.
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8
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Dineen R, Stewart PM, Sherlock M. Factors impacting on the action of glucocorticoids in patients receiving glucocorticoid therapy. Clin Endocrinol (Oxf) 2019; 90:3-14. [PMID: 30120786 DOI: 10.1111/cen.13837] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/27/2018] [Accepted: 08/15/2018] [Indexed: 01/16/2023]
Abstract
Glucocorticoids (GCs) are steroid hormones, which are essential for life. They are secreted by the adrenal cortex under the control of the hypothalamic-pituitary-adrenal (HPA) axis. Glucocorticoids are essential for the normal function of most organ systems and, in both, excess and deficiency can lead to significant adverse consequences. Adrenal insufficiency (AI) is a rare, life-threatening disorder characterized by insufficient production of corticosteroid hormones. Primary AI is defined by the inability of the adrenal cortex to produce sufficient amounts of glucocorticoids and/or mineralocorticoids despite normal or increased adrenocorticotropin hormone (ACTH). Secondary AI is adrenal hypofunction due to insufficient amount of ACTH produced by the pituitary gland. Conventional treatment of both primary and secondary adrenal insufficiencies involves lifelong glucocorticoid replacement therapy. The role of cortisol deficiency and the impact of hydrocortisone replacement on morbidity and mortality in this patient group are under increasing scrutiny. Established glucocorticoid replacement regimens do not completely mirror endogenous hormonal production, and their monitoring to ensure optimum therapy is hampered by the lack of reliable biomarkers of hormone sufficiency. A further confounding issue is the tissue-specific regulation of glucocorticoid through the two isozymes of 11β-hydroxysteroid dehydrogenase (11β-HSD) with research focusing on the role of this prereceptor regulation in the development of adverse metabolic features in patients. This review defines the factors influencing glucocorticoid action in patients with adrenal insufficiency receiving glucocorticoid therapy.
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Affiliation(s)
- Rosemary Dineen
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul M Stewart
- Department of Endocrinology, University of Leeds, Leeds, UK
| | - Mark Sherlock
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
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Trends in Analysis of Cortisol and Its Derivatives. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1140:649-664. [DOI: 10.1007/978-3-030-15950-4_39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Leong SH, Shander S, Ratnasingam J. PREDICTING RECOVERY OF THE HYPOTHALAMIC-PITUITARY-ADRENAL AXIS AFTER PROLONGED GLUCOCORTICOID USE. Endocr Pract 2018; 24:14-20. [PMID: 29368966 DOI: 10.4158/ep-2017-0074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Prolonged exposure to glucocorticoids lead to hypothalamic-pituitary-adrenal (HPA) axis suppression that recovers after cessation of treatment. We aimed to identify the predictive factors for HPA axis recovery after prolonged glucocorticoid use. METHODS Retrospective review of patients who had undergone first short Synacthen test (SST) to assess HPA axis recovery after prolonged use of glucocorticoids. RESULTS A total of 61% (20/33) of patients had adequate SST response at a median time of 2 years after diagnosis of adrenal insufficiency. Those who had adequate response during SST had higher ambulatory early morning cortisol ( P<.01), shorter duration of exposure to glucocorticoids ( P = .01), and lower final cumulative hydrocortisone replacement dose ( P = .03). Age, gender, body mass index, indications for glucocorticoid use, and basal adrenocorticotropic hormone levels were not predictive of HPA axis recovery. On multivariate analysis, ambulatory early morning cortisol was the only independent predictor of adequate SST response (odds ratio, 1.02; 95% confidence interval, 1.01 to 1.04; P = .02). Using receiver operating characteristic curve analysis, ambulatory early morning cortisol of 8.8 μg/dL predicted a positive SST response with a sensitivity of 70% and specificity of 93%. CONCLUSION Early morning ambulatory cortisol could be used to decide on timely SST in order to prevent complications from unnecessary replacement with glucocorticoids. ABBREVIATIONS ACTH = adrenocorticotropic hormone; BMI = body mass index; CV = coefficient of variation; HPA = hypothalamic-pituitary-adrenal; SST = short Synacthen test.
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Quinkler M, Ekman B, Zhang P, Isidori AM, Murray RD. Mortality data from the European Adrenal Insufficiency Registry-Patient characterization and associations. Clin Endocrinol (Oxf) 2018; 89:30-35. [PMID: 29682773 DOI: 10.1111/cen.13609] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/23/2018] [Accepted: 03/29/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Mortality from primary and secondary adrenal insufficiency (AI; PAI and SAI, respectively) is 2-3-fold higher than in the general population. Mortality relates to cardiovascular disease, acute adrenal crisis (AC), cancer and infections; however, there has been little further characterization of patients who have died. DESIGN/METHODS We analysed real-world data from 2034 patients (801 PAI, 1233 SAI) in the European Adrenal Insufficiency Registry (EU-AIR; NCT01661387). Baseline clinical and biochemical data of patients who subsequently died were compared with those who remained alive. RESULTS From August 2012 to June 2017, 26 deaths occurred (8 PAI, 18 SAI) from cardiovascular disease (n = 9), infection (n = 4), suicide (n = 2), drug-induced hepatitis (n = 2), and renal failure, brain tumour, cachexia and AC (each n = 1); cause of death was unclear in 5 patients. Patients who died were significantly older at baseline than alive patients. Causes of AI were representative of patients with SAI; however, 3-quarters of deceased patients with PAI had undergone bilateral adrenalectomy (3 with uncontrolled Cushing's disease, 3 with metastatic renal cell cancer). There were no significant differences in body mass index, blood pressure, low-density lipoprotein cholesterol, total cholesterol or electrolytes between deceased and alive patients. Deceased patients with SAI were more frequently male individuals, were receiving higher daily doses of hydrocortisone (24.0 ± 7.6 vs 19.3 ± 5.7 mg, P = .0016) and experienced more frequent ACs (11.1 vs 2.49/100 patient-years, P = .0389) than alive patients. CONCLUSIONS This is the first study to provide detailed characteristics of deceased patients with AI. Older, male patients with SAI and frequent AC had a high mortality risk.
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Affiliation(s)
| | - Bertil Ekman
- Department of Endocrinology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | | | - Robert D Murray
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
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Ferreira L, Silva J, Garrido S, Bello C, Oliveira D, Simões H, Paiva I, Guimarães J, Ferreira M, Pereira T, Bettencourt-Silva R, Martins AF, Silva T, Fernandes V, Pereira ML. Primary adrenal insufficiency in adult population: a Portuguese Multicentre Study by the Adrenal Tumours Study Group. Endocr Connect 2017; 6:935-942. [PMID: 29089364 PMCID: PMC5712836 DOI: 10.1530/ec-17-0295] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 10/31/2017] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Primary adrenal insufficiency (PAI) is a rare but severe and potentially life-threatening condition. No previous studies have characterized Portuguese patients with PAI. AIMS To characterize the clinical presentation, diagnostic workup, treatment and follow-up of Portuguese patients with confirmed PAI. METHODS This multicentre retrospective study examined PAI patients in 12 Portuguese hospitals. RESULTS We investigated 278 patients with PAI (55.8% were females), with a mean age of 33.6 ± 19.3 years at diagnosis. The most frequent presenting clinical features were asthenia (60.1%), mucocutaneous hyperpigmentation (55.0%) and weight loss (43.2%); 29.1% of the patients presented with adrenal crisis. Diagnosis was established by high plasma ACTH and low serum cortisol in most patients (43.9%). The most common aetiology of PAI was autoimmune adrenalitis (61.0%). There were 38 idiopathic cases. Autoimmune comorbidities were found in 70% of the patients, the most frequent being autoimmune thyroiditis (60.7%) and type 1 diabetes mellitus (17.3%). Seventy-nine percent were treated with hydrocortisone (mean dose 26.3 ± 8.3 mg/day) mostly in three (57.5%) or two (37.4%) daily doses. The remaining patients were treated with prednisolone (10.1%), dexamethasone (6.2%) and methylprednisolone (0.7%); 66.2% were also on fludrocortisone (median dose of 100 µg/day). Since diagnosis, 33.5% of patients were hospitalized for disease decompensation. In the last appointment, 17.2% of patients had complaints (7.6% asthenia and 6.5% depression) and 9.7% had electrolyte disturbances. CONCLUSION This is the first multicentre Portuguese study regarding PAI. The results emphasize the need for standardization in diagnostic tests and etiological investigation and provide a framework for improving treatment.
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Affiliation(s)
- Lia Ferreira
- Department of EndocrinologyCentro Hospitalar do Porto, Porto, Portugal
| | - João Silva
- Department of EndocrinologyHospital das Forças Armadas, Lisboa, Portugal
| | - Susana Garrido
- Department of EndocrinologyCentro Hospitalar Tâmega e Sousa, Porto, Portugal
| | - Carlos Bello
- Department of EndocrinologyCentro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Diana Oliveira
- Department of EndocrinologyCentro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Hélder Simões
- Department of EndocrinologyInstituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal
| | - Isabel Paiva
- Department of EndocrinologyCentro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joana Guimarães
- Department of EndocrinologyCentro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Marta Ferreira
- Department of EndocrinologyCentro Hospitalar de Leiria, Leiria, Portugal
| | - Teresa Pereira
- Department of EndocrinologyCentro Hospitalar de Leiria, Leiria, Portugal
| | | | - Ana Filipa Martins
- Department of EndocrinologyCentro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Tiago Silva
- Department of EndocrinologyHospital Garcia da Orta, Lisboa, Portugal
| | - Vera Fernandes
- Department of EndocrinologyHospital de Braga, Braga, Portugal
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Porter J, Blair J, Ross RJ. Is physiological glucocorticoid replacement important in children? Arch Dis Child 2017; 102:199-205. [PMID: 27582458 PMCID: PMC5284474 DOI: 10.1136/archdischild-2015-309538] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/09/2016] [Accepted: 08/10/2016] [Indexed: 12/13/2022]
Abstract
Cortisol has a distinct circadian rhythm with low concentrations at night, rising in the early hours of the morning, peaking on waking and declining over the day to low concentrations in the evening. Loss of this circadian rhythm, as seen in jetlag and shift work, is associated with fatigue in the short term and diabetes and obesity in the medium to long term. Patients with adrenal insufficiency on current glucocorticoid replacement with hydrocortisone have unphysiological cortisol concentrations being low on waking and high after each dose of hydrocortisone. Patients with adrenal insufficiency complain of fatigue, a poor quality of life and there is evidence of poor health outcomes including obesity potentially related to glucocorticoid replacement. New technologies are being developed that deliver more physiological glucocorticoid replacement including hydrocortisone by subcutaneous pump, Plenadren, a once-daily modified-release hydrocortisone and Chronocort, a delayed and sustained absorption hydrocortisone formulation that replicates the overnight profile of cortisol. In this review, we summarise the evidence regarding physiological glucocorticoid replacement with a focus on relevance to paediatrics.
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Affiliation(s)
| | - Joanne Blair
- Department of Endocrinology, AlderHey Children's Hospital, Liverpool, UK
| | - Richard J Ross
- Diurnal Ltd, Cardiff, UK,Department of Endocrinology, The University of Sheffield, Sheffield, UK
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14
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Oster H, Challet E, Ott V, Arvat E, de Kloet ER, Dijk DJ, Lightman S, Vgontzas A, Van Cauter E. The Functional and Clinical Significance of the 24-Hour Rhythm of Circulating Glucocorticoids. Endocr Rev 2017; 38:3-45. [PMID: 27749086 PMCID: PMC5563520 DOI: 10.1210/er.2015-1080] [Citation(s) in RCA: 282] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/21/2016] [Indexed: 02/07/2023]
Abstract
Adrenal glucocorticoids are major modulators of multiple functions, including energy metabolism, stress responses, immunity, and cognition. The endogenous secretion of glucocorticoids is normally characterized by a prominent and robust circadian (around 24 hours) oscillation, with a daily peak around the time of the habitual sleep-wake transition and minimal levels in the evening and early part of the night. It has long been recognized that this 24-hour rhythm partly reflects the activity of a master circadian pacemaker located in the suprachiasmatic nucleus of the hypothalamus. In the past decade, secondary circadian clocks based on the same molecular machinery as the central master pacemaker were found in other brain areas as well as in most peripheral tissues, including the adrenal glands. Evidence is rapidly accumulating to indicate that misalignment between central and peripheral clocks has a host of adverse effects. The robust rhythm in circulating glucocorticoid levels has been recognized as a major internal synchronizer of the circadian system. The present review examines the scientific foundation of these novel advances and their implications for health and disease prevention and treatment.
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Affiliation(s)
- Henrik Oster
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Etienne Challet
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Volker Ott
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Emanuela Arvat
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - E Ronald de Kloet
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Derk-Jan Dijk
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Stafford Lightman
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Alexandros Vgontzas
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Eve Van Cauter
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
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15
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Rauseo AM, Llanos-Chea F, Jaggi S, Jaber T, Orlander PR. An Unusual Etiology Of Hypokalemic Paralysis Secondary To Mineralocorticoid Excess In A Patient With Addison Disease. AACE Clin Case Rep 2017. [DOI: 10.4158/ep161470.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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16
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Yanase T, Tajima T, Katabami T, Iwasaki Y, Tanahashi Y, Sugawara A, Hasegawa T, Mune T, Oki Y, Nakagawa Y, Miyamura N, Shimizu C, Otsuki M, Nomura M, Akehi Y, Tanabe M, Kasayama S. Diagnosis and treatment of adrenal insufficiency including adrenal crisis: a Japan Endocrine Society clinical practice guideline [Opinion]. Endocr J 2016; 63:765-784. [PMID: 27350721 DOI: 10.1507/endocrj.ej16-0242] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This clinical practice guideline of the diagnosis and treatment of adrenal insufficiency (AI) including adrenal crisis was produced on behalf of the Japan Endocrine Society. This evidence-based guideline was developed by a committee including all authors, and was reviewed by a subcommittee of the Japan Endocrine Society. The Japanese version has already been published, and the essential points have been summarized in this English language version. We recommend diagnostic tests, including measurement of basal cortisol and ACTH levels in combination with a rapid ACTH (250 μg corticotropin) test, the CRH test, and for particular situations the insulin tolerance test. Cut-off values in basal and peak cortisol levels after the rapid ACTH or CRH tests are proposed based on the assumption that a peak cortisol level ≥18 μg/dL in the insulin tolerance test indicates normal adrenal function. In adult AI patients, 15-25 mg hydrocortisone (HC) in 2-3 daily doses, depending on adrenal reserve and body weight, is a basic replacement regime for AI. In special situations such as sickness, operations, pregnancy and drug interactions, cautious HC dosing or the correct choice of glucocorticoids is necessary. From long-term treatment, optimal diurnal rhythm and concentration of serum cortisol are important for the prevention of cardiovascular disease and osteoporosis. In maintenance therapy during the growth period of patients with 21-hydroxylase deficiency, proper doses of HC should be used, and long-acting glucocorticoids should not be used. Education and carrying an emergency card are essential for the prevention and rapid treatment of adrenal crisis.
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Affiliation(s)
- Toshihiko Yanase
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoa 814-0180, Japan
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Bensing S, Hulting AL, Husebye ES, Kämpe O, Løvås K. MANAGEMENT OF ENDOCRINE DISEASE: Epidemiology, quality of life and complications of primary adrenal insufficiency: a review. Eur J Endocrinol 2016; 175:R107-16. [PMID: 27068688 DOI: 10.1530/eje-15-1242] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/06/2016] [Indexed: 12/13/2022]
Abstract
In this article, we review published studies covering epidemiology, natural course and mortality in primary adrenal insufficiency (PAI) or Addison's disease. Autoimmune PAI is a rare disease with a prevalence of 100-220 per million inhabitants. It occurs as part of an autoimmune polyendocrine syndrome in more than half of the cases. The patients experience impaired quality of life, reduced parity and increased risk of preterm delivery. Following a conventional glucocorticoid replacement regimen leads to a reduction in bone mineral density and an increase in the prevalence of fractures. Registry studies indicate increased mortality, especially evident in patients diagnosed with PAI at a young age and in patients with the rare disease autoimmune polyendocrine syndrome type-1. Most notably, unnecessary deaths still occur because of adrenal crises. All these data imply the need to improve the therapy and care of patients with PAI.
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Affiliation(s)
- Sophie Bensing
- Department of Molecular Medicine and SurgeryKarolinska Institutet, and Department of Endocrinology, Diabetes and Metabolism, Karolinska University Hospital, Stockholm, Sweden
| | - Anna-Lena Hulting
- Department of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - Eystein S Husebye
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway Department of MedicineHaukeland University Hospital, Bergen, Norway
| | - Olle Kämpe
- Department of Medicine (Solna)Centre for Molecular Medicine, Karolinska Institutet, and Department of Endocrinology, Diabetes and Metabolism, Karolinska University Hospital, Stockholm, Sweden
| | - Kristian Løvås
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway Department of MedicineHaukeland University Hospital, Bergen, Norway
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18
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Liern M, Codianni P, Vallejo G. [Comparative study of the conventional scheme and prolonged treatment with steroids on primary steroid-sensitive nephrotic syndrome in children]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2016; 73:309-317. [PMID: 29384123 DOI: 10.1016/j.bmhimx.2016.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 07/06/2016] [Accepted: 07/25/2016] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND In the steroid-sensitive nephrotic syndrome (SSNS) the prolonged treatment with steroids could decrease the frequency of relapses. We conducted a comparative study of prolonged steroid scheme and the usual treatment of primary SSNS to assess: the number of patients with relapses, mean time to treatment initiation, to remission and to first relapse, total number of relapses, total cumulative dose of steroids, and the steroid toxicity. METHODS Patients were divided into two groups: group A (27 patients) received 16-β-methylprednisolone for 12 weeks, reducing the steroid until week 24. Group B (29 patients) received 16-β-methylprednisolone for 12 weeks and placebo until week 24. RESULTS Cumulative incidence rate of relapse (person/years) for group A was of 36/100 and 66/100 for group B (p=0.04). Average elapsed time to first relapse was of 114 days for group A and of 75 days to for group B (p=0.01). The difference in time for initial response to treatment and up to achieve remission between both groups was not significant. Total cumulative relapses were 9 for group A and 17 for group B (p=0.04). Total patients with relapses were 3 for group A and 7 for group B (p=0.17). Cumulative average dose per patient was 5,243mg/m2 for group A and 4,306mg/m2 for group B (p=0.3), and serum cortisol was 14μg/dl for group A and 16μg/dl for group B (p=0.4). There were no steroid toxicity differences between groups. CONCLUSIONS The duration of the treatment had an impact on the number of relapses without increasing steroid toxicity.
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Affiliation(s)
- Miguel Liern
- Servicio de Nefrología, Hospital General de Niños Dr. Ricardo Gutiérrez, Ciudad de Buenos Aires, Argentina.
| | - Paola Codianni
- Servicio de Nefrología, Hospital General de Niños Dr. Ricardo Gutiérrez, Ciudad de Buenos Aires, Argentina
| | - Graciela Vallejo
- Servicio de Nefrología, Hospital General de Niños Dr. Ricardo Gutiérrez, Ciudad de Buenos Aires, Argentina
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Chung TT, Gunganah K, Monson JP, Drake WM. Circadian variation in serum cortisol during hydrocortisone replacement is not attributable to changes in cortisol-binding globulin concentrations. Clin Endocrinol (Oxf) 2016; 84:496-500. [PMID: 26603673 DOI: 10.1111/cen.12982] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 10/06/2015] [Accepted: 11/17/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients taking hydrocortisone (HC) replacement for primary or secondary adrenal failure require individual adjustment of their dose. In addition to modifying the administered doses of HC for each patient, physicians are increasingly interested in variations in the bioavailability of glucocorticoid replacement. One potential determinant of the bioavailability of replaced HC is a variation in serum cortisol-binding globulin (CBG) concentration, which may, in turn, affect interpretation of cortisol profiles and individual dose selection for patients on hydrocortisone replacement therapy. AIM To investigate the hypothesis that there is a circadian variation in CBG levels. METHODS AND RESULTS A total of 34 male patients divided into 3 groups (10 patients with non-somatotroph structural pituitary disease on HC replacement, 11 patients with treated acromegaly on HC replacement and 13 patients with treated acromegaly not on HC replacement) and 10 healthy volunteers were included. Cortisol and CBG levels were measured at 6 time points (0800, 1100, 1300, 1500, 1700 and 1900). No significant circadian variation in CBG concentration was found in any of the 4 groups. CONCLUSION Circadian variation in serum cortisol during hydrocortisone replacement is not attributable to changes in cortisol-binding globulin concentration. Changes in serum cortisol levels may thus be explained by other factors including 11 β-hydroxysteroid dehydrogenase type 1 activity or circadian changes in the binding properties of CBG.
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Affiliation(s)
- T T Chung
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - K Gunganah
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - J P Monson
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - W M Drake
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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20
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Kalafatakis K, Russell GM, Harmer CJ, Munafo MR, Marchant N, Wilson A, Brooks JCW, Thai NJ, Ferguson SG, Stevenson K, Durant C, Schmidt K, Lightman SL. Effects of the pattern of glucocorticoid replacement on neural processing, emotional reactivity and well-being in healthy male individuals: study protocol for a randomised controlled trial. Trials 2016; 17:44. [PMID: 26801980 PMCID: PMC4724084 DOI: 10.1186/s13063-016-1159-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 01/06/2016] [Indexed: 01/31/2023] Open
Abstract
Background Deviation from the physiological glucocorticoid dynamics (circadian and underlying ultradian rhythmicity) is a common characteristic of various neuropsychiatric and endocrine disorders as well as glucocorticoid-based therapeutics. These states may be accompanied by neuropsychiatric symptomatology, suggesting continuous dynamic glucocorticoid equilibrium is essential for brain homeostasis. Methods/design The study consists of two parts. The preliminary stage of the study aims to validate (technically and pharmacologically) and optimise three different patterns of systemic cortisol administration in man. These patterns are based on the combinatory administration of metyrapone, to suppress endogenous cortisol production, and concurrent hydrocortisone replacement. The second, subsequent, core part of the study is a randomised, double-blinded, placebo-controlled, crossover study, where participants (healthy male individuals aged 18–60 years) will undergo all three hydrocortisone replacement schemes. During these infusion regimes, we plan a number of neurobehavioural tests and imaging of the brain to assess neural processing, emotional reactivity and perception, mood and self-perceived well-being. The psychological tests include: ecological momentary assessment, P1vital Oxford Emotional Test Battery and Emotional Potentiated Startle Test, Leeds Sleep Evaluation Questionnaire and the visual working memory task (n-back). The neuroimaging protocol combines magnetic resonance sequences that capture data related to the functional and perfusion status of the brain. Discussion Results of this clinical trial are designed to evaluate the impact (with possible mechanistic insights) of different patterns of daily glucocorticoid dynamics on neural processing and reactivity related to emotional perception and mood. This evidence should contribute to the optimisation of the clinical application of glucocorticoid-based therapeutics. Trial registration UK Clinical Research Network, IRAS Ref: 106181, UKCRN-ID-15236 (23 October 2013)
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Affiliation(s)
- Konstantinos Kalafatakis
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, School of Clinical Sciences, Faculty of Medicine and Dentistry, University of Bristol, Dorothy Hodgkin Building, Whitson Street, Bristol, BS1 3NY, UK. .,Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, BS28HW, UK. .,Clinical Research and Imaging Centre, University of Bristol, Bristol, BS28DX, UK.
| | - Georgina M Russell
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, School of Clinical Sciences, Faculty of Medicine and Dentistry, University of Bristol, Dorothy Hodgkin Building, Whitson Street, Bristol, BS1 3NY, UK. .,Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, BS28HW, UK.
| | - Catherine J Harmer
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, OX37JX, UK.
| | - Marcus R Munafo
- MRC Integrative Epidemiology Unit at the University of Bristol, UK Centre for Tobacco and Alcohol Studies, School of Experimental Psychology, University of Bristol, Bristol, BS81TU, UK.
| | - Nicky Marchant
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, School of Clinical Sciences, Faculty of Medicine and Dentistry, University of Bristol, Dorothy Hodgkin Building, Whitson Street, Bristol, BS1 3NY, UK. .,Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, BS28HW, UK.
| | - Aileen Wilson
- Clinical Research and Imaging Centre, University of Bristol, Bristol, BS28DX, UK.
| | - Jonathan C W Brooks
- Clinical Research and Imaging Centre, University of Bristol, Bristol, BS28DX, UK.
| | - Ngoc J Thai
- Clinical Research and Imaging Centre, University of Bristol, Bristol, BS28DX, UK.
| | - Stuart G Ferguson
- School of Medicine, University of Tasmania, Hobart, TAS 7000, Australia.
| | - Kirsty Stevenson
- Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, BS28HW, UK.
| | - Claire Durant
- Clinical Research and Imaging Centre, University of Bristol, Bristol, BS28DX, UK.
| | - Kristin Schmidt
- Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, OX37JX, UK.
| | - Stafford L Lightman
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, School of Clinical Sciences, Faculty of Medicine and Dentistry, University of Bristol, Dorothy Hodgkin Building, Whitson Street, Bristol, BS1 3NY, UK. .,Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, BS28HW, UK.
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21
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Kalafatakis K, Russell GM, Zarros A, Lightman SL. Temporal control of glucocorticoid neurodynamics and its relevance for brain homeostasis, neuropathology and glucocorticoid-based therapeutics. Neurosci Biobehav Rev 2015; 61:12-25. [PMID: 26656793 DOI: 10.1016/j.neubiorev.2015.11.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 10/09/2015] [Accepted: 11/19/2015] [Indexed: 11/26/2022]
Abstract
Glucocorticoids mediate plethora of actions throughout the human body. Within the brain, they modulate aspects of immune system and neuroinflammatory processes, interfere with cellular metabolism and viability, interact with systems of neurotransmission and regulate neural rhythms. The influence of glucocorticoids on memory and emotional behaviour is well known and there is increasing evidence for their involvement in many neuropsychiatric pathologies. These effects, which at times can be in opposing directions, depend not only on the concentration of glucocorticoids but also the duration of their presence, the temporal relationship between their fluctuations, the co-influence of other stimuli, and the overall state of brain activity. Moreover, they are region- and cell type-specific. The molecular basis of such diversity of effects lies on the orchestration of the spatiotemporal interplay between glucocorticoid- and mineralocorticoid receptors, and is achieved through complex dynamics, mainly mediated via the circadian and ultradian pattern of glucocorticoid secretion. More sophisticated methodologies are therefore required to better approach the study of these hormones and improve the effectiveness of glucocorticoid-based therapeutics.
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Affiliation(s)
- Konstantinos Kalafatakis
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, School of Clinical Sciences, Faculty of Medicine and Dentistry, University of Bristol, Bristol BS1 3NY, United Kingdom.
| | - Georgina M Russell
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, School of Clinical Sciences, Faculty of Medicine and Dentistry, University of Bristol, Bristol BS1 3NY, United Kingdom.
| | - Apostolos Zarros
- Research Department of Pharmaceutics, UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, United Kingdom.
| | - Stafford L Lightman
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, School of Clinical Sciences, Faculty of Medicine and Dentistry, University of Bristol, Bristol BS1 3NY, United Kingdom.
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22
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Dube S, Slama MQ, Basu A, Rizza RA, Basu R. Glucocorticoid Excess Increases Hepatic 11β-HSD-1 Activity in Humans: Implications in Steroid-Induced Diabetes. J Clin Endocrinol Metab 2015; 100:4155-62. [PMID: 26308294 PMCID: PMC4702452 DOI: 10.1210/jc.2015-2673] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
CONTEXT Animal studies indicate that glucocorticoids increase hepatic 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD-1) expression and activity. OBJECTIVE Our goal was to determine whether glucocorticoid excess increases cortisol production in the liver via 11β-HSD-1 enzyme pathway in humans. DESIGN A total of 1 mg each [4-(13)C] cortisone and [9,12,12-(2)H3] cortisol were ingested, and [1,2,6,7-(3)H] cortisol was infused to measure C13 cortisol (derived from ingested [4-(13)C] cortisone) turnover using the triple tracer technique, whereas glucose turnover was measured using isotope dilution technique following [6-6(2)H2] glucose infusion during a saline clamp. SETTING This study took place at the Mayo Clinic Clinical Research Unit. PARTICIPANTS Thirty nondiabetic healthy subjects participated. INTERVENTION Subjects were randomized to hydrocortisone (n = 15) or placebo 50 mg twice daily (n = 15) for 1 week. OUTCOME MEASURES Hepatic cortisol production and endogenous glucose production were measured. RESULTS Plasma cortisol concentrations were higher throughout the study period in hydrocortisone group. Rates of appearance of C13 cortisol and hepatic C13 cortisol production were higher in hydrocortisone vs placebo group, indicating increased hepatic 11β-HSD-1 activity. Higher plasma cortisol and presumably higher intrahepatic cortisol was associated with impaired suppression of endogenous glucose production in hydrocortisone vs placebo group. CONCLUSION Chronic glucocorticoid excess increases intrahepatic cortisone to cortisol conversion via the 11β-HSD-1 pathway. The extent to which this causes or exacerbates steroid induced hepatic insulin resistance remains to be determined.
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Affiliation(s)
- Simmi Dube
- Endocrine Research Unit (S.D., M.Q.S., A.B., R.A.R., R.B.), Division of Endocrinology, Diabetes, Nutrition; Mayo Clinic, Rochester, MN 55905
| | - Michael Q Slama
- Endocrine Research Unit (S.D., M.Q.S., A.B., R.A.R., R.B.), Division of Endocrinology, Diabetes, Nutrition; Mayo Clinic, Rochester, MN 55905
| | - Ananda Basu
- Endocrine Research Unit (S.D., M.Q.S., A.B., R.A.R., R.B.), Division of Endocrinology, Diabetes, Nutrition; Mayo Clinic, Rochester, MN 55905
| | - Robert A Rizza
- Endocrine Research Unit (S.D., M.Q.S., A.B., R.A.R., R.B.), Division of Endocrinology, Diabetes, Nutrition; Mayo Clinic, Rochester, MN 55905
| | - Rita Basu
- Endocrine Research Unit (S.D., M.Q.S., A.B., R.A.R., R.B.), Division of Endocrinology, Diabetes, Nutrition; Mayo Clinic, Rochester, MN 55905
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Sherlock M, Behan LA, Hannon MJ, Alonso AA, Thompson CJ, Murray RD, Crabtree N, Hughes BA, Arlt W, Agha A, Toogood AA, Stewart PM. The modulation of corticosteroid metabolism by hydrocortisone therapy in patients with hypopituitarism increases tissue glucocorticoid exposure. Eur J Endocrinol 2015; 173:583-93. [PMID: 26264718 DOI: 10.1530/eje-15-0490] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/10/2015] [Indexed: 11/08/2022]
Abstract
CONTEXT Patients with hypopituitarism have increased morbidity and mortality. There is ongoing debate about the optimum glucocorticoid (GC) replacement therapy. OBJECTIVE To assess the effect of GC replacement in hypopituitarism on corticosteroid metabolism and its impact on body composition. DESIGN AND PATIENTS We assessed the urinary corticosteroid metabolite profile (using gas chromatography/mass spectrometry) and body composition (clinical parameters and full body DXA) of 53 patients (19 female, median age 46 years) with hypopituitarism (33 ACTH-deficient/20 ACTH-replete) (study A). The corticosteroid metabolite profile of ten patients with ACTH deficiency was then assessed prospectively in a cross over study using three hydrocortisone (HC) dosing regimens (20/10 mg, 10/10 mg and 10/5 mg) (study B) each for 6 weeks. 11 beta-hydroxysteroid dehydrogenase 1 (11β-HSD1) activity was assessed by urinary THF+5α-THF/THE. SETTING Endocrine Centres within University Teaching Hospitals in the UK and Ireland. MAIN OUTCOME MEASURES Urinary corticosteroid metabolite profile and body composition assessment. RESULTS In study A, when patients were divided into three groups - patients not receiving HC and patients receiving HC≤20 mg/day or HC>20 mg/day - patients in the group receiving the highest daily dose of HC had significantly higher waist-to-hip ratio (WHR) than the ACTH replete group. They also had significantly elevated THF+5α-THF/THE (P=0.0002) and total cortisol metabolites (P=0.015). In study B, patients on the highest HC dose had significantly elevated total cortisol metabolites and all patients on HC had elevated THF+5α-THF/THE ratios when compared to controls. CONCLUSIONS In ACTH-deficient patients daily HC doses of >20 mg/day have increased WHR, THF+5α-THF/THE ratios and total cortisol metabolites. GC metabolism and induction of 11β-HSD1 may play a pivitol role in the development of the metabolically adverse hypopituitary phenotype.
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Affiliation(s)
- Mark Sherlock
- Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK
| | - Lucy Ann Behan
- Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK
| | - Mark J Hannon
- Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK
| | - Aurora Aragon Alonso
- Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK
| | - Christopher J Thompson
- Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK
| | - Robert D Murray
- Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK
| | - Nicola Crabtree
- Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK
| | - Beverly A Hughes
- Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK
| | - Wiebke Arlt
- Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK
| | - Amar Agha
- Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK
| | - Andrew A Toogood
- Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK
| | - Paul M Stewart
- Centre for EndocrinologyDiabetes and Metabolism, University of Birmingham, Birmingham, UKDepartment of Endocrinology and DiabetesAdelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Tallaght Hospital, Dublin 24, IrelandDepartment of EndocrinologyDiabetes and Metabolism, Beaumont Hospital and RCSI Medical School, Dublin, IrelandDepartment of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UKDepartment of Nuclear MedicineQueen Elizabeth Hospital, Birmingham, UKDepartment of Medicine and EndocrinologyUniversity of Leeds, Leeds, UK
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Rousseau E, Joubert M, Trzepla G, Parienti JJ, Freret T, Vanthygem MC, Desailloud R, Lefebvre H, Coquerel A, Reznik Y. Usefulness of Time-Point Serum Cortisol and ACTH Measurements for the Adjustment of Glucocorticoid Replacement in Adrenal Insufficiency. PLoS One 2015; 10:e0135975. [PMID: 26317782 PMCID: PMC4552782 DOI: 10.1371/journal.pone.0135975] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 07/28/2015] [Indexed: 11/22/2022] Open
Abstract
Background Adjustment of daily hydrocortisone dose on clinical criteria lacks sensitivity for fine tuning. Long term hydrocortisone (HC) over-replacement may lead to increased morbidity and mortality in patients with adrenal insufficiency (AI). Biochemical criteria may help detecting over- or under-replacement but have been poorly evaluated. Methods Multicenter, institutional, pharmacokinetic study on ACTH and cortisol plasma profiles during HC replacement in 27 AI patients compared to 29 matched controls. All AI patients were administered HC thrice daily at doses of 6, 10 and 14 mg/m2/d. Blood samples were drawn hourly from 0800h to 1900h. The main outcome measures were: i) plasma peak cortisol and cortisol area under the curve (AUC) in AI patients compared to controls, ii) correlations between cortisol AUC vs single-point cortisol or ACTH decrease from baseline (ΔACTH) and iii) the predictive value of the two latters for obtaining AI patients’ cortisol AUC in the control range. Results Cortisol peaks were observed 1h after each HC intake and a dose response was demonstrated for cortisol peak and cortisol AUC. The comparison of AI patients’ cortisol AUC to controls showed that 81.5% AI patients receiving 6mg/m2/d were adequately replaced, whereas most patients receiving higher doses were over-replaced. The correlation coefficient between 1000h/1400h cortisol concentrations and 0800-1900h cortisol AUC were 0.93/0.88 respectively, whereas the 0800-1200h ΔACTH fairly correlated with 0800-1900h cortisol AUC (R = 0.57). ROC curve analysis indicated that the 1000h and 1400h cortisol concentrations best predicted over-replacement. Conclusions Patients receiving a 6mg/m2 hydrocortisone daily dose exhibited the most physiological daytime cortisol profile. Single point plasma cortisol correlated with daytime cortisol AUC in AI patients. Although hydrocortisone dose should be currently determined on clinical grounds, our data suggest that single point plasma cortisol may be an adjunct for further hydrocortisone dose adjustment in AI patients.
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Affiliation(s)
- Elise Rousseau
- Department of Endocrinology, Caen University Hospital, 14033, Caen, France
| | - Michael Joubert
- Department of Endocrinology, Caen University Hospital, 14033, Caen, France
| | - Géraldine Trzepla
- Department of Endocrinology, Caen University Hospital, 14033, Caen, France
| | - Jean Jacques Parienti
- Department of Clinical Research, Caen University Hospital, 14033, Caen, France
- University of Caen Basse-Normandie, Medical School, Caen, F-14032, France
| | - Thomas Freret
- UFR Pharmaceutical Sciences, EA4259, University of Caen Basse-Normandie, 14032, Caen, France
- University of Caen Basse-Normandie, Medical School, Caen, F-14032, France
| | | | - Rachel Desailloud
- Department of Endocrinology, Amiens University Hospital, Hopital SUD, 80054, Amiens, France
| | - Hervé Lefebvre
- Department of Endocrinology and INSERM U413, IFRMP23, Rouen University Hospital, 76031, Rouen, France
| | - Antoine Coquerel
- Department of Pharmacology, Caen University Hospital, 14033, Caen, France
- University of Caen Basse-Normandie, Medical School, Caen, F-14032, France
| | - Yves Reznik
- Department of Endocrinology, Caen University Hospital, 14033, Caen, France
- University of Caen Basse-Normandie, Medical School, Caen, F-14032, France
- * E-mail:
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Broussard JR, Mitre N. Successful use of continuous subcutaneous hydrocortisone infusion after bilateral adrenalectomy secondary to bilateral pheochromocytoma. J Pediatr Endocrinol Metab 2015; 28:947-9. [PMID: 25781534 DOI: 10.1515/jpem-2014-0473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 02/04/2015] [Indexed: 11/15/2022]
Abstract
We report the use of continuous subcutaneous hydrocortisone infusion in an adolescent patient with primary adrenal insufficiency. This novel hydrocortisone delivery method proved to be a feasible, well-tolerated and safe option for selected patients with poor response to conventional therapy.
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26
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Russell GM, Kalafatakis K, Lightman SL. The importance of biological oscillators for hypothalamic-pituitary-adrenal activity and tissue glucocorticoid response: coordinating stress and neurobehavioural adaptation. J Neuroendocrinol 2015; 27:378-88. [PMID: 25494867 PMCID: PMC4539599 DOI: 10.1111/jne.12247] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 11/26/2014] [Accepted: 12/10/2014] [Indexed: 12/28/2022]
Abstract
The hypothalamic-pituitary-adrenal (HPA) axis is critical for life. It has a circadian rhythm that anticipates the metabolic, immunoregulatory and cognitive needs of the active portion of the day, and retains an ability to react rapidly to perceived stressful stimuli. The circadian variation in glucocorticoids is very 'noisy' because it is made up from an underlying approximately hourly ultradian rhythm of glucocorticoid pulses, which increase in amplitude at the peak of circadian secretion. We have shown that these pulses emerge as a consequence of the feedforward-feedback relationship between the actions of corticotrophin hormone (ACTH) on the adrenal cortex and of endogenous glucocorticoids on pituitary corticotrophs. The adrenal gland itself has adapted to respond preferentially to a digital signal of ACTH and has its own feedforward-feedback system that effectively amplifies the pulsatile characteristics of the incoming signal. Glucocorticoid receptor signalling in the body is also adapted to respond in a tissue-specific manner to oscillating signals of glucocorticoids, and gene transcriptional and behavioural responses depend on the pattern (i.e. constant or pulsatile) of glucocorticoid presentation. During major stressful activation of the HPA, there is a marked remodelling of the pituitary-adrenal interaction. The link between ACTH and glucocorticoid pulses is maintained, although there is a massive increase in the adrenal responsiveness to the ACTH signals.
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Affiliation(s)
- G M Russell
- Henry Wellcome Laboratories of Integrative Neuroscience and Endocrinology, School of Clinical Sciences, Faculty of Medicine and Dentistry, University of Bristol, Bristol, UK
| | - K Kalafatakis
- Henry Wellcome Laboratories of Integrative Neuroscience and Endocrinology, School of Clinical Sciences, Faculty of Medicine and Dentistry, University of Bristol, Bristol, UK
| | - S L Lightman
- Henry Wellcome Laboratories of Integrative Neuroscience and Endocrinology, School of Clinical Sciences, Faculty of Medicine and Dentistry, University of Bristol, Bristol, UK
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An observational study on adrenal insufficiency in a French tertiary centre: Real life versus theory. ANNALES D'ENDOCRINOLOGIE 2015; 76:1-8. [DOI: 10.1016/j.ando.2014.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 11/04/2014] [Accepted: 11/10/2014] [Indexed: 11/19/2022]
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Johannsson G, Falorni A, Skrtic S, Lennernäs H, Quinkler M, Monson JP, Stewart PM. Adrenal insufficiency: review of clinical outcomes with current glucocorticoid replacement therapy. Clin Endocrinol (Oxf) 2015; 82:2-11. [PMID: 25187037 DOI: 10.1111/cen.12603] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 06/25/2014] [Accepted: 08/27/2014] [Indexed: 11/28/2022]
Abstract
Glucocorticoid replacement therapy in patients with adrenal insufficiency (AI), whether primary (Addison's disease) or secondary (due to hypopituitarism), has been established for some 50 years. The current standard treatment regimen involves twice- or thrice-daily dosing with a glucocorticoid, most commonly oral hydrocortisone. Based on previous small-scale studies and clinical perception, life expectancy with conventional glucocorticoid replacement therapy has been considered normal, with a low incidence of adverse events. Data from the past 10-15 years, however, have shown that morbidity remains high and life expectancy is reduced. The increased morbidity and decreased life expectancy appear to be due to both increased exposure to cortisol and insufficient cortisol coverage during infections and other stress-related events. This is thought to reflect a failure of treatment to replicate the natural circadian rhythm of cortisol release, together with a failure to identify and deliver individualized cortisol exposure and to manage patients adequately when increased doses are required. The resulting over- or under-treatment may result in Cushing-like symptoms or adrenal crisis, respectively. This review summarizes the morbidity and mortality seen in patients receiving the current standard of care for AI and suggests areas for improvement in glucocorticoid replacement therapy.
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Affiliation(s)
- Gudmundur Johannsson
- Department of Endocrinology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Abstract
Adrenal insufficiency (glucocorticoid deficiency) comprises a group of rare diseases, including primary adrenal insufficiency, secondary adrenal insufficiency and congenital adrenal hyperplasia. Lifesaving glucocorticoid therapy was introduced over 60 years ago, but since then a number of advances in treatment have taken place. Specifically, little is known about short- and long-term treatment effects, and morbidity and mortality. Over the past decade, systematic cohort and registry studies have described reduced health-related quality of life, an unfavourable metabolic profile and increased mortality in patients with adrenal insufficiency, which may relate to unphysiological glucocorticoid replacement. This has led to the development of new modes of replacement that aim to mimic normal glucocorticoid physiology. Here, evidence for the inadequacy of conventional glucocorticoid therapy and recent developments in treatment are reviewed, with an emphasis on primary adrenal insufficiency.
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Affiliation(s)
- Marianne Øksnes
- Department of Clinical Science, University of Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | | | - Kristian Løvås
- Department of Clinical Science, University of Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Jung C, Greco S, Nguyen HHT, Ho JT, Lewis JG, Torpy DJ, Inder WJ. Plasma, salivary and urinary cortisol levels following physiological and stress doses of hydrocortisone in normal volunteers. BMC Endocr Disord 2014; 14:91. [PMID: 25425285 PMCID: PMC4280712 DOI: 10.1186/1472-6823-14-91] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 11/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Glucocorticoid replacement is essential in patients with primary and secondary adrenal insufficiency, but many patients remain on higher than recommended dose regimens. There is no uniformly accepted method to monitor the dose in individual patients. We have compared cortisol concentrations in plasma, saliva and urine achieved following "physiological" and "stress" doses of hydrocortisone as potential methods for monitoring glucocorticoid replacement. METHODS Cortisol profiles were measured in plasma, saliva and urine following "physiological" (20 mg oral) or "stress" (50 mg intravenous) doses of hydrocortisone in dexamethasone-suppressed healthy subjects (8 in each group), compared to endogenous cortisol levels (12 subjects). Total plasma cortisol was measured half-hourly, and salivary cortisol and urinary cortisol:creatinine ratio were measured hourly from time 0 (between 0830 and 0900) to 5 h. Endogenous plasma corticosteroid-binding globulin (CBG) levels were measured at time 0 and 5 h, and hourly from time 0 to 5 h following administration of oral or intravenous hydrocortisone. Plasma free cortisol was calculated using Coolens' equation. RESULTS Plasma, salivary and urine cortisol at 2 h after oral hydrocortisone gave a good indication of peak cortisol concentrations, which were uniformly supraphysiological. Intravenous hydrocortisone administration achieved very high 30 minute cortisol concentrations. Total plasma cortisol correlated significantly with both saliva and urine cortisol after oral and intravenous hydrocortisone (P <0.0001, correlation coefficient between 0.61 and 0.94). There was no difference in CBG levels across the sampling period. CONCLUSIONS An oral dose of hydrocortisone 20 mg is supraphysiological for routine maintenance, while stress doses above 50 mg 6-hourly would rarely be necessary in managing acute illness. Salivary cortisol and urinary cortisol:creatinine ratio may provide useful alternatives to plasma cortisol measurements to monitor replacement doses in hypoadrenal patients.
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Affiliation(s)
- Caroline Jung
- />Department of Endocrinology and Diabetes, St Vincent’s Hospital, Melbourne, VIC Australia
- />School of Medicine, The University of Melbourne, Melbourne, VIC Australia
| | - Santo Greco
- />Department of Biochemistry, Melbourne Pathology, Melbourne, VIC Australia
| | - Hanh HT Nguyen
- />Department of Biochemistry, Melbourne Pathology, Melbourne, VIC Australia
| | - Jui T Ho
- />Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia Australia
| | - John G Lewis
- />Steroid & Immunobiochemistry Laboratory, Canterbury Health Laboratories, Christchurch, New Zealand
| | - David J Torpy
- />Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia Australia
- />Endocrine Research, Hanson Institute, Adelaide, South Australia Australia
- />School of Medicine, The University of Adelaide, Adelaide, South Australia Australia
| | - Warrick J Inder
- />Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, QLD Australia
- />School of Medicine, The University of Queensland, Brisbane, QLD Australia
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Russell GM, Lightman SL. Can side effects of steroid treatments be minimized by the temporal aspects of delivery method? Expert Opin Drug Saf 2014; 13:1501-13. [DOI: 10.1517/14740338.2014.965141] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Johannsson G, Skrtic S, Lennernäs H, Quinkler M, Stewart PM. Improving outcomes in patients with adrenal insufficiency: a review of current and future treatments. Curr Med Res Opin 2014; 30:1833-47. [PMID: 24849526 DOI: 10.1185/03007995.2014.925865] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Adrenal insufficiency is a rare but life-threatening disease. Conventional therapy consists of glucocorticoid replacement using hydrocortisone administered two or three times daily. Although such therapy extends life expectancy, mortality is not normalized, and quality of life remains poor. This failure to restore normal health is thought to be due to the inability of conventional glucocorticoid replacement therapy to normalize total cortisol exposure and to respond to the increased need for glucocorticoids during illness and stress. Also, current management regimens do not restore or replicate the intrinsic circadian rhythm of cortisol secretion. AREAS COVERED This narrative review was based on a PubMed and Medline search of all English-language articles on the safety and efficacy of glucocorticoid replacement therapy in patients with adrenal insufficiency. Based on this search we discuss current treatment strategies in terms of the failure to maintain or normalize metabolism and quality of life in patients with adrenal insufficiency. The rationale for, and technology behind, the development of modified-release preparations of hydrocortisone are described, together with the evidence suggesting that hydrocortisone preparations that mimic the physiological circadian pattern of cortisol release are more effective than conventional glucocorticoid replacement therapies. CONCLUSIONS Modified-release hydrocortisone treatments for patients with adrenal insufficiency more closely mimic the physiological circadian pattern of cortisol secretion than conventional twice or thrice daily treatment. The available evidence suggests that these modified-release preparations should improve metabolic outcomes and quality of life.
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Affiliation(s)
- Gudmundur Johannsson
- Department of Endocrinology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
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Russell GM, Durant C, Ataya A, Papastathi C, Bhake R, Woltersdorf W, Lightman S. Subcutaneous pulsatile glucocorticoid replacement therapy. Clin Endocrinol (Oxf) 2014; 81:289-93. [PMID: 24735400 PMCID: PMC4231230 DOI: 10.1111/cen.12470] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 04/05/2014] [Accepted: 04/11/2014] [Indexed: 11/29/2022]
Abstract
The glucocorticoid hormone cortisol is released in pulses resulting in a complex and dynamic ultradian rhythm of plasma cortisol that underlies the classical circadian rhythm. These oscillating levels are also seen at the level of tissues such as the brain and trigger pulses of gene activation and downstream signalling. Different patterns of glucocorticoid presentation (constant vs pulsatile) result not only in different patterns of gene regulation but also in different neuroendocrine and behavioural responses. Current 'optimal' glucocorticoid replacement therapy results in smooth hormone blood levels and does not replicate physiological pulsatile cortisol secretion. Validation of a novel portable pulsatile continuous subcutaneous delivery system in healthy volunteers under dexamethasone and metyrapone suppression. Pulsatile subcutaneous hydrocortisone more closely replicates physiological circadian and ultradian rhythmicity.
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Affiliation(s)
- Georgina M Russell
- Henry Wellcome Laboratories for Integrative Neurosciences and Endocrinology, Dorothy Hodgkin Building, University of BristolBristol, UK
| | - Claire Durant
- Henry Wellcome Laboratories for Integrative Neurosciences and Endocrinology, Dorothy Hodgkin Building, University of BristolBristol, UK
| | - Alia Ataya
- School of experimental psychology, University of BristolBristol, UK
| | - Chrysoula Papastathi
- Henry Wellcome Laboratories for Integrative Neurosciences and Endocrinology, Dorothy Hodgkin Building, University of BristolBristol, UK
| | - Ragini Bhake
- Henry Wellcome Laboratories for Integrative Neurosciences and Endocrinology, Dorothy Hodgkin Building, University of BristolBristol, UK
| | | | - Stafford Lightman
- Henry Wellcome Laboratories for Integrative Neurosciences and Endocrinology, Dorothy Hodgkin Building, University of BristolBristol, UK
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Abstract
Corticosteroids secreted as end product of the hypothalamic-pituitary-adrenal axis act like a double-edged sword in the brain. The hormones coordinate appraisal processes and decision making during the initial phase of a stressful experience and promote subsequently cognitive performance underlying the management of stress adaptation. This action exerted by the steroids on the initiation and termination of the stress response is mediated by 2 related receptor systems: mineralocorticoid receptors (MRs) and glucocorticoid receptors (GRs). The receptor types are unevenly distributed but colocalized in abundance in neurons of the limbic brain to enable these complementary hormone actions. This contribution starts from a historical perspective with the observation that phasic occupancy of GR during ultradian rhythmicity is needed to maintain responsiveness to corticosteroids. Then, during stress, initially MR activation enhances excitability of limbic networks that are engaged in appraisal and emotion regulation. Next, the rising hormone concentration occupies GR, resulting in reallocation of energy to limbic-cortical circuits with a role in behavioral adaptation and memory storage. Upon MR:GR imbalance, dysregulation of the hypothalamic-pituitary-adrenal axis occurs, which can enhance an individual's vulnerability. Imbalance is characteristic for chronic stress experience and depression but also occurs during exposure to synthetic glucocorticoids. Hence, glucocorticoid psychopathology may develop in susceptible individuals because of suppression of ultradian/circadian rhythmicity and depletion of endogenous corticosterone from brain MR. This knowledge generated from testing the balance hypothesis can be translated to a rational glucocorticoid therapy.
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Affiliation(s)
- E Ron de Kloet
- Department of Medical Pharmacology, Leiden Academic Centre for Drug Research, Leiden University and Department of Endocrinology and Metabolism, Leiden University Medical Center, 2300 RA Leiden, The Netherlands
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Oksnes M, Björnsdottir S, Isaksson M, Methlie P, Carlsen S, Nilsen RM, Broman JE, Triebner K, Kämpe O, Hulting AL, Bensing S, Husebye ES, Løvås K. Continuous subcutaneous hydrocortisone infusion versus oral hydrocortisone replacement for treatment of addison's disease: a randomized clinical trial. J Clin Endocrinol Metab 2014; 99:1665-74. [PMID: 24517155 DOI: 10.1210/jc.2013-4253] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTEXT Conventional glucocorticoid replacement therapy fails to mimic the physiological cortisol rhythm, which may have implications for morbidity and mortality in patients with Addison's disease. OBJECTIVE The objective of the study was to compare the effects of continuous sc hydrocortisone infusion (CSHI) with conventional oral hydrocortisone (OHC) replacement therapy. DESIGN, PATIENTS, AND INTERVENTIONS This was a prospective crossover, randomized, multicenter clinical trial comparing 3 months of treatment with thrice-daily OHC vs CSHI. From Norway and Sweden, 33 patients were enrolled from registries and clinics. All patients were assessed at baseline and after 8 and 12 weeks in each treatment arm. MAIN OUTCOME MEASURES The morning ACTH level was the primary outcome measure. Secondary outcome measures were effects on metabolism, health-related quality of life (HRQoL), sleep, and safety. RESULTS CSHI yielded normalization of morning ACTH and cortisol levels, and 24-hour salivary cortisol curves resembled the normal circadian variation. Urinary concentrations of glucocorticoid metabolites displayed a normal pattern with CSHI but were clearly altered with OHC. Several HRQoL indices in the vitality domain improved over time with CSHI. No benefit was found for either treatments for any subjective (Pittsburgh Sleep Quality Index questionnaire) or objective (actigraphy) sleep parameters. CONCLUSION CSHI safely brought ACTH and cortisol toward normal circadian levels without adversely affecting glucocorticoid metabolism in the way that OHC did. Positive effects on HRQoL were noted with CSHI, indicating that physiological glucocorticoid replacement therapy may be beneficial and that CSHI might become a treatment option for patients poorly controlled on conventional therapy.
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Affiliation(s)
- Marianne Oksnes
- Department of Clinical Science (M.Ø., P.M., K.T., K.L., E.S.H.), University of Bergen, N-5009 Bergen, Norway; Department of Medicine (M.Ø., K.L., E.S.H.) and Centre for Clinical Research, Haukeland University Hospital, N-5021 Bergen, Norway (R.M.N.); Department of Molecular Medicine and Surgery (S.Bj., A.-L.H., S.Be.), Karolinska Institutet, SE-171 77 Stockholm, Sweden; Departments of Medical Sciences (M.I., S.B., O.K.) and Neuroscience and Psychiatry (J.-E.B.), Uppsala University, SE-751 05 Uppsala, Sweden; and Department of Medicine (S.C.), Stavanger University Hospital, N-4068 Stavanger, Norway
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Cambiaso P, Schiaffini R, Pontrelli G, Carducci C, Ubertini G, Crea F, Cappa M. Nocturnal hypoglycaemia in ACTH and GH deficient children: role of continuous glucose monitoring. Clin Endocrinol (Oxf) 2013; 79:232-7. [PMID: 23215896 DOI: 10.1111/cen.12123] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 10/03/2012] [Accepted: 11/30/2012] [Indexed: 02/01/2023]
Abstract
OBJECTIVES To evaluate the usefulness of continuous glucose monitoring (CGM) to identify nocturnal hypoglycaemia in children affected by combined ACTH and GH deficiency and to optimize the hydrocortisone replacement therapy in these patients. STUDY DESIGN Eleven patients with ACTH and GH deficiency (five boys and six girls, age 1·6-16·8 years) underwent CGM for 36 h, including two nights. At least two consecutive glucose levels <2·78 mm were considered hypoglycaemic episodes. The differences in age and doses of hydrocortisone and recombinant human growth hormone (rhGH) between children with and without hypoglycaemia were analysed. The percentage of the glucose values <3·33 mm and the mean glucose levels were also evaluated. RESULTS Continuous glucose monitoring demonstrated nocturnal hypoglycaemia lasting from 30 to 155 min (1·5% of the total monitoring time) in three cases (27%). No statistically significant differences in age and rhGH dose were observed between children with or without hypoglycaemia. Conversely, the difference in the hydrocortisone doses between the patients with and without hypoglycaemia resulted statistically significant (5·9 vs 8·5 mg/m²/day; P = 0·04). Eight patients presented glucose values less than 3·33 mm during 5% of the total monitoring time. Hydrocortisone dose showed significant positive linear relation with mean glucose level (r = 0·79, P = 0·0035) and inverse relation with time lags of glucose levels under 3·33 mm (r = -0·65, P = 0·03). CONCLUSIONS Our study shows that CGM may represent a valuable tool to detect nocturnal asymptomatic hypoglycaemic episodes and optimize the hydrocortisone therapeutic regimen in children with ACTH and GH deficiency.
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Affiliation(s)
- Paola Cambiaso
- Division of Endocrinology and Diabetology, University-Hospital Pediatric Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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Björnsdottir S, Sundström A, Ludvigsson JF, Blomqvist P, Kämpe O, Bensing S. Drug prescription patterns in patients with Addison's disease: a Swedish population-based cohort study. J Clin Endocrinol Metab 2013; 98:2009-18. [PMID: 23543658 DOI: 10.1210/jc.2012-3561] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTEXT There are no published data on drug prescription in patients with Addison's disease (AD). OBJECTIVE Our objective was to describe the drug prescription patterns in Swedish AD patients before and after diagnosis compared with population controls. DESIGN AND SETTING We conducted a population-based cohort study in Sweden. PATIENTS Through the Swedish National Patient Register and the Swedish Prescribed Drug Register, we identified 1305 patients with both a diagnosis of AD and on combination treatment with hydrocortisone/cortisone acetate and fludrocortisone. Direct evidence of the AD diagnosis from patient charts was not available. We identified 11 996 matched controls by the Register of Population. MAIN OUTCOME MEASURE We determined the ratio of observed to expected number of patients treated with prescribed drugs. RESULTS Overall, Swedish AD patients received more prescribed drugs than controls, and 59.3% of the AD patients had medications indicating concomitant autoimmune disease. Interestingly, both before and after the diagnosis of AD, patients used more gastrointestinal medications, antianemic preparations, lipid-modifying agents, antibiotics for systemic use, hypnotics and sedatives, and drugs for obstructive airway disease (all P values < .05). Notably, an increased prescription of several antihypertensive drugs and high-ceiling diuretics was observed after the diagnosis of AD. CONCLUSION Gastrointestinal symptoms and anemia, especially in conjunction with autoimmune disorders, should alert the physician about the possibility of AD. The higher use of drugs for cardiovascular disorders after diagnosis in patients with AD raises concerns about the replacement therapy.
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Affiliation(s)
- Sigridur Björnsdottir
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden.
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Aulinas A, Casanueva F, Goñi F, Monereo S, Moreno B, Picó A, Puig-Domingo M, Salvador J, Tinahones FJ, Webb SM. Insuficiencia suprarrenal y su tratamiento sustitutivo. Su realidad en España. ACTA ACUST UNITED AC 2013; 60:136-43. [DOI: 10.1016/j.endonu.2012.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 12/17/2012] [Accepted: 12/18/2012] [Indexed: 12/01/2022]
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Zueger T, Kirchner P, Herren C, Fischli S, Zwahlen M, Christ E, Stettler C. Glucocorticoid replacement and mortality in patients with nonfunctioning pituitary adenoma. J Clin Endocrinol Metab 2012; 97:E1938-42. [PMID: 22872686 DOI: 10.1210/jc.2012-2432] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CONTEXT Current treatment guidelines generally suggest using lower and weight-adjusted glucocorticoid replacement doses in patients with insufficiency of the hypothalamic-pituitary-adrenal (HPA) axis. Although data in patients with acromegaly revealed a positive association between glucocorticoid dose and mortality, no comparable results exist in patients with nonfunctioning pituitary adenomas (NFPA). OBJECTIVE Our objective was to assess whether higher glucocorticoid replacement doses are associated with increased mortality in patients with NFPA and HPA axis insufficiency. DESIGN, PARTICIPANTS, AND INTERVENTION We included 105 patients receiving glucocorticoid replacement after pituitary surgery due to NFPA and concomitant HPA axis insufficiency. Patients were grouped according weight-adapted and absolute hydrocortisone (HC) replacement doses. Mortality was assessed using Kaplan-Meier methodology as well as multivariable Cox regression models. SETTING This was a retrospective analysis conducted at a tertiary referral center. MAIN OUTCOME We evaluated overall mortality based on HC replacement doses. RESULTS Average age at inclusion was 58.9±14.8 yr, and mean follow-up was 12.7±9.4 yr. The groups did not differ according to age, follow-up time, pattern of hypopituitarism, and comorbidities. Kaplan-Meier survival probabilities differed significantly when comparing individuals with differing weight-adjusted HC dose (P=0.001) as well as absolute HC dose (5-19, 20-29, and ≥30 mg, P=0.009). Hazard ratios for mortality increased from 1 (0.05-0.24 mg/kg) to 2.62 (0.25-0.34 mg/kg) to 4.56 (≥0.35 mg/kg, P for trend=0.006) and from 1 (5-19 mg) to 2.03 (20-29 mg) to 4 (≥30 mg, P for trend=0.029), respectively. CONCLUSION Higher glucocorticoid replacement doses are associated with increased overall mortality in patients with NFPA and insufficiency of HPA axis. This further substantiates the importance of a balanced and adjusted glucocorticoid replacement therapy in these patients.
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Affiliation(s)
- Thomas Zueger
- Division of Endocrinology, Diabetes, and Clinical Nutrition, Inselspital, Bern University Hospital, and Institute of Social and Preventive Medicine, University of Bern, CH-3010 Bern, Switzerland
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Shaikh S, Verma H, Yadav N, Jauhari M, Bullangowda J. Applications of Steroid in Clinical Practice: A Review. ACTA ACUST UNITED AC 2012. [DOI: 10.5402/2012/985495] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Steroids are perhaps one of the most widely used group of drugs in present day anaesthetic practice, sometimes with indication and sometimes without indications. Because of their diverse effects on various systems of the body, there has been renewed interest in the use of steroids in modern day anaesthetic practice. This paper focuses on the synthesis and functions of steroids and risks associated with their supplementation. This paper also highlights the recent trends, relevance, and consensus issues on the use of steroids as adjunct pharmacological agents in relation to anaesthetic practice and intensive care, along with emphasis on important clinical aspects of perioperative usefulness and supplementation.
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Affiliation(s)
- Safiya Shaikh
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences (KIMS), Hubli 580029, India
| | - Himanshu Verma
- Department of Anaesthesiology, SRMS IMS, Bhojipura, Bareilly 243202, India
| | - Nirmal Yadav
- Department of Internal Medicine, SRMS IMS, Bhojipura, Bareilly 243202, India
| | - Mirinda Jauhari
- Department of Pulmonary Medicine, SRMS IMS, Bhojipura, Bareilly 243202, India
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Meyer G, Hackemann A, Reusch J, Badenhoop K. Nocturnal hypoglycemia identified by a continuous glucose monitoring system in patients with primary adrenal insufficiency (Addison's Disease). Diabetes Technol Ther 2012; 14:386-8. [PMID: 22242902 PMCID: PMC3338953 DOI: 10.1089/dia.2011.0158] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Hypoglycemia can be a symptom in patients with Addison's disease. The common regimen of replacement therapy with oral glucocorticoids results in unphysiological low cortisol levels in the early morning, the time of highest insulin sensitivity. Therefore patients with Addison's disease are at risk for unrecognized and potentially severe nocturnal hypoglycemia also because of a disturbed counterregulatory function. Use of a continuous glucose monitoring system (CGMS) could help to adjust hydrocortisone treatment and to avoid nocturnal hypoglycemia in these patients. METHODS Thirteen patients with Addison's disease were screened for hypoglycemia wearing a CGMS for 3-5 days. RESULTS In one patient we identified a hypoglycemic episode at 3:45 a.m. with a blood glucose level of 46 mg/dL, clearly beneath the 95% tolerance interval of minimal glucose levels between 2 and 4 a.m. (53.84 mg/dL). After the hydrocortisone replacement scheme was changed, the minimum blood glucose level between 2 and 4 a.m. normalized to 87 mg/dL. CONCLUSIONS Continuous glucose monitoring can detect nocturnal hypoglycemia in patients with primary adrenal insufficiency and hence prevent in these patients an impaired quality of life and even serious adverse effects.
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Affiliation(s)
- Gesine Meyer
- Department of Endocrinology and Diabetes, University Hospital, Frankfurt, Germany.
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Ragnarsson O, Nyström HF, Johannsson G. Glucocorticoid replacement therapy is independently associated with reduced bone mineral density in women with hypopituitarism. Clin Endocrinol (Oxf) 2012; 76:246-52. [PMID: 21767286 DOI: 10.1111/j.1365-2265.2011.04174.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Patients with hypopituitarism have adverse cardiovascular morbidity and reduced bone mineral density (BMD). The objective of this study was to analyse the effects of glucocorticoid (GC) replacement on cardiovascular risk factors and BMD in patients with hypopituitarism. DESIGN, PATIENTS AND METHODS This was a cross-sectional study on 365 patients with hypopituitarism. Two-hundred and four patients (56%) were ACTH insufficient (ACTHins), receiving a mean ± SD hydrocortisone equivalent (HCeq) dose of 20·5 ± 5·8 mg/day. The difference in BMD and cardiovascular risk profile between ACTH sufficient (ACTHsuff) and ACTHins patients, before commencement of GH replacement, was analysed by multiple linear and logistic regression. RESULTS ACTHins was independently associated with lower fasting glucose but not other cardiovascular risk factors. The mean HCeq dose per kg body weight was 15% higher in ACTHins women than in ACTHins men (P = 0·009). In women, ACTHins was independently associated with decreased BMD at the lumbar spine (P = 0·002) and femoral neck (P = 0·006) and the presence of osteopenia (P = 0·004). BMD was not different between ACTHins and ACTHsuff men. CONCLUSION The current average HCeq dose of approximately 20 mg per day is not associated with an adverse metabolic profile, as compared with ACTHsuff patients with hypopituitarism. GC replacement in ACTHins women is independently associated with reduced BMD and higher prevalence of osteopenia.
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Affiliation(s)
- Oskar Ragnarsson
- Department of Endocrinology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Göteborg, Sweden.
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Quinkler M, Hahner S. What is the best long-term management strategy for patients with primary adrenal insufficiency? Clin Endocrinol (Oxf) 2012; 76:21-5. [PMID: 21585418 DOI: 10.1111/j.1365-2265.2011.04103.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Primary adrenal insufficiency is treated with glucocorticoid and mineralocorticoid replacement therapy. Recent data revealed that health-related quality of life in adrenal insufficiency is impaired in many patients and that patients with adrenal insufficiency are also threatened by an increased mortality and morbidity. This may be caused by inadequate glucocortiocid therapy and adrenal crisis. Therefore, the optimization of hormone replacement therapy remains one of the most challenging tasks in endocrinology because it is largely based on clinical grounds because of the lack of objective assessment tools. This article provides answers to the important daily clinical questions, such as correct dose finding, dose adaptation in special situations, e g, pregnancy, improvement of quality of life and measures for protection from adrenal crisis. Other important aspects discussed are side effects of glucocortiocid replacement therapy and interactions with other drugs.
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Affiliation(s)
- Marcus Quinkler
- Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany.
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Methlie P, Husebye EES, Hustad S, Lien EA, Løvås K. Grapefruit juice and licorice increase cortisol availability in patients with Addison's disease. Eur J Endocrinol 2011; 165:761-9. [PMID: 21896619 DOI: 10.1530/eje-11-0518] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Failure to mirror the diurnal cortisol profile could contribute to the impaired subjective health status in Addison's disease (AD). Some patients report benefit from the use of various nutritional compounds. The objective of this study was to investigate the impact of licorice and grapefruit juice (GFJ) on the absorption and metabolism of cortisone acetate (CA). DESIGN Patients (n=17) with AD on stable CA replacement therapy were recruited from the outpatient clinic at Haukeland University Hospital, Norway. They were assessed on their ordinary CA medication and following two 3-day periods of co-administration of licorice or GFJ. METHODS Time series of glucocorticoids (GCs) in serum and saliva were obtained, and GCs in 24 h urine samples were determined. The main outcome measure was the area under the curve (AUC) for serum cortisol in the first 2.6 h after orally administered CA. RESULTS Compared with the ordinary treatment, the median AUC for serum cortisol increased with licorice (53 783 vs 50 882, P<0.05) and GFJ (60 661 vs 50 882, P<0.05). Median cortisol levels in serum were also elevated 2.6 h after tablet ingestion (licorice 223 vs 186 nmol/l, P<0.05; GFJ 337 vs 186 nmol/l, P<0.01). Licorice increased the median urinary cortisol/cortisone ratio (0.43 vs 0.21, P<0.00001), whereas GFJ increased the (allo-tetrahydrocortisol+tetrahydrocortisol)/tetrahydrocortisone ratio (0.55 vs 0.43, P<0.05). CONCLUSION Licorice and in particular GFJ increased cortisol available to tissues in the hours following oral CA administration. Both patients and physicians should be aware of these interactions.
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Affiliation(s)
- Paal Methlie
- Institute of Medicine, University of Bergen, 5021 Bergen, Norway. )
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Abstract
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.
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Simon N, Castinetti F, Ouliac F, Lesavre N, Brue T, Oliver C. Pharmacokinetic Evidence for Suboptimal Treatment of Adrenal Insufficiency with Currently Available Hydrocortisone Tablets. Clin Pharmacokinet 2010; 49:455-63. [DOI: 10.2165/11531290-000000000-00000] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Harsch IA, Schuller A, Hahn EG, Hensen J. Cortisone replacement therapy in endocrine disorders - quality of self-care. J Eval Clin Pract 2010; 16:492-8. [PMID: 20210825 DOI: 10.1111/j.1365-2753.2009.01149.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Some endocrine disorders make cortisone replacement therapy (CRT) mandatory. Patients need to be well informed about the therapy and to be able to adapt the dose in case of stress, trauma or surgery. It is unknown where the patients mainly get their information from and what their preferences in learning about the disease are, as well as what their ideas are on how to improve the knowledge transfer. STUDY DESIGN We used an anonymized questionnaire to evaluate these objectives as well as the patients' present state of knowledge. PATIENTS AND METHODS A total of 338 patients with Addison's disease, hypopituitarism or adrenogenital syndrome (mean age 39.8 +/- 21.1 years, mean duration of disease 11.4 +/- 10.8 years) took part in the study. RESULTS Spoken information by doctors is the main source of information for the patients (89%). Apart from counselling by physicians, journals of self-help groups (66%), brochures/guidebooks (60%) and the Internet (45%) are important sources of information. Asked for suggestions for further improvement of knowledge transfer, information available on paper is still the first choice (65%). 51.9% of the questions about CRT were answered correctly. 24% of the patients reported hospitalizations because of Addisonian crisis. CONCLUSION Information transfer by doctors is the main source of information for the patients. The low patient numbers make the development of structured education programmes unlikely. Given that only the half of the answers in the 'knowledge' section of the questionnaire were correct, the available media could contribute to the improvement of information transfer.
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Affiliation(s)
- Igor A Harsch
- Department of Medicine, Division of Endocrinology and Metabolism, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.
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Sherlock M, Ayuk J, Tomlinson JW, Toogood AA, Aragon-Alonso A, Sheppard MC, Bates AS, Stewart PM. Mortality in patients with pituitary disease. Endocr Rev 2010; 31:301-42. [PMID: 20086217 DOI: 10.1210/er.2009-0033] [Citation(s) in RCA: 253] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Pituitary disease is associated with increased mortality predominantly due to vascular disease. Control of cortisol secretion and GH hypersecretion (and cardiovascular risk factor reduction) is key in the reduction of mortality in patients with Cushing's disease and acromegaly, retrospectively. For patients with acromegaly, the role of IGF-I is less clear-cut. Confounding pituitary hormone deficiencies such as gonadotropins and particularly ACTH deficiency (with higher doses of hydrocortisone replacement) may have a detrimental effect on outcome in patients with pituitary disease. Pituitary radiotherapy is a further factor that has been associated with increased mortality (particularly cerebrovascular). Although standardized mortality ratios in pituitary disease are falling due to improved treatment, mortality for many conditions are still elevated above that of the general population, and therefore further measures are needed. Craniopharyngioma patients have a particularly increased risk of mortality as a result of the tumor itself and treatment to control tumor growth; this is a key area for future research in order to optimize the outcome for these patients.
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Affiliation(s)
- Mark Sherlock
- Centre for Endocrinology, Diabetes, and Metabolism, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, United Kingdom
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Giordano R, Marzotti S, Balbo M, Romagnoli S, Marinazzo E, Berardelli R, Migliaretti G, Benso A, Falorni A, Ghigo E, Arvat E. Metabolic and cardiovascular profile in patients with Addison's disease under conventional glucocorticoid replacement. J Endocrinol Invest 2009; 32:917-23. [PMID: 19620820 DOI: 10.1007/bf03345773] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Although two studies have shown that Addison's disease (AD) is still a potentially lethal condition for cardiovascular, malignant, and infectious diseases, a recent retrospective study showed a normal overall mortality rate. Differently from secondary hypoadrenalism, scanty data exist on the role of conventional glucocorticoid replacement on metabolic and cardiovascular outcome in AD. SUBJECTS AND METHODS In 38 AD under conventional glucocorticoid replacement (hydrocortisone 30 mg/day or cortisone 37.5 mg/day) ACTH, plasma renin activity (PRA), DHEAS, fasting glucose and insulin, 2-h glucose after oral glucose tolerance test, serum lipids, 24-h blood pressure and intima-media thickness (IMT) were evaluated and compared with 38 age-, sex- and body mass index (BMI)-matched controls (CS). RESULTS AD had ACTH and PRA higher and DHEAS lower (p<0.0005) than CS. Mean waist was higher (p<0.05) in AD than in CS. Although no differences were found for mean gluco-lipids levels, a higher percentage of AD compared to CS were IGT (8 vs 0%), hypercholesterolemic (18 vs 8%), and hypertriglyceridemic (18 vs 8%); none of the AD and CS showed either HDL<40 mg/dl or LDL>190 mg/dl. At the multiple regression analysis, in both AD and CS, BMI was the best predictor of 2-h glucose and age of total and LDL cholesterol; in AD, no significant correlation was found between the above mentioned metabolic parameters and either hormone levels or disease duration. In both AD and CS 24-h blood pressure and IMT were normal. CONCLUSIONS Our study shows a higher prevalence of central adiposity, impaired glucose tolerance and dyslipidemia in AD patients.
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Affiliation(s)
- R Giordano
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, Italy
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