1
|
Henry RK, Miller BS. Approach to the Patient: Case Studies in Pediatric Growth Hormone Deficiency and Their Management. J Clin Endocrinol Metab 2023; 108:3009-3021. [PMID: 37246615 DOI: 10.1210/clinem/dgad305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 05/30/2023]
Abstract
CONTEXT Pathologies attributed to perturbations of the GH/IGF-I axis are among the most common referrals received by pediatric endocrinologists. AIM In this article, distinctive cased-based presentations are used to provide a practical and pragmatic approach to the management of pediatric growth hormone deficiency (GHD). CASES We present 4 case vignettes based on actual patients that illustrate (1) congenital GHD, (2) childhood GHD presenting as failure to thrive, (3) childhood GHD presenting in adolescence as growth deceleration, and (4) childhood-onset GHD manifesting as metabolic complications in adolescence. We review patient presentation and a management approach that aims to highlight diagnostic considerations for treatment based on current clinical guidelines, with mention of new therapeutic and diagnostic modalities being used in the field. CONCLUSION Pediatric GHD is diverse in etiology and clinical presentation. Timely management has the potential not only to improve growth but can also ameliorate or even mitigate adverse metabolic outcomes, which can be directly attributed to a GH deficient state.
Collapse
Affiliation(s)
- Rohan K Henry
- Section of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH 43205, USA
| | - Bradley S Miller
- Division of Endocrinology, Department of Pediatrics, University of Minnesota Medical School, MHealth Fairview Masonic Children's Hospital, Minneapolis, MN 55454, USA
| |
Collapse
|
2
|
Bulan A, Pyle-Eilola AL, Mamilly L, Chaudhari M, Henry RK. The utility of a random cortisol level in determining neonatal central adrenal insufficiency. Clin Endocrinol (Oxf) 2023; 98:779-787. [PMID: 36859827 DOI: 10.1111/cen.14903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/13/2023] [Accepted: 02/27/2023] [Indexed: 03/03/2023]
Abstract
OBJECTIVES While it has been established within the first 4 months of life that there is no circadian rhythm, what is unclear is the usefulness of a random serum cortisol (rSC) level in determining neonatal central adrenal insufficiency (CAI). The objective of the study is to determine the utility of using rSC in infants less than 4 months old in the evaluation of CAI. DESIGN AND PATIENTS Retrospective chart review of infants who underwent a low dose cosyntropin stimulation test ≤4 months of life with rSC taken as baseline cortisol before stimulation. Infants were divided into three groups: those diagnosed with CAI, those at risk for CAI (ARF-CAI) and a non-CAI group. Mean rSC for each group was compared, and ROC analysis was used to identify rSC cut-off for the diagnosis of CAI. RESULTS Two hundred and fifty one infants with the mean age of 50.5 ± 38.08 days, and 37% of these were born at term gestation. The mean rSC were lower in the CAI group (1.98 ± 1.88 mcg/dl) as compared to the ARF-CAI (6.27 ± 5.48 mcg/dl, p = .002) and non-CAI (4.6 ± 4.02 mcg/dl, p = .007) groups. ROC analysis identified a cut-off of rSC level of 5.6 mcg/dL is associated with 42.6% sensitivity and 100% specificity for the diagnosis of CAI in term infants. CONCLUSIONS This study demonstrates that though an rSC can be used within the first 4 months of life, its value is best when done ≤30 days of life. Moreover, a diagnostic cut-off for CAI using rSC levels was identified for term infants.
Collapse
Affiliation(s)
- Ayse Bulan
- Section of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Amy L Pyle-Eilola
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pathology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Leena Mamilly
- Section of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Monika Chaudhari
- Section of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Rohan K Henry
- Section of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
| |
Collapse
|
3
|
Garner T, Wangsaputra I, Whatmore A, Clayton PE, Stevens A, Murray PG. Diagnosis of childhood and adolescent growth hormone deficiency using transcriptomic data. Front Endocrinol (Lausanne) 2023; 14:1026187. [PMID: 36864831 PMCID: PMC9973753 DOI: 10.3389/fendo.2023.1026187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Gene expression (GE) data have shown promise as a novel tool to aid in the diagnosis of childhood growth hormone deficiency (GHD) when comparing GHD children to normal children. The aim of this study was to assess the utility of GE data in the diagnosis of GHD in childhood and adolescence using non-GHD short stature children as a control group. METHODS GE data was obtained from patients undergoing growth hormone stimulation testing. Data were taken for the 271 genes whose expression was utilized in our previous study. The synthetic minority oversampling technique was used to balance the dataset and a random forest algorithm applied to predict GHD status. RESULTS 24 patients were recruited to the study and eight subsequently diagnosed with GHD. There were no significant differences in gender, age, auxology (height SDS, weight SDS, BMI SDS) or biochemistry (IGF-I SDS, IGFBP-3 SDS) between the GHD and non-GHD subjects. A random forest algorithm gave an AUC of 0.97 (95% CI 0.93 - 1.0) for the diagnosis of GHD. CONCLUSION This study demonstrates highly accurate diagnosis of childhood GHD using a combination of GE data and random forest analysis.
Collapse
Affiliation(s)
- Terence Garner
- Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Ivan Wangsaputra
- Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Andrew Whatmore
- Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Peter Ellis Clayton
- Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Adam Stevens
- Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Philip George Murray
- Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
- *Correspondence: Philip George Murray,
| |
Collapse
|
4
|
Henry RK. Macimorelin Acetate for the Diagnosis of Childhood-onset Growth Hormone Deficiency. TOUCHREVIEWS IN ENDOCRINOLOGY 2022; 18:84-85. [PMID: 36694890 PMCID: PMC9835807 DOI: 10.17925/ee.2022.18.2.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/04/2022] [Indexed: 12/12/2022]
Abstract
Growth hormone provocation testing forms the cornerstone of the diagnosis of childhood growth hormone deficiency in clinical practice. Despite the widespread use of these tests, various criticisms have been levelled against them, such as the labour-intensive nature of the tests, their potential for serious adverse effects and their questionable reproducibility. Macimorelin acetate, a ghrelin mimetic approved for the diagnosis of adult growth hormone deficiency, could serve an unmet need in the diagnosis of childhood-onset growth hormone deficiency based on its good tolerability and benign side effect profile.
Collapse
Affiliation(s)
- Rohan K Henry
- Section of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine Columbus, OH, USA
| |
Collapse
|
5
|
Hanukoglu A, Weisglass R. Is the fear from insulin tolerance test in the evaluation of short stature justified? Eur J Pediatr 2022; 181:2867-2871. [PMID: 35459965 DOI: 10.1007/s00431-021-04364-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 11/24/2022]
Abstract
UNLABELLED Among growth hormone (GH) provocative tests, insulin tolerance test (ITT) is considered a valuable test in children with short stature to diagnose GH deficiency. However, many pediatric endocrinologists are reluctant to perform it. We conducted a nationwide survey among all the pediatric endocrine clinics' heads in Israel regarding their position on this issue. We found that the number of endocrine units performing ITT is almost nil. Sense of fear from severe hypoglycemia was a dominating cause for not performing ITT. We review the pros and cons of performing ITT versus other tests, especially glucagon test. Glucagon tolerance test is not considered the test of choice by some endocrinologists but recommended by others including in Israel. We also note the influence of a widely cited report published in 1992 (many times inaccurately) on endocrinologists' views. CONCLUSION A nationwide survey in Israel revealed a high rate of reluctance to perform ITT. The rationale behind this attitude was a sense of fear of performing the test by many endocrinologists. We discuss the preferences for choosing GH stimulation tests and the pros and cons of alternatives to ITT. The fear of not performing ITT was not always justified. WHAT IS KNOWN • ITT test is considered a gold standard in the evaluation of short stature to diagnose GH deficiency by many endocrinologists. WHAT IS NEW • High reluctance rate found in Israel to perform ITT, prompted us to evaluate the attitudes of pediatric endocrinologists around the world showing conflicting ideas. • The role of a single paper sometimes misquoted also contributed to these conflicting results.
Collapse
Affiliation(s)
- Aaron Hanukoglu
- Division of Pediatric Endocrinology, E. Wolfson Medical Center, Holon, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Regina Weisglass
- Division of Pediatric Endocrinology, E. Wolfson Medical Center, Holon, Israel
| |
Collapse
|
6
|
Yeoh P, Dwyer AA, Anghel E, Bouloux PM, Khoo B, Chew S, Wernig F, Carroll P, Aylwin SJB, Baldeweg SE, Drake W, Todd J, Mangena L, Grossman A. A Comparison of the Blood Glucose, Growth Hormone, and Cortisol Responses to Two Doses of Insulin (0.15 U/kg vs. 0.10 U/kg) in the Insulin Tolerance Test: A Single-Centre Audit of 174 Cases. Int J Endocrinol 2022; 2022:7360282. [PMID: 35465075 PMCID: PMC9019435 DOI: 10.1155/2022/7360282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The insulin tolerance test (ITT) is the gold standard endocrine test used to assess the integrity of the growth hormone (GH) and cortisol axes. The ITT has potential risks, and severe hypoglycaemia may necessitate intravenous glucose rescue. There is no clear consensus as to the optimal insulin dose for the ITT. Therefore, we sought to compare the standard dose (0.15 U/kg) and a low-dose ITT (0.1 U/kg). DESIGN Single-centre audit of ITT data (2012-2021). Patients and Measurements. Patients who underwent an ITT to assess possible GH deficiency/adrenal insufficiency were included. Glucose, GH, and cortisol were measured at baseline and 30, 45, 60, 90, and 120 minutes following I.V. insulin bolus (0.15 U/kg or 0.10 U/kg). RESULTS Of the ITTs performed, only 3/177 (1.7%) did not achieve adequate hypoglycaemia (≤2.2 mmol/L) with a single insulin dose. In total, 174 patients (43.5 ± 12.1 yrs, mean ± standard deviation) were included for analysis (0.15 U/kg: n = 113, 0.10 U/kg: n = 61). All 174 subjects had adequate hypoglycaemia regardless of baseline fasting blood glucose level or insulin dose. Neither nadir glucose nor glucose delta (i.e., baseline minus nadir) differed between insulin doses. Trends in both cortisol and GH responses over time were similar between groups, and a greater proportion of patients receiving the standard dose had an adequate cortisol response (77/106 (72.6%) vs. 32/60 (53.3%), p=0.01). The rates of glucose rescue did not differ in a subset of 79 patients, with on-demand glucose rescue in 4/35 (11%) for the standard dose and 2/44 (5%) for the low dose (p=0.25). CONCLUSIONS Our results suggest that the low-dose ITT produces comparable glucose, cortisol, and GH responses to the higher dose. Given the risks associated with hypoglycaemia, the low dose appears to be preferable to the standard dose ITT in most circumstances.
Collapse
Affiliation(s)
- Phillip Yeoh
- The London Clinic Centre for Endocrinology, London, UK
- Florence Nightingale School of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Andrew A. Dwyer
- Boston College William F. Connell School of Nursing, Chestnut Hill, MA, USA
- Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA, USA
| | - Ella Anghel
- Boston College, Department of Measurement, Evaluation, Statistics and Assessment, Chestnut Hill, MA, USA
| | - Pierre M. Bouloux
- The London Clinic Centre for Endocrinology, London, UK
- Royal Free London NHS Foundation Trust, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Bernard Khoo
- The London Clinic Centre for Endocrinology, London, UK
- Royal Free London NHS Foundation Trust, London, UK
- Division of Medicine, University College London, London, UK
| | - Shern Chew
- The London Clinic Centre for Endocrinology, London, UK
- OneWelbeck Endocrine Partners, London, UK
| | - Florian Wernig
- The London Clinic Centre for Endocrinology, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Paul Carroll
- The London Clinic Centre for Endocrinology, London, UK
- Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Simon J. B. Aylwin
- The London Clinic Centre for Endocrinology, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Stephanie E. Baldeweg
- The London Clinic Centre for Endocrinology, London, UK
- Division of Medicine, University College London, London, UK
- Department of Diabetes & Endocrinology, University College London NHS Foundation Trust, London, UK
| | - William Drake
- The London Clinic Centre for Endocrinology, London, UK
- Barts Health NHS Trust, Saint Bartholomew's Hospital, London, UK
| | - Jeannie Todd
- The London Clinic Centre for Endocrinology, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | | | - Ashley Grossman
- The London Clinic Centre for Endocrinology, London, UK
- Centre for Endocrinology, Barts and the London School of Medicine, Queen Mary University of London, UK
| |
Collapse
|
7
|
Henry RK. When They're Done Growing, Don't Forget They May Still Need Growth Hormone. Metab Syndr Relat Disord 2021; 19:257-263. [PMID: 33596132 DOI: 10.1089/met.2020.0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The effect of the growth hormone (GH) in promoting linear growth is well known; however, less recognized by practitioners especially pediatric, are its metabolic properties. This may be because the deleterious effects of improperly treated or untreated growth hormone deficiency (GHD) can present beyond the pediatric years. In addition, clinicians may lack familiarity with the potential issues that can arise due to inadequately treated GHD. Considering information from both the basic sciences research and clinical medicine, pediatric practitioners should be cognizant about the metabolic effects of GH. They should also be equipped to provide anticipatory guidance to patients regarding the importance of adherence to therapy in GHD and be prepared to transition patients with permanent GHD from pediatric GH supplementation to adult GH dosing. With a lack of proper transitioning, adverse outcomes may present beyond childhood.
Collapse
Affiliation(s)
- Rohan K Henry
- Section of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| |
Collapse
|
8
|
Henry RK. Childhood growth hormone deficiency, a diagnosis in evolution: The intersection of growth hormone history and ethics. Growth Horm IGF Res 2020; 55:101358. [PMID: 33065486 DOI: 10.1016/j.ghir.2020.101358] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 11/17/2022]
Abstract
In 1958 the first recorded case of a patient treated with human growth hormone for growth hormone deficiency was published. Since that time, the source and availability of human growth hormone have changed. With the increased availability of growth hormone, there has been an uptrend in the level below which childhood growth hormone deficiency is diagnosed based on provocative GH stimulation testing. This increase is despite better specificity of growth hormone assays in addition to a lack of supportive evidence regarding appropriate normal values. With these trends the diagnosis of childhood growth hormone deficiency is evolving, and clinicians should be aware that this may have potential ethical implications.
Collapse
Affiliation(s)
- Rohan K Henry
- Section of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH 43205, USA.
| |
Collapse
|
9
|
Adrenal Insufficiency in Children With Eosinophilic Esophagitis Treated With Topical Corticosteroids. J Pediatr Gastroenterol Nutr 2020; 70:324-329. [PMID: 31688699 DOI: 10.1097/mpg.0000000000002537] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of the study was to identify practices of gastroenterologists screening for adrenal insufficiency (AI) and report prevalence of AI in children with eosinophilic esophagitis (EoE) treated with topical corticosteroids (TCS); compare serum dehydroepiandrosterone sulfate (DHEA-S) levels to morning serum cortisol (MSC) levels as screening tool for AI. METHODS A multipart study was conducted. In part 1, a survey about screening practices for AI in children with EoE on TCS was sent to gastroenterologists belonging to a PedsGI listserv and to EoE consortia. In part 2, children with EoE on TCS for ≥6 months were prospectively screened for AI with MSC levels. For subjects with a MSC level of <10 μg/dL, a repeat MSC level and/or confirmatory adrenocorticotropic hormone (ACTH) stimulation testing was offered. AI was defined by peak serum cortisol level <18 μg/dL. In part 3, DHEA-S levels were drawn with MSC levels. RESULTS Seven percent (16/238) of gastroenterologists screened for AI. Providers in EoE consortia were more likely to screen than nonconsortia providers [9/21(43%) vs 7/217(3%); P = 0.0001]. Thirty-seven children were prospectively screened for AI, and 51% (19/37) had a low MSC level. Ten patients had a low-dose ACTH stimulation test (LDST) after 1 or more low MSC levels. Five percent (2/37) of patients were diagnosed with AI. DHEA-S and MSC levels had a moderate correlation (rs = 0.44, P = 0.03). CONCLUSIONS Gastroenterologists belonging to EoE consortia were more likely to screen for AI. Prevalence of AI in our prospective cohort was 5%. DHEA-S has a moderate correlation with MSC levels, but more data is required to assess utility as a screening tool for AI.
Collapse
|
10
|
Richmond E, Rogol AD. Testing for growth hormone deficiency in children. Growth Horm IGF Res 2020; 50:57-60. [PMID: 31865218 DOI: 10.1016/j.ghir.2019.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 11/21/2019] [Accepted: 12/09/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Erick Richmond
- Pediatric Endocrinology, National Children's Hospital, San José, Costa Rica
| | - Alan D Rogol
- Pediatric Endocrinology, University of Virginia, Charlottesville, VA, USA.
| |
Collapse
|
11
|
Zhang Y, Sun S, Jia H, Qi Y, Zhang J, Lin L, Chen Y, Wang W, Ning G. The Optimized Calculation Method for Insulin Dosage in an Insulin Tolerance Test (ITT): A Randomized Parallel Control Study. Front Endocrinol (Lausanne) 2020; 11:202. [PMID: 32328036 PMCID: PMC7160329 DOI: 10.3389/fendo.2020.00202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 03/23/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: To explore the most suitable calculation method for insulin dosage in an insulin tolerance test (ITT) and to evaluate the clinical application value of the optimization coefficient (γ). Methods: In this study, 140 adult patients with congenital growth hormone deficiency (GHD) or acquired hypopituitarism were randomized into the following two groups: the conventional group (n = 70) and the optimized group (n = 70). Oral glucose tolerance tests (OGTTs), insulin release tests (IRTs), and ITTs were conducted. For ITTs, insulin doses were the product of body weight (kg) and related coefficient (0.15 IU/kg for the control group and γ IU/kg for the optimized group, respectively). Notably, γ was defined as -0.034 + 0.000176 × AUCINS + 0.009846 × BMI, which was based on our previous study. Results: In the ITTs, the rate of achieving adequate hypoglycemia with a single insulin dose was significantly higher for the optimized group compared with the conventional group (92.9 vs. 60.0%, P < 0.001). The optimized group required higher initial doses of insulin (0.23 IU/kg). Meanwhile, the two groups did not differ significantly in their nadir blood glucose (1.9 vs. 1.9 mmol/L, P = 0.828). Conclusion: This study confirmed that the proposed optimized calculation method for insulin dosage in ITTs led to more efficient hypoglycemia achievement, without increasing the incidence of serious adverse events.
Collapse
Affiliation(s)
- Yuwen Zhang
- Department of Endocrine and Metabolic Diseases, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shouyue Sun
- Department of Endocrine and Metabolic Diseases, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- State Key Laboratory of Medical Genomics, National Clinical Research Center for Metabolic Diseases, Collaborative Innovation Center of Systems Biomedicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huiying Jia
- Department of Endocrine and Metabolic Diseases, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Qi
- Department of Endocrine and Metabolic Diseases, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Zhang
- Department of Endocrine and Metabolic Diseases, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Lin
- Department of Endocrine and Metabolic Diseases, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuhong Chen
- Department of Endocrine and Metabolic Diseases, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- State Key Laboratory of Medical Genomics, National Clinical Research Center for Metabolic Diseases, Collaborative Innovation Center of Systems Biomedicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiqing Wang
- State Key Laboratory of Medical Genomics, National Clinical Research Center for Metabolic Diseases, Collaborative Innovation Center of Systems Biomedicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Weiqing Wang
| | - Guang Ning
- State Key Laboratory of Medical Genomics, National Clinical Research Center for Metabolic Diseases, Collaborative Innovation Center of Systems Biomedicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Guang Ning
| |
Collapse
|
12
|
Cattoni A, Molinari S, Medici F, De Lorenzo P, Valsecchi MG, Masera N, Adavastro M, Biondi A. Dexamethasone Stimulation Test in the Diagnostic Work-Up of Growth Hormone Deficiency in Childhood: Clinical Value and Comparison With Insulin-Induced Hypoglycemia. Front Endocrinol (Lausanne) 2020; 11:599302. [PMID: 33362716 PMCID: PMC7757782 DOI: 10.3389/fendo.2020.599302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/02/2020] [Indexed: 11/13/2022] Open
Abstract
CONTEXT dexamethasone has been demonstrated to elicit GH secretion in adults, but few data are available about its effectiveness as a provocative stimulus in the diagnostic work-up of GH deficiency (GHD) in childhood. OBJECTIVE to assess the clinical value of dexamethasone stimulation test (DST) as a diagnostic tool for pediatric GHD. DESIGN AND SETTING retrospective single-center analysis. The study population included 166 patients with a pathological response to arginine stimulation test (AST, first-line test) and subsequently tested with either insulin tolerance test (ITT) or DST as a second-line investigation between 2008 and 2019. MAIN OUTCOME MEASURES comparison between GH peaks and secretory curves induced by ITT and DST; degree of agreement between DST and AST versus ITT and AST. RESULTS the pathological response to AST (GH peak < 8 ng/mL) was confirmed by an ITT in 80.2% (89/111) of patients and by a DST in 76.4% (42/55), with no statistical difference between the two groups (p value 0.69). Mean GH peaks achieved after ITT and DST were entirely comparable (6.59 ± 3.59 versus 6.50 ± 4.09 ng/ml, respectively, p 0.97) and statistically higher than those elicited by arginine (p < 0.01 for both), irrespectively of the average GH peaks recorded for each patient (Bland-Altman method). Dexamethasone elicited a longer lasting and later secretory response than AST and ITT. No side effects were recorded after DST. CONCLUSIONS DST and ITT confirmed GHD in a superimposable percentage of patients with a pathological first-line test. DST and ITT share a similar secretagogue potency, overall greater than AST.
Collapse
Affiliation(s)
- Alessandro Cattoni
- Department of Pediatrics, Università degli studi di Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Silvia Molinari
- Department of Pediatrics, Università degli studi di Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
- *Correspondence: Silvia Molinari,
| | - Francesco Medici
- Department of Pediatrics, Università degli studi di Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Paola De Lorenzo
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, Università degli studi di Milano-Bicocca, Monza, Italy
- Tettamanti Research Center, Pediatric Clinic, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Maria Grazia Valsecchi
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, Università degli studi di Milano-Bicocca, Monza, Italy
| | - Nicoletta Masera
- Department of Pediatrics, Università degli studi di Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Marta Adavastro
- Department of Pediatrics, Università degli studi di Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Andrea Biondi
- Department of Pediatrics, Università degli studi di Milano-Bicocca, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| |
Collapse
|
13
|
Acar S, Paketçi A, Tuhan H, Demir K, Böber E, Abaci A. Comparison of the effects of the L-dopa and insulin tolerance tests on cortisol secretion. J Endocrinol Invest 2018; 41:901-907. [PMID: 29353394 DOI: 10.1007/s40618-017-0815-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/09/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE The aims of the present study are to evaluate the effect of L-dopa on the secretion of cortisol and adrenocorticotropic hormone (ACTH) in short children and compare the performance of this test with the insulin tolerance test (ITT) in a large number of patients. METHODS A total of 29 short but otherwise healthy children [mean age 9.5 ± 3.1 years (range 3.7-14.9 years)] who had inadequate growth hormone (GH) responses to ITT, which was performed as the first test, were consecutively enrolled in this study. GH, cortisol, and ACTH levels were measured just before administration of L-dopa and then at 30-min intervals afterward over a total time of 120 min. Peak concentrations of cortisol and ACTH exceeding 18 µg/dL (496 mmol/L) and 46 pg/mL (10.2 pmol/L), respectively, were defined as an adequate response. RESULTS While the L-dopa test revealed that 26 of the 29 children (89.7%) had peak serum cortisol levels of > 18 µg/dL, the ITT revealed that only 23 children (79.3%) had adequate cortisol responses. The L-dopa test revealed normal ACTH responses (> 46 pg/mL) in 24 (82.8%) patients. Peak cortisol levels were higher in children with normal ACTH responses than in those with subnormal ACTH responses (25.6 ± 6.2 vs. 19.5 ± 6.4 µg/dL, p = 0.054), but the difference observed was statistically insignificant. CONCLUSION The results of the current study confirm that the L-dopa test is a reliable test of cortisol secretion. As such, this test may be applicable to assessments of the hypothalamic-pituitary-adrenal axis.
Collapse
Affiliation(s)
- S Acar
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University School of Medicine, Narlıdere, 35340, Izmir, Turkey
| | - A Paketçi
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University School of Medicine, Narlıdere, 35340, Izmir, Turkey
| | - H Tuhan
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University School of Medicine, Narlıdere, 35340, Izmir, Turkey
| | - K Demir
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University School of Medicine, Narlıdere, 35340, Izmir, Turkey
| | - E Böber
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University School of Medicine, Narlıdere, 35340, Izmir, Turkey
| | - A Abaci
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University School of Medicine, Narlıdere, 35340, Izmir, Turkey.
| |
Collapse
|
14
|
Garg BMK, Harikumar KVS. Growth Hormone Stimulation: An Achilles Heel in the Evaluation of Short Stature. Indian J Endocrinol Metab 2018; 22:439-440. [PMID: 30148084 PMCID: PMC6085959 DOI: 10.4103/ijem.ijem_255_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Brig M. K. Garg
- Dy Commandant & Consultant (Medicine and Endocrinology), Officer's Training College, AMC Centre and College, Lucknow, Uttar Pradesh, India
| | - K. V. S. Harikumar
- Senior Adviser (Medicine and Endocrinology), Army Hospital (Research and Referral), Delhi Cantt, India
| |
Collapse
|
15
|
Rensen N, Gemke RJBJ, van Dalen EC, Rotteveel J, Kaspers GJL. Hypothalamic-pituitary-adrenal (HPA) axis suppression after treatment with glucocorticoid therapy for childhood acute lymphoblastic leukaemia. Cochrane Database Syst Rev 2017; 11:CD008727. [PMID: 29106702 PMCID: PMC6486149 DOI: 10.1002/14651858.cd008727.pub4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Glucocorticoids play a major role in the treatment of acute lymphoblastic leukaemia (ALL). However, supraphysiological doses can suppress the hypothalamic-pituitary-adrenal (HPA) axis. HPA axis suppression resulting in reduced cortisol response may cause an impaired stress response and an inadequate host defence against infection, which remain a cause of morbidity and death. Suppression commonly occurs in the first days after cessation of glucocorticoid therapy, but the exact duration is unclear. This review is the second update of a previously published Cochrane review. OBJECTIVES To examine the occurrence and duration of HPA axis suppression after (each cycle of) glucocorticoid therapy for childhood ALL. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), MEDLINE/PubMed (from 1945 to December 2016), and Embase/Ovid (from 1980 to December 2016). In addition, we searched reference lists of relevant articles, conference proceedings (the International Society for Paediatric Oncology and the American Society of Clinical Oncology from 2005 up to and including 2016, and the American Society of Pediatric Hematology/Oncology from 2014 up to and including 2016), and ongoing trial databases (the International Standard Registered Clinical/Social Study Number (ISRCTN) register via http://www.controlled-trials.com, the National Institutes of Health (NIH) register via www.clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP) of the World Health Organization (WHO) via apps.who.int/trialsearch) on 27 December 2016. SELECTION CRITERIA All study designs, except case reports and patient series with fewer than 10 children, examining effects of glucocorticoid therapy for childhood ALL on HPA axis function. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection. One review author extracted data and assessed 'Risk of bias'; another review author checked this information. MAIN RESULTS We identified 10 studies (total of 298 children; we identified two studies for this update) including two randomised controlled trials (RCTs) that assessed adrenal function. None of the included studies assessed the HPA axis at the level of the hypothalamus, the pituitary, or both. Owing to substantial differences between studies, we could not pool results. All studies had risk of bias issues. Included studies demonstrated that adrenal insufficiency occurs in nearly all children during the first days after cessation of glucocorticoid treatment for childhood ALL. Most children recovered within a few weeks, but a small number of children had ongoing adrenal insufficiency lasting up to 34 weeks.Included studies evaluated several risk factors for (prolonged) adrenal insufficiency. First, three studies including two RCTs investigated the difference between prednisone and dexamethasone in terms of occurrence and duration of adrenal insufficiency. The RCTs found no differences between prednisone and dexamethasone arms. In the other (observational) study, children who received prednisone recovered earlier than children who received dexamethasone. Second, treatment with fluconazole appeared to prolong the duration of adrenal insufficiency, which was evaluated in two studies. One of these studies reported that the effect was present only when children received fluconazole at a dose higher than 10 mg/kg/d. Finally, two studies evaluated the presence of infection, stress episodes, or both, as a risk factor for adrenal insufficiency. In one of these studies (an RCT), trial authors found no relationship between the presence of infection/stress and adrenal insufficiency. The other study found that increased infection was associated with prolonged duration of adrenal insufficiency. AUTHORS' CONCLUSIONS We concluded that adrenal insufficiency commonly occurs in the first days after cessation of glucocorticoid therapy for childhood ALL, but the exact duration is unclear. No data were available on the levels of the hypothalamus and the pituitary; therefore, we could draw no conclusions regarding these outcomes. Clinicians may consider prescribing glucocorticoid replacement therapy during periods of serious stress in the first weeks after cessation of glucocorticoid therapy for childhood ALL to reduce the risk of life-threatening complications. However, additional high-quality research is needed to inform evidence-based guidelines for glucocorticoid replacement therapy.Special attention should be paid to patients receiving fluconazole therapy, and perhaps similar antifungal drugs, as these treatments may prolong the duration of adrenal insufficiency, especially when administered at a dose higher than 10 mg/kg/d.Finally, it would be relevant to investigate further the relationship between present infection/stress and adrenal insufficiency in a larger, separate study specially designed for this purpose.
Collapse
Affiliation(s)
- Niki Rensen
- VU University Medical CenterDepartment of Pediatrics, Division of Oncology/HematologyDe Boelelaan 1117AmsterdamNetherlands1081 HZ
| | - Reinoud JBJ Gemke
- VU University Medical CenterDepartment of Pediatrics, Division of General Pediatrics and other subspecialtiesPO Box 7057AmsterdamNetherlands1007 MB
| | - Elvira C van Dalen
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyPO Box 22660 (room H4‐139)AmsterdamNetherlands1100 DD
| | - Joost Rotteveel
- VU University Medical CenterDepartment of Pediatrics, Division of EndocrinologyPO Box 7057AmsterdamNetherlands1007 MB
| | - Gertjan JL Kaspers
- VU University Medical CenterDepartment of Pediatrics, Division of Oncology/HematologyDe Boelelaan 1117AmsterdamNetherlands1081 HZ
| | | |
Collapse
|
16
|
Brown S, Hadlow N, Badshah I, Henley D. A time-adjusted cortisol cut-off can reduce referral rate for Synacthen stimulation test whilst maintaining diagnostic performance. Clin Endocrinol (Oxf) 2017; 87:418-424. [PMID: 28653409 DOI: 10.1111/cen.13405] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/12/2017] [Accepted: 06/17/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Cortisol cut-offs can predict requirement for Synacthen stimulation tests (SST). We assessed the performance of a standard cortisol cut-off (375 nmol/L) across the morning and compared this with a time-adjusted cut-off. DESIGN Retrospective audit PATIENTS: Community reference set (n=12 550) and SST patients (n=757). MEASUREMENTS In the reference population, time-specific cortisol medians were calculated and used to convert cortisol to time-adjusted Multiples of the Median (MoM). In 757 SST patients, the predictive performance of a standard cortisol cut-off (375 nmol/L) and its time-adjusted MoM equivalent were compared. RESULTS Median cortisol decreased by ~30 nmol/L per hour between 0700 and 1200h. In the reference population, proportions below the 375 nmol/L cut-off increased throughout the morning (range 35%-64%), whereas using the time-adjusted MoM cut-off proportions were consistent (range 46%-50%), with a 17% maximal difference in referral rates between the two cut-offs after 1100h. A similar pattern was noted in the SST cohort. When a cortisol MoM cut-off was used to predict SST success, the excess proportion of patients tested and misclassification rates were lower and more consistent than when the standard cut-off was used. A median cortisol of 375 nmol/L equated to 444 and 313 nmol/L before 0800 and after 1100 h, respectively. CONCLUSION The use of a standard cortisol cut-off results in 17% more patients being referred for SST later in the morning. A time-adjusted cortisol cut-off provides consistent and lower referral rates, whilst maintaining similar or better performance than a standard single cut-off in predicting outcome of SST.
Collapse
Affiliation(s)
- Suzanne Brown
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Narelle Hadlow
- Department of Biochemistry, PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Imran Badshah
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - David Henley
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| |
Collapse
|
17
|
Takahashi K, Nakamura A, Miyoshi H, Nomoto H, Kameda H, Cho KY, Nagai S, Shimizu C, Taguri M, Terauchi Y, Atsumi T. Factors associated with an inadequate hypoglycemia in the insulin tolerance test in Japanese patients with suspected or proven hypopituitarism. Endocr J 2017; 64:387-392. [PMID: 28260701 DOI: 10.1507/endocrj.ej16-0332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We attempted to identify the predictors of an inadequate hypoglycemia in insulin tolerance test (ITT), defined as a blood glucose level higher than 2.8 mmol/L after insulin injection, in Japanese patients with suspected or proven hypopituitarism. A total of 78 patients who had undergone ITT were divided into adequate and inadequate hypoglycemia groups. The relationships between the subjects' clinical parameters and inadequate hypoglycemia in ITT were analyzed. Stepwise logistic regression analysis identified high systolic blood pressure (SBP) and high homeostasis model assessment of insulin resistance (HOMA-IR) as being independent factors associated with inadequate hypoglycemia in ITT. Receiver operating characteristic (ROC) curve analysis revealed the cutoff value for inadequate hypoglycemia was 109 mmHg for SBP and 1.4 for HOMA-IR. The areas under ROC curve for SBP and HOMA-IR were 0.72 and 0.86, respectively. We confirmed that high values of SBP and HOMA-IR were associated with inadequate hypoglycemia in ITT, regardless of the degree of reduction of pituitary hormone levels. Furthermore, the strongest predictor of inadequate hypoglycemia was obtained by using the cutoff value of HOMA-IR. Our results suggest that HOMA-IR is a useful pre-screening tool for ITT in these populations.
Collapse
Affiliation(s)
- Kiyohiko Takahashi
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Akinobu Nakamura
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hideaki Miyoshi
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroshi Nomoto
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiraku Kameda
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kyu Yong Cho
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - So Nagai
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Chikara Shimizu
- Division of Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Masataka Taguri
- Department of Biostatistics, Yokohama City University, Yokohama, Japan
| | - Yasuo Terauchi
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Tatsuya Atsumi
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| |
Collapse
|
18
|
Chinoy A, Murray PG. Diagnosis of growth hormone deficiency in the paediatric and transitional age. Best Pract Res Clin Endocrinol Metab 2016; 30:737-747. [PMID: 27974187 DOI: 10.1016/j.beem.2016.11.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Growth hormone deficiency is a rare cause of childhood short stature, but one for which treatment exists in the form of recombinant human growth hormone. A diagnosis of growth hormone deficiency is made based on auxology, biochemistry and imaging. Although no diagnostic gold standard exists, growth hormone provocation tests are considered the mainstay of diagnostic investigations. However, these must be interpreted with caution in view of issues with variability and reproducibility, as well as the limited evidence-base for cut-off values used to distinguish growth hormone deficient and non-growth hormone deficient subjects. In addition, nutritional and pubertal status can affect results, with no consensus on the role of priming with sex steroid hormones. Difficulties with assays exist both for growth hormone as well as insulin-like growth factor-1. Pituitary magnetic resonance imaging is a useful diagnostic, and possibly prognostic, aid. Although genetic testing is not routine, the discovery of more relevant mutations makes it an increasingly important investigation. Children with growth hormone deficiency are retested biochemically on completion of growth, to assess whether they remain so into adulthood.
Collapse
Affiliation(s)
- A Chinoy
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester, UK
| | - P G Murray
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester, UK; Centre for Paediatrics and Child Health, Institute of Human Development, University of Manchester, Manchester, UK.
| |
Collapse
|
19
|
Park J, Didi M, Blair J. The diagnosis and treatment of adrenal insufficiency during childhood and adolescence. Arch Dis Child 2016; 101:860-5. [PMID: 27083756 DOI: 10.1136/archdischild-2015-308799] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 03/23/2016] [Indexed: 01/10/2023]
Abstract
The diagnosis and treatment of adrenal insufficiency in childhood and adolescence poses a number of challenges. Clinical features of chronic adrenal insufficiency are vague and non-specific, and mimic many other causes of chronic ill health. A range of diagnostic tests are available for the assessment of adrenal function, all of which have advantages and disadvantages. Cortisol responses to these tests may vary with age and between genders. Knowledge of normal cortisol levels during health and ill health in childhood is also limited, and the cortisol replacement therapies available in clinical practice enable only crude mimicry of physiological patterns of cortisol secretion. An awareness of the limitations of diagnostic tests and treatments is important, and critical clinical assessment, integrating clinical and biochemical data, is essential for the diagnosis and treatment of children with suspected adrenal insufficiency. The aim of this review is to draw on data from clinical studies to inform a pragmatic approach to the child presenting with symptoms of chronic adrenal insufficiency. Clinical features of primary and secondary adrenal insufficiency, and syndromes associated with these diagnoses are described. Factors to consider when selecting a diagnostic test of adrenal function and interpretation of test results are considered. Finally, the limitations of cortisol replacement therapy are also discussed.
Collapse
Affiliation(s)
- Julie Park
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Mohammed Didi
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Joanne Blair
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| |
Collapse
|
20
|
Klein-Schwartz W, Stassinos GL, Isbister GK. Treatment of sulfonylurea and insulin overdose. Br J Clin Pharmacol 2016; 81:496-504. [PMID: 26551662 DOI: 10.1111/bcp.12822] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 11/02/2015] [Accepted: 11/03/2015] [Indexed: 11/26/2022] Open
Abstract
The most common toxicity associated with sulfonylureas and insulin is hypoglycaemia. The article reviews existing evidence to better guide hypoglycaemia management. Sulfonylureas and insulin have narrow therapeutic indices. Small doses can cause hypoglycaemia, which may be delayed and persistent. All children and adults with intentional overdoses need to be referred for medical assessment and treatment. Unintentional supratherapeutic ingestions can be initially managed at home but if symptomatic or if there is persistent hypoglycaemia require medical referral. Patients often require intensive care and prolonged observation periods. Blood glucose concentrations should be assessed frequently. Asymptomatic children with unintentional sulfonylurea ingestions should be observed for 12 h, except if this would lead to discharge at night when they should be kept until the morning. Prophylactic intravenous dextrose is not recommended. The goal of therapy is to restore and maintain euglycaemia for the duration of the drug's toxic effect. Enteral feeding is recommended in patients who are alert and able to tolerate oral intake. Once insulin or sulfonylurea-induced hypoglycaemia has developed, it should be initially treated with an intravenous dextrose bolus. Following this the mainstay of therapy for insulin-induced hypoglycaemia is intravenous dextrose infusion to maintain the blood glucose concentration between 5.5 and 11 mmol l(-1) . After sulfonylurea-induced hypoglycaemia is initially corrected with intravenous dextrose, the main treatment is octreotide which is administered to prevent insulin secretion and maintain euglycaemia. The observation period varies depending on drug, product formulation and dose. A general guideline is to observe for 12 h after discontinuation of intravenous dextrose and, if applicable, octreotide.
Collapse
Affiliation(s)
- Wendy Klein-Schwartz
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, USA
| | - Gina L Stassinos
- Maryland Poison Center, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, USA
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| |
Collapse
|
21
|
Murray PG, Dattani MT, Clayton PE. Controversies in the diagnosis and management of growth hormone deficiency in childhood and adolescence. Arch Dis Child 2016; 101:96-100. [PMID: 26153506 DOI: 10.1136/archdischild-2014-307228] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 06/15/2015] [Indexed: 11/04/2022]
Abstract
Growth hormone deficiency (GHD) is a rare but important cause of short stature in childhood with a prevalence of 1 in 4000. The diagnosis is currently based on an assessment of auxology along with supporting evidence from biochemical and neuroradiological studies. There are significant controversies in the diagnosis and management of GHD. Growth hormone (GH) stimulation tests continue to play a key role in GHD diagnosis but the measured GH concentration can vary significantly with stimulation test and GH assay used, creating difficulties for diagnostic accuracy. Such issues along with the use of adjunct biochemical markers such as IGF-I and IGFBP-3 for the diagnosis of GHD, will be discussed in this review. Additionally, the treatment of GHD remains a source of much debate; there is no consensus on the best mechanism for determining the starting dose of GH in patients with GHD. Weight and prediction based models will be discussed along with different mechanisms for dose adjustment during treatment (auxology or IGF-I targeting approaches). At the end of growth and childhood treatment, many subjects diagnosed with isolated GHD re-test normal. It is not clear if this represents a form of transient GHD or a false positive diagnosis during childhood. Given the difficulties inherent in the diagnosis of GHD, an early reassessment of the diagnosis in those who respond poorly to GH is to be recommended.
Collapse
Affiliation(s)
- P G Murray
- Centre for Paediatrics and Child Health, Institute of Human Development, University of Manchester, Manchester, UK Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - M T Dattani
- Section of Genetics and Epigenetics in Health and Disease, Genetics and Genomic Medicine Programme, UCL Institute of Child Health, London, UK London Centre for Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - P E Clayton
- Centre for Paediatrics and Child Health, Institute of Human Development, University of Manchester, Manchester, UK Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
22
|
Cavkaytar O, Vuralli D, Arik Yilmaz E, Buyuktiryaki B, Soyer O, Sahiner UM, Kandemir N, Sekerel BE. Evidence of hypothalamic-pituitary-adrenal axis suppression during moderate-to-high-dose inhaled corticosteroid use. Eur J Pediatr 2015; 174:1421-31. [PMID: 26255048 DOI: 10.1007/s00431-015-2610-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 07/26/2015] [Accepted: 07/29/2015] [Indexed: 11/26/2022]
Abstract
The possible risk of adverse effects due to regular use of inhaled corticosteroids (ICS) is a real concern. Our aim was to describe the factors that have an impact on hypothalamic-pituitary-adrenal axis suppression (HPA-AS) in children and adolescents taking ICS regularly. The HPA axis status of patients who were on moderate-to-high-dose ICS [>176 and >264 μg/day fluticasone propionate-hydrofluoroalkane (FP-HFA) for patients 0-11 and ≥12 years, respectively] was investigated. Various types of ICS were converted to FP-HFA equivalent according to National Asthma Education and Prevention Program (NAEPP) guidelines. Participants with a baseline (8 a.m.) serum cortisol <15 μg/dL underwent a low-dose ACTH stimulation test (LDAT) to diagnose HPA-AS. Among 91 patients, 60 (75.9 %) participants underwent LDAT, and seven (7.7, 95 % CI 3.5-15.3 %) were diagnosed with HPA-AS. Ciclesonide was more frequently used by the participants with HPA-AS compared to patients with a normal HPA axis (42.9 vs. 4.8 %, p = 0.009). Use of ICS at moderate-to-high doses for at least 7 months distinguished participants with HPA-AS from those with a normal HPA axis. Among the duration, type, and dose of ICS, solely the use of ICS with a body mass index (BMI)-adjusted daily dose of ≥22 μg FP was found to increase the risk for HPA-AS (odds ratio (OR) 7.22, 95 % confidence interval (CI) 1.23-42.26, p = 0.028). The receiver operating characteristics (ROC) curve analysis revealed a cutoff value of 291 μg/day FP (area under the curve (AUC) = 0.840, p = 0.003) for predicting HPA-AS Conclusion: The prevalence of HPA-AS was found to be 7.7 % in children taking not only high-dose ICS but also moderate-dose ICS. Dose alone was found to be an actual risk factor for HPA-AS.
Collapse
Affiliation(s)
- Ozlem Cavkaytar
- Department of Pediatric Allergy, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Dogus Vuralli
- Department of Pediatric Endocrinology, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Ebru Arik Yilmaz
- Department of Pediatric Allergy, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Betul Buyuktiryaki
- Department of Pediatric Allergy, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Ozge Soyer
- Department of Pediatric Allergy, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Umit M Sahiner
- Department of Pediatric Allergy, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Nurgun Kandemir
- Department of Pediatric Endocrinology, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Bulent E Sekerel
- Department of Pediatric Allergy, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| |
Collapse
|
23
|
Vajravelu ME, Tobolski J, Burrows E, Chilutti M, Xiao R, Bamba V, Willi S, Palladino A, Burnham JM, McCormack SE. Peak cortisol response to corticotropin-releasing hormone is associated with age and body size in children referred for clinical testing: a retrospective review. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2015; 2015:22. [PMID: 26500680 PMCID: PMC4618529 DOI: 10.1186/s13633-015-0018-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 10/01/2015] [Indexed: 11/11/2022]
Abstract
Background Corticotropin-Releasing Hormone (CRH) testing is used to evaluate suspected adrenocorticotropic hormone (ACTH) deficiency, but the clinical characteristics that affect response in young children are incompletely understood. Our objective was to determine the effect of age and body size on cortisol response to CRH in children at risk for ACTH deficiency referred for clinical testing. Methods Retrospective, observational study of 297 children, ages 30 days – 18 years, undergoing initial, clinically indicated outpatient CRH stimulation testing at a tertiary referral center. All subjects received 1mcg/kg corticorelin per institutional protocol. Serial, timed ACTH and cortisol measurements were obtained. Patient demographic and clinical factors were abstracted from the medical record. Patients without full recorded anthropometric data, pubertal assessment, ACTH measurements, or clear indication for testing were excluded (number remaining = 222). Outcomes of interest were maximum cortisol after stimulation (peak) and cortisol rise from baseline (delta). Bivariable and multivariable linear regression analyses were used to assess the effects of age and size (weight, height, body mass index (BMI), body surface area (BSA), BMI z-score, and height z-score) on cortisol response while accounting for clinical covariates including sex, race/ethnicity, pubertal status, indication for testing, and time of testing. Results Subjects were 27 % female, with mean age of 8.9 years (SD 4.5); 75 % were pre-pubertal. Mean peak cortisol was 609.2 nmol/L (SD 213.0); mean delta cortisol was 404.2 nmol/L (SD 200.2). In separate multivariable models, weight, height, BSA and height z-score each remained independently negatively associated (p < 0.05) with peak and delta cortisol, controlling for indication of testing, baseline cortisol, and peak or delta ACTH, respectively. Age was negatively associated with peak but not delta cortisol in multivariable analysis. Conclusions Despite the use of a weight-based dosing protocol, both peak and delta cortisol response to CRH are negatively associated with several measures of body size in children referred for clinical testing, raising the question of whether alternate CRH dosing strategies or age- or size-based thresholds for adequate cortisol response should be considered in pediatric patients, or, alternatively, whether this finding reflects practice patterns followed when referring children for clinical testing. Electronic supplementary material The online version of this article (doi:10.1186/s13633-015-0018-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Mary Ellen Vajravelu
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Suite 11NW, Philadelphia, USA
| | - Jared Tobolski
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Suite 11NW, Philadelphia, USA
| | - Evanette Burrows
- Center for Biomedical Informatics, The Children's Hospital of Philadelphia, 3535 Market St, Philadelphia, PA 19104 USA
| | - Marianne Chilutti
- Center for Biomedical Informatics, The Children's Hospital of Philadelphia, 3535 Market St, Philadelphia, PA 19104 USA
| | - Rui Xiao
- Department of Biostatistics and Epidemiology, University of Pennsylvania, 635 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021 USA
| | - Vaneeta Bamba
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Suite 11NW, Philadelphia, USA
| | - Steven Willi
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Suite 11NW, Philadelphia, USA
| | - Andrew Palladino
- Global Innovative Pharma, Pfizer, Inc, 500 Arcola Road, Collegeville, PA 19426 USA
| | - Jon M Burnham
- The Children's Hospital of Philadelphia, Division of Rheumatology, 10103 Colket Building, 34th & Civic Center Blvd, Philadelphia, PA 19104 USA
| | - Shana E McCormack
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Suite 11NW, Philadelphia, USA
| |
Collapse
|
24
|
Gordijn MS, Rensen N, Gemke RJBJ, van Dalen EC, Rotteveel J, Kaspers GJL. Hypothalamic-pituitary-adrenal (HPA) axis suppression after treatment with glucocorticoid therapy for childhood acute lymphoblastic leukaemia. Cochrane Database Syst Rev 2015:CD008727. [PMID: 26282194 DOI: 10.1002/14651858.cd008727.pub3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Glucocorticoids play a major role in the treatment of acute lymphoblastic leukaemia (ALL). However, supraphysiological doses can suppress the hypothalamic-pituitary-adrenal (HPA) axis. HPA axis suppression resulting in reduced cortisol response may cause an impaired stress response and an inadequate host defence against infections, which remains a cause of morbidity and death. Suppression commonly occurs in the first days after cessation of glucocorticoid therapy, but the exact duration is unclear. This review is an update of a previously published Cochrane review. OBJECTIVES To examine the occurrence and duration of HPA axis suppression after (each cycle of) glucocorticoid therapy for childhood ALL. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 6, 2014), MEDLINE/PubMed (from 1945 to June 2014), and EMBASE/Ovid (from 1980 to June 2014). In addition, we searched reference lists of relevant articles, conference proceedings (the International Society for Paediatric Oncology and the American Society of Clinical Oncology from 2005 to 2013), and ongoing trial databases (the ISRCTN register and the NIH register via http://www.controlled-trials.com in June 2014). SELECTION CRITERIA All study designs, except case reports and patient series with fewer than 10 children, examining the effect of glucocorticoid therapy for childhood ALL on the HPA axis function. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessment, which another review author checked. MAIN RESULTS We identified eight studies (total of 218 children), including two randomised controlled trials (RCTs), that assessed the adrenal function. None of the studies assessed the HPA axis at the level of the hypothalamus, pituitary, or both. Due to substantial differences between studies, we could not pool results. All of the studies had some methodological limitations. The included studies demonstrated that adrenal insufficiency occurs in nearly all children in the first days after cessation of glucocorticoid treatment for childhood ALL. The majority of children recovered within a few weeks, but a small number of children had ongoing adrenal insufficiency lasting up to 34 weeks. In the RCTs, the occurrence and duration of adrenal insufficiency did not differ between the prednisone and dexamethasone arms. In one study, it appeared that treatment with fluconazole prolonged the duration of adrenal insufficiency. Furthermore, one of the studies evaluated the presence of infections or stress episodes, or both as a risk factor for adrenal insufficiency. The authors found no relationship between the presence of infection/stress and adrenal insufficiency. AUTHORS' CONCLUSIONS We concluded that adrenal insufficiency commonly occurs in the first days after cessation of glucocorticoid therapy for childhood ALL, but the exact duration is unclear. Since no data on the level of the hypothalamus and the pituitary were available, we cannot make any conclusions regarding those outcomes. Clinicians should consider prescribing glucocorticoid replacement therapy during periods of serious stress in the first weeks after cessation of glucocorticoid therapy for childhood ALL to reduce the risk of life-threatening complications. However, more high-quality research is needed for evidence-based guidelines for glucocorticoid replacement therapy.Special attention should be paid to patients receiving fluconazole therapy, and perhaps similar antifungal drugs, as this may prolong the duration of adrenal insufficiency.Finally, it would be relevant to further investigate the relationship between present infection/stress and adrenal insufficiency in a larger, separate study specially designed for this purpose.
Collapse
Affiliation(s)
- Maartje S Gordijn
- Department of Pediatrics, Division of Oncology/Hematology, VU University Medical Center, PO Box 7057, Amsterdam, Netherlands, 1007 MB
| | | | | | | | | | | |
Collapse
|
25
|
Andersen M. The robustness of diagnostic tests for GH deficiency in adults. Growth Horm IGF Res 2015; 25:108-114. [PMID: 25900364 DOI: 10.1016/j.ghir.2015.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 03/01/2015] [Accepted: 03/18/2015] [Indexed: 12/28/2022]
Abstract
Since the 1970s, GH treatment has been an important tool in paediatric endocrinology for the management of growth retardation. It is now accepted that adults with severe GH deficiency (GHD) demonstrate impaired physical and psychological well-being and may benefit from replacement therapy with recombinant human GH. There is, however, an ongoing debate on how to diagnose GHD, especially in adults. A GH response below the cut-off limit of a GH-stimulation test is required in most cases for establishing GHD in adults. No 'gold standard' GH-stimulation test exists, but some GH stimulation tests may be more robust to variations in patient characteristics such as age and gender, as well as to pre-test conditions like heat exposure due to a hot bath or bicycling. However, body mass index (BMI) is negatively associated with GH-responses to all available GH-stimulation tests and glucocorticoid treatment, including conventional substitution therapy, influences the GH-responses. Recently, the role of IGF-I measurements in the clinical decision making has been discussed. The aim of this review is to discuss the available GH-stimulation tests. In this author's opinion, tests which include growth-hormone-releasing hormone (GHRH) tend to be more potent and robust, especially the GHRH+arginine test which has been proven to be of clinical use. In contrast, the insulin tolerance test (ITT) and the glucagon test appear to have too many drawbacks.
Collapse
Affiliation(s)
- Marianne Andersen
- Department of Endocrinology, Odense University Hospital, University of Southern Denmark, Kløvervænget 6, 5000 Odense C, Denmark.
| |
Collapse
|
26
|
Tenenbaum A, Phillip M, de Vries L. The intramuscular glucagon stimulation test does not provide good discrimination between normal and inadequate ACTH reserve when used in the investigation of short healthy children. Horm Res Paediatr 2015; 82:194-200. [PMID: 25139316 DOI: 10.1159/000365190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 06/10/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Few studies have addressed the role of the glucagon stimulation test (GST) in evaluating the hypothalamic-pituitary-adrenal axis in children. We investigated the diagnostic value of the GST in evaluating the adrenocortical response in short healthy children. METHODS The GST was performed in 190 children investigated for short stature. A peak cortisol >500 nmol/l was considered a normal response. In the 45 (23.7%) with subnormal response, a 250-μg ACTH test was done. RESULTS The rate of subnormal adrenal response to GST was higher among boys (33.9 vs. 8.9%, p < 0.001) and among children ≥6 years than among younger children (32.7 vs. 18.4%, p < 0.02). Both mean basal and peak cortisol levels were higher in girls than in boys: 381 ± 165 vs. 319 ± 151 nmol/l (p = 0.003) and 741 ± 102 vs. 595 ± 208 nmol/l (p < 0.001), respectively. Peak cortisol on GST was associated with basal cortisol (r = 0.45, p < 0.001) but not with glucose nadir (r = -0.31, p = 0.67), peak GH (r = 0.069, p = 0.33) or BMI-SDS (r = -0.08, p = 0.28). Peak cortisol was >500 nmol/l in all the patients undergoing an ACTH stimulation test. CONCLUSIONS Since adrenal response to GST is age- and gender-related and the false-positive rate is high, its routine performance in healthy children warrants reconsideration.
Collapse
Affiliation(s)
- Ariel Tenenbaum
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | | | | |
Collapse
|
27
|
Marakaki C, Papadimitriou DT, Papadopoulou A, Fretzayas A, Papadimitriou A. L-dopa is a potent stimulator of cortisol in short children. Horm Res Paediatr 2015; 81:386-90. [PMID: 24802138 DOI: 10.1159/000357268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 11/11/2013] [Indexed: 11/19/2022] Open
Abstract
AIMS In this study, we evaluated the diagnostic usefulness of oral L-dopa as a stimulatory agent for cortisol. METHODS In 27 short children that were evaluated for possible growth hormone deficiency (GHD), the levels of serum GH and cortisol were determined after oral L-dopa administration and after i.m. glucagon administration. We defined cortisol concentrations >18 μg/dl (496 nmol/l) as adequate response. Peak GH concentration <10 ng/ml in both tests defined GHD. RESULTS Twenty-five out of the 27 children (93%) studied showed a normal cortisol response, i.e. a peak serum cortisol >18 μg/dl in the L-dopa test, whereas 19 children (70%) had a normal cortisol response after stimulation with glucagon. In the children with normal cortisol response in both tests, the mean peak serum cortisol concentration was 28.7 (SD 1.59) after L-dopa and 26.65 (SD 1.26) μg/dl after glucagon administration. There was no statistically significant difference in peak serum cortisol response to L-dopa between GH-deficient and GH-sufficient children [25.90 (SD 4.9) vs. 29.87 (SD 9.9) μg/dl, respectively]. CONCLUSIONS These results clearly suggest that L-dopa administration is a potent stimulus for cortisol secretion at least in short children.
Collapse
Affiliation(s)
- C Marakaki
- Third Department of Pediatrics, Attikon University Hospital, Athens, Greece
| | | | | | | | | |
Collapse
|
28
|
|
29
|
Klein RH, Alvarez-Jimenez R, Sukhai RN, Oostdijk W, Bakker B, Reeser HM, Ballieux BEPB, Hu P, Klaassen ES, Freijer J, Burggraaf J, Cohen AF, Wit JM. Pharmacokinetics and pharmacodynamics of orally administered clonidine: a model-based approach. Horm Res Paediatr 2014; 79:300-9. [PMID: 23735833 DOI: 10.1159/000350819] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 03/13/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The oral clonidine test is a diagnostic procedure performed in children with suspected growth hormone (GH) deficiency. It is associated with untoward effects, including bradycardia, hypotension and sedation. Serum clonidine levels have not previously been assessed during this test. METHODS In 40 children referred for an oral clonidine test, blood samples were drawn for clonidine and GH. Vital statistics and sedation scores were recorded until 210 min post-dose. We explored the relationship between clonidine concentrations and effects such as GH peak and blood pressure. RESULTS Of 40 participants, 5 children were GH deficient. Peak clonidine concentrations of 0.846 ± 0.288 ng/ml were reached after 1 h. Serum levels declined slowly, with concentrations of 0.701 ± 0.189 ng/ml 210 min post-dose. A large interindividual variation of serum levels was observed. During the procedure, systolic blood pressure dropped by 12.8%, diastolic blood pressure by 19.7% and heart rate by 8.4%. Moderate sedation levels were observed. Concentration-effect modeling showed that the amount of GH available for secretion as determined by previous bursts was an important factor influencing GH response. CONCLUSION Clonidine concentrations during the test were higher than necessary according to model-based predictions. A lower clonidine dose may be sufficient and may produce fewer side effects.
Collapse
Affiliation(s)
- R H Klein
- Centre for Human Drug Research, Leiden University Medical Center, NL-2300 RC Leiden, The Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Soliman AT, Yassin M, Majuid NMSA, Sabt A, Abdulrahman MO, De Sanctis V. Cortisol response to low dose versus standard dose (back-to-back) adrenocorticotrophic stimulation tests in children and young adults with thalassemia major. Indian J Endocrinol Metab 2013; 17:1046-1052. [PMID: 24381882 PMCID: PMC3872683 DOI: 10.4103/2230-8210.122620] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Thalassemia major patients with repeated blood transfusion have high prevalence of endocrinopathies due to iron overload. MATERIALS AND METHODS We examined the adrenocortical function in 23 thalassemic patients (10 children and 13 young adults) aged 8-26 years. Serum cortisol and dehydroepiandrosterone sulfate (DHEA-S) concentrations were determined in each subject before blood transfusion both in basal condition and after low dose (LD) (1 μg), followed by standard dose (SD) (250 μg, respectively) with synthetic corticotrophin beta 1-24 ACTH (Synacthen, Ciba). Normal controls were a group of 13 age- and sex-matched normal subjects. RESULTS Using a peak total cortisol cutoff level of 550 nmol/L and increments of 200 μg above basal cortisol, adrenal insufficiency (AI) was demonstrated in 8 patients (34.7%) after the LD ACTH and in 2 patients (8.7%) after SD cosyntropin (ACTH) test, but none of the controls. Using a peak total cortisol cutoff level of 420 nmol/L and increments of 200 μg above basal cortisol, AI was demonstrated in 5 patients (21.7%) after the LD ACTH and in 2 patients after SD ACTH test (8.7%), but none of controls. All patients with biochemical AI were asymptomatic with normal serum sodium and potassium concentrations and had no history suggestive of adrenal pathology. The peak cortisol concentrations in thalassemic patients with impaired adrenal function both after 1 μg and 250 μg cosyntropin (294 ± 51 nmol/L and 307 ± 58.6) were significantly lower than those with patients with normal (454 ± 79.7 nmol/L and 546.1 ± 92.2 nmol/L, respectively) and controls (460.2 ± 133.4 nmol/L and 554.3 ± 165.8 nmol/L, respectively). Adolescents and young adults, but not children with thalassaemia, had significantly lower peak cortisol concentration after SD ACTH versus controls. Peak cortisol response to LD ACTH was correlated significantly with peak cortisol response to SD in all patients (r = 0.83, P < 0.0001). In adolescents and young adults with thalassemia, DHEA-S levels before and after LD ACTH stimulation were significantly lower and the cortisol/DHEA-S ratios were significantly higher than the controls. CONCLUSION The use of LD ACTH test diagnoses more adrenal abnormalities versus SD ACTH in thalassemic patients. The relatively high prevalence of AI in thalassemic adolescents and young adults necessitates that these patients have to be investigated for AI before major surgery and those with impaired cortisol secretion should receive stress doses of corticosteroids during the stressful event.
Collapse
Affiliation(s)
| | - Mohamed Yassin
- Department of Hematology, Hamad Medical Center, Doha, Qatar
| | | | - Aml Sabt
- Department of Pediatrics, Hamad Medical Center, Doha, Qatar
| | | | | |
Collapse
|
31
|
Abstract
The availability of synthetic recombinant human growth hormone (GH) in potentially unlimited quantities since the 1980s has improved understanding of the many nonstatural effects of GH on metabolism, body composition, physical and psychological function, as well as the consequences of GH deficiency in adult life. Adult GH deficiency is now recognized as a distinct if nonspecific syndrome with considerable adverse health consequences. GH replacement therapy in lower doses than those used in children can reverse many of these abnormalities and restore functional capacities toward or even to normal; if dosed appropriately, GH therapy has few adverse effects. Although some doubts remain about possible long-term risks of childhood GH therapy, most registries of adult GH replacement therapy, albeit limited in study size and duration, have not shown an increased incidence of cancers or of cardiovascular morbidity or mortality.
Collapse
Affiliation(s)
- Atil Y Kargi
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami Miller School of Medicine, 1400 North West 10th Avenue, Suite 807, Miami, FL 33136, USA
| | | |
Collapse
|
32
|
El-Farhan N, Pickett A, Ducroq D, Bailey C, Mitchem K, Morgan N, Armston A, Jones L, Evans C, Rees DA. Method-specific serum cortisol responses to the adrenocorticotrophin test: comparison of gas chromatography-mass spectrometry and five automated immunoassays. Clin Endocrinol (Oxf) 2013; 78:673-80. [PMID: 22994849 DOI: 10.1111/cen.12039] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 08/02/2012] [Accepted: 09/05/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The serum cortisol response to the adrenocorticotrophin (ACTH) test is known to vary significantly by assay, but lower reference limits (LRL) for this response have not been established by the reference gas chromatography-mass spectrometry (GC-MS) method or modern immunoassays. We aimed to compare the normal cortisol response to ACTH stimulation using GC-MS with five widely used immunoassays. DESIGN, PATIENTS AND MEASUREMENTS An ACTH test (250 μg iv ACTH1-24 ) was undertaken in 165 healthy volunteers (age, 20-66 years; 105 women, 24 of whom were taking an oestrogen-containing oral contraceptive pill [OCP]). Serum cortisol was measured using GC-MS, Advia Centaur (Siemens), Architect (Abbott), Modular Analytics E170 (Roche), Immulite 2000 (Siemens) and Access (Beckman) automated immunoassays. The estimated LRL for the 30 min cortisol response to ACTH was derived from the 2·5th percentile of log-transformed concentrations. RESULTS The GC-MS-measured cortisol response was normally distributed in males but not females, with no significant gender difference in baseline or post-ACTH cortisol concentration. Immunoassays were positively biased relative to GC-MS, except in samples from women on the OCP, who showed a consistent negative bias. The LRL for cortisol was method-specific [GC-MS: 420 nm; Architect: 430 nm; Centaur: 446 nm; Access 459 nm; Immulite (2000) 474 nm] and, for the E170, also gender-specific (female: 524 nm; male 574 nm). A separate LRL is necessary for women on the OCP. CONCLUSIONS Normal cortisol responses to the ACTH test are influenced significantly by assay and oestrogen treatment. We recommend the use of separate reference limits in premenopausal women on the OCP and warn users that cortisol measurements in this subgroup are subject to assay interference.
Collapse
Affiliation(s)
- Nadia El-Farhan
- Department of Medical Biochemistry and Immunology, University Hospital of Wales, Cardiff, UK
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
O'Grady MJ, Hensey C, Fallon M, Hoey H, Murphy N, Costigan C, Cody D. Lack of sensitivity of the 1-μg low-dose ACTH stimulation test in a paediatric population with suboptimal cortisol responses to insulin-induced hypoglycaemia. Clin Endocrinol (Oxf) 2013; 78:73-8. [PMID: 22712566 DOI: 10.1111/j.1365-2265.2012.04474.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 05/09/2012] [Accepted: 06/12/2012] [Indexed: 01/05/2023]
Abstract
CONTEXT The insulin-tolerance test (ITT) is the gold standard for evaluation of the hypothalamic-pituitary-adrenal (HPA) axis. The low-dose ACTH stimulation test is increasingly used for evaluation of secondary adrenal insufficiency as several studies performed in adults have demonstrated high sensitivity and specificity when compared to the ITT. Whether the ACTH stimulation test demonstrates similar sensitivity in a paediatric and adolescent population compared with the gold standard is unclear. OBJECTIVE To compare the sensitivity of the low-dose (1-μg) Synacthen(™) test (LDSST) and the gold-standard ITT in a paediatric and adolescent population. DESIGN AND PATIENTS A retrospective review of 42 consecutive LDSSTs in children and adolescents with suboptimal cortisol responses (peak <500 nm) on ITT. RESULTS Thirty-one patients (74%) had an adequate cortisol response to low-dose Synacthen(™) (sensitivity 26%). Patients had a higher cortisol increment with the LDSST than ITT (median Δ cortisol 294 vs 168 nm, P < 0.0001) and correspondingly a higher cortisol peak (median peak cortisol 572 vs 396 nm, P < 0.0001). Patients who had a suboptimal peak cortisol both on ITT and on LDSST had a lower baseline cortisol on ITT (median 178 vs 227 nm, P = 0.04). Peak cortisol on ITT was significantly higher in patients who had a subsequent normal LDSST than those that did not (median 417 vs 300 nm, P = 0.0005). CONCLUSIONS The 1-μg LDSST lacks sensitivity in detection of secondary adrenal insufficiency in children when compared to the gold-standard ITT.
Collapse
Affiliation(s)
- Michael J O'Grady
- Department of Endocrinology and Diabetes, Our Ladys' Childrens Hospital, Crumlin, Dublin, Ireland.
| | | | | | | | | | | | | |
Collapse
|
34
|
Su PH, Yang SF, Yu JS, Chen SJ, Chen JY. A polymorphism in the leptin receptor gene at position 223 is associated with growth hormone replacement therapy responsiveness in idiopathic short stature and growth hormone deficiency patients. Eur J Med Genet 2012; 55:682-7. [DOI: 10.1016/j.ejmg.2012.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 09/12/2012] [Indexed: 11/29/2022]
|
35
|
Kargi AY, Merriam GR. Testing for growth hormone deficiency in adults: doing without growth hormone-releasing hormone. Curr Opin Endocrinol Diabetes Obes 2012; 19:300-5. [PMID: 22596248 DOI: 10.1097/med.0b013e32835430da] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article summarizes recent advances in testing for growth hormone deficiency (GHD) in adults, focusing on critical appraisal of existing growth hormone (GH) provocative tests as well as newer tests in development. RECENT FINDINGS The diagnosis of GHD can be challenging and often requires the use of GH provocative testing. The most widely validated of these is insulin-induced hypoglycemia (ITT), which requires close supervision and has significant contraindications and side-effects. The arginine-growth hormone-releasing hormone (GHRH) test had become widely used as a safe and accurate alternative to the ITT, but GHRH is currently unavailable for clinical use in the USA. On the basis of review of recent literature we recommend that in the absence of GHRH, glucagon stimulation testing should be the preferred alternative to ITT. Several synthetic GH secretagogues that mimic the gastric peptide ghrelin are currently in development and may become available for use in the diagnosis of GHD in the near future. Other GH provocative tests suitable for use in children lack adequate specificity for the diagnosis of GHD in adults. SUMMARY Due to the current unavailability of the arginine-GHRH test in the USA, when ITT is contraindicated or impractical we recommend the glucagon stimulation testing as the GH provocative test of choice. There remains a need for a simple, safe and accurate test for the diagnosis of GHD.
Collapse
Affiliation(s)
- Atil Y Kargi
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | |
Collapse
|
36
|
Ajala O, Lockett H, Twine G, Flanagan DE. Depth and duration of hypoglycaemia achieved during the insulin tolerance test. Eur J Endocrinol 2012; 167:59-65. [PMID: 22529198 DOI: 10.1530/eje-12-0068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CONTEXT The insulin tolerance test (ITT) is the gold standard for assessment of the pituitary adrenal axis but its use is limited because of concerns relating to the risk of hypoglycaemia. OBJECTIVE This study examined the depth and duration of hypoglycaemia achieved during the test in a large cohort of patients. DESIGN Two hundred and twenty ITTs were performed from 2005 to 2010. SETTING A 1200-bed University Teaching Hospital. PATIENTS Two hundred and twenty ITTs were carried out in patients with suspected or known pituitary disorders. INTERVENTIONS Intravenous insulin was administered to achieve nadir plasma glucose (NPG) of 2.2 mmol/l (39.6 mg/dl). Blood chemistry to show the cortisol and GH response to hypoglycaemic stress was measured. MAIN OUTCOME MEASURES Predictors of depth and duration of hypoglycaemia, adverse events and within-subject variability of nadir glucose, peak cortisol and peak GH were studied. RESULTS Thirty percent of the cohort achieved a nadir glucose of <2.0 mmol/l (36 mg/dl) that lasted for 60 min or more. The NPG correlated positively with fasting plasma glucose (FPG; r=0:56; P<0.0005), insulin dose (r=0.27; P<0.0005) and weight (r=0.21; P<0.004). The within subject variability of nadir glucose was 15.2%, peak cortisol was 11.7% and peak GH was 6.4%. The factors determining nadir blood glucose were FPG (b=0.56, P<0.0005, 20% contribution) and weight (b=0.14, P<0.05, 2% contribution). The five patients with adverse events had NPG and insulin dose comparable with the rest of the population. CONCLUSIONS The hypoglycaemia achieved during the ITT is much lower than the target required. However, adverse events are few and do not relate to the depth of hypoglycaemia.
Collapse
Affiliation(s)
- O Ajala
- Department of Endocrinology, Derriford Hospital, Level 9, Plymouth PL6 8DH, UK.
| | | | | | | |
Collapse
|
37
|
Gordijn MS, Gemke RJ, van Dalen EC, Rotteveel J, Kaspers GJ. Hypothalamic-pituitary-adrenal (HPA) axis suppression after treatment with glucocorticoid therapy for childhood acute lymphoblastic leukaemia. Cochrane Database Syst Rev 2012:CD008727. [PMID: 22592733 DOI: 10.1002/14651858.cd008727.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Glucocorticoids play a major role in the treatment of acute lymphoblastic leukaemia (ALL). However, supraphysiological doses may cause suppression of the hypothalamic-pituitary-adrenal (HPA) axis. HPA axis suppression resulting in reduced cortisol response may cause an impaired stress response and an inadequate host defence against infections, which remains a cause of morbidity and death. The exact occurrence and duration of HPA axis suppression after glucocorticoid therapy for childhood ALL are unclear. OBJECTIVES To examine the occurrence and duration of HPA axis suppression after (each cycle of) glucocorticoid therapy for childhood ALL. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (in The Cochrane Library, issue 3, 2010), MEDLINE/PubMed (from 1945 to July 2010) and EMBASE/Ovid (from 1980 to July 2010). In addition, we searched reference lists of relevant articles, conference proceedings and ongoing trial databases. SELECTION CRITERIA All study designs, except case reports and patient series with fewer than 10 patients, examining the effect of glucocorticoid therapy for childhood ALL on the HPA axis function. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessment, which was checked by another review author. MAIN RESULTS We identified seven studies (total number of participants = 189), including one randomised controlled trial (RCT), which assessed the adrenal function. None of the studies assessed the HPA axis at the level of the hypothalamus, pituitary, or both. Due to substantial differences between studies, results could not be pooled. All studies had some methodological limitations. The included studies demonstrated that adrenal insufficiency occurs in nearly all patients in the first days after cessation of glucocorticoid treatment for childhood ALL. The majority of patients recovered within a few weeks, but a small amount of patients had ongoing adrenal insufficiency lasting up to 34 weeks. In the RCT, the occurrence and duration of adrenal insufficiency did not differ between the prednisolone and dexamethasone arms. In one study included in the review it appeared that treatment with fluconazole prolonged the duration of adrenal insufficiency. AUTHORS' CONCLUSIONS Based on the available evidence, we conclude that adrenal insufficiency commonly occurs in the first days after cessation of glucocorticoid therapy for childhood ALL, but the exact duration is unclear. Since no data on the level of the hypothalamus and the pituitary were available we cannot make any conclusions regarding those outcomes. Clinicians should consider prescribing glucocorticoid replacement therapy during periods of serious stress in the first weeks after cessation of glucocorticoid therapy for childhood ALL, to reduce the risk of life-threatening complications. However, more high-quality research is needed for evidence-based guidelines for glucocorticoid replacement therapy.Special attention should be paid to patients receiving fluconazole therapy, and perhaps similar antifungal drugs, as this may prolong the duration of adrenal insufficiency.
Collapse
Affiliation(s)
- Maartje S Gordijn
- Department of Pediatrics, Division of Oncology/Hematology, VU University Medical Center, Amsterdam,
| | | | | | | | | |
Collapse
|
38
|
Smith RW, Downey K, Gordon M, Hudak A, Meeder R, Barker S, Smith WG. Prevalence of hypothalamic-pituitary-adrenal axis suppression in children treated for asthma with inhaled corticosteroid. Paediatr Child Health 2012; 17:e34-9. [PMID: 23633903 PMCID: PMC3381924 DOI: 10.1093/pch/17.5.e34] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2012] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To determine the prevalence of hypothalamic-pituitary-adrenal (HPA) axis suppression in asthmatic children on inhaled corticosteroids (ICS). METHODS Clinical and demographic variables were recorded on preconstructed, standardized forms. HPA axis suppression was measured by morning serum cortisol levels and confirmed by low-dose adrenocorticotropic hormone stimulation testing. RESULTS In total, 214 children participated. Twenty children (9.3%, 95% CI 5.3% to 13.4%) had HPA axis suppression. Odds of HPA axis suppression increased with ICS dose (OR 1.005, 95% CI 1.003 to 1.009, P<0.001). All children with HPA axis suppression were on a medium or lower dose of ICS for their age (200 μg/day to 500 μg/day). HPA axis suppression was not predicted by drug type, dose duration, concomitant use of long-acting beta-agonist or nasal steroid, or clinical features. CONCLUSION Laboratory evidence of HPA axis suppression exists in children taking ICS for asthma. Children should be regularly screened for the presence of HPA axis suppression when treated with high-dose ICS (>500 μg/day). Consideration should be given to screening children on medium-dose ICS.
Collapse
Affiliation(s)
- Ryan W Smith
- Department of Medicine and Health, University College Cork, Cork, Ireland
| | - Kim Downey
- Regional Paediatric Asthma Center, Orillia Soldiers’ Memorial Hospital, Orillia
| | - Michelle Gordon
- Regional Paediatric Asthma Center, Orillia Soldiers’ Memorial Hospital, Orillia
- Department of Paediatrics, University of Toronto, Toronto
- Department of Paediatrics, Northern Ontario School of Medicine, Sudbury
| | - Alan Hudak
- Regional Paediatric Asthma Center, Orillia Soldiers’ Memorial Hospital, Orillia
- Department of Paediatrics, Northern Ontario School of Medicine, Sudbury
| | - Rob Meeder
- Regional Paediatric Asthma Center, Orillia Soldiers’ Memorial Hospital, Orillia
- Department of Paediatrics, Schulich School of Medicine, University of Western Ontario, London, Ontario
| | - Sarah Barker
- Regional Paediatric Asthma Center, Orillia Soldiers’ Memorial Hospital, Orillia
| | - W Gary Smith
- Regional Paediatric Asthma Center, Orillia Soldiers’ Memorial Hospital, Orillia
- Department of Paediatrics, University of Toronto, Toronto
- Department of Paediatrics, Northern Ontario School of Medicine, Sudbury
- Department of Paediatrics, Schulich School of Medicine, University of Western Ontario, London, Ontario
| |
Collapse
|
39
|
Lim SH, Vasanwala R, Lek N, Yap F. Quantifying the risk of hypoglycaemia in children undergoing the glucagon stimulation test. Clin Endocrinol (Oxf) 2011; 75:489-94. [PMID: 21609349 DOI: 10.1111/j.1365-2265.2011.04117.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The low-dose (15-30 μg/kg) glucagon stimulation test (GST) is assumed to be associated with fewer episodes of low blood glucose (BG). We aimed to quantify the risk of hypoglycaemia in children undergoing the low-dose GST to evaluate their growth hormone status. DESIGN AND PATIENTS Blood glucose fluctuations during the GST in 80 children (median age 8·7 years, 45 boys, 66 prepubertal) who received a median 20·5 μg/kg of intramuscular glucagon were reviewed. MEASUREMENTS The rate of (i) hypoglycaemia (BG < 3·3 mm), (ii) falling BG trend at the end of the GST (lower BG at 180 min than at 120 min), (iii) hypoglycaemia and falling BG trend at the end of the GST, and (iv) at-risk patients (those with at least one of the three risks measures). RESULTS Twenty-seven of the 80 children had hypoglycaemia during the GST. Twenty-six children showed a falling BG trend at the end of the GST and were significantly younger than the other 54 children with a rising BG trend [5·1 (3·1-10·4) years vs 9·6 (5·4-11·8) years, P = 0·02]. Eight children had both a falling BG trend and hypoglycaemia at end of the test. Forty-four children were at-risk patients, and the odds ratio of being an at-risk patient in those <8 years old was 2·63 (95% CI 1·06-6·57, P = 0·04). CONCLUSIONS Hypoglycaemia is not uncommon during the low-dose GST. Young children, especially those <8 years old, are particularly at risk. BG monitoring should be considered essential from a safety perspective.
Collapse
Affiliation(s)
- Song Hai Lim
- Endocrinology Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | | | | | | |
Collapse
|
40
|
Abstract
Growth hormone is a widely used hormone. This article describes its historical use, current indications and studies for possible future uses.
Collapse
|
41
|
Vestergaard TR, Juul A, Lausten-Thomsen U, Lausen B, Hjalgrim H, Kvist TK, Andersen EW, Schmiegelow K. Duration of adrenal insufficiency during treatment for childhood acute lymphoblastic leukemia. J Pediatr Hematol Oncol 2011; 33:442-9. [PMID: 21792040 DOI: 10.1097/mph.0b013e3182260cbe] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Children with acute lymphoblastic leukemia (ALL) recive high doses of glucocorticosteroid as part of their treatment. This may lead to suppression of the hypothalamic-pituitary-adrenal axis, acute adrenal insufficiency, and ultimately to life-threatening conditions. This study explores the adrenal function in 96 children with ALL treated according to common protocols. After cessation of induction glucocorticosteroid therapy, they received hydrocortisone substitution therapy (10 mg/m/24 h) until an adrenocorticotropic hormone test (250 μg tetracosatide) showed a sufficient adrenal response [plasma (p)-cortisol ≥500 nM]. At the first adrenocorticotropic hormone test, 67% of the patients had adrenal insufficiency. When including these patients in a multivariate model, not adjusting for risk factors, the mean elapsed time between end of induction therapy and adrenal sufficiency was 8.5 months (95% confidence interval: 6.3;10.7). Low 0-minute p-cortisol (P=0.02) and low rise in p-cortisol (P<0.0001) at first test caused a longer time of adrenal insufficiency. In addition, patients with B-cell precursor leukemia reached adrenal sufficiency later than those with T-cell leukemia (P=0.067). As adrenal insufficiency is frequent in children treated for ALL and as they often experience infections and other stressors, the adrenal response should be determined and hydrocortisone substitution therapy should be considered during such episodes in patients with adrenal insufficiency.
Collapse
|
42
|
Kayemba-Kay's S, Epstein S, Hindmarsh P, Burguet A, Ingrand P, Hankard R. Does plasma IGF-BP3 measurement contribute to the diagnosis of growth hormone deficiency in children? ANNALES D'ENDOCRINOLOGIE 2011; 72:218-23. [PMID: 21641574 DOI: 10.1016/j.ando.2011.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 09/01/2010] [Accepted: 01/06/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To audit the contribution of plasma IGF-PB3 measurement to the diagnosis of growth hormone deficiency (GHD) in children. POPULATION AND METHODS Retrospective case study including boys and girls aged 0 to 18 years who attended our paediatric endocrinology clinic for short stature and/or post-irradiation follow-up, and had at least one GH provocative testing. Children with hypothyroidism, Laron or Kowarski syndromes, severe malnutrition, chronic renal failure and liver failure were excluded. RESULTS Fifty-eight children were enrolled and grouped as GHD [+] (19 cases) and GDH [-] (39 cases). IGF-I and IGF-BP3 assay was carried out in 88% and 62% cases respectively, both groups were comparable for age, sex, BMI, target height, pubertal stage and bone age. There was a significant difference in peak GH between GDH [-] and GHD [+] groups (41.8 mUI/L ± 21.7 versus 11.5 ± 5.9 mUI/L, P<0.00001, respectively). No difference was found between groups with regards to IGF-I Z-scores and IGF-BP3 Z-scores. There was, however, a positive correlation between IGF-I Z-scores and IGF-BP3 Z-scores (r=0.50; P<0.0016). IGF-BP3 measurement could not differentiate between GHD [+] and GHD [-] groups. CONCLUSIONS Measurement of plasma IGF-BP3 level contributes poorly to the diagnosis of GHD. We do not recommend it in routine use.
Collapse
Affiliation(s)
- S Kayemba-Kay's
- Paediatric Endocrinology Unit, Department of Pediatrics, Poitiers University Teaching Hospital, France.
| | | | | | | | | | | |
Collapse
|
43
|
Kamrath C, Boehles H. The low-dose ACTH test does not identify mild insufficiency of the hypothalamnic-pituitary-adrenal axis in children with inadequate stress response. J Pediatr Endocrinol Metab 2010; 23:1097-104. [PMID: 21284322 DOI: 10.1515/jpem.2010.174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate retrospectively the sensitivity of published cortisol cut-off points of the low-dose ACTH test (LDAT) in children with proven mild hypothalamic-pituitary-adrenal (HPA) axis insufficiency. PATIENTS AND METHODS The HPA axis of 11 pediatric patients (age range: 5.5-14.5 yr) with established mild HPA axis insufficiency was reinvestigated with the LDAT. The sensitivity of the LDAT was calculated on the basis of published stimulated cortisol cut-off points. RESULTS The LDAT showed both a significantly higher cortisol peak and a greater cortisol rise compared with the ITT (both P < 0.01). The LDAT yielded a low sensitivity of 9-55% using published cortisol cut-off points as references. CONCLUSION Using published cortisol cut-off points, the LDAT showed a poor sensitivity to detect mild HPA axis insufficiency. We cannot recommend the use of the LDAT as a screening test of HPA axis impairment in such children.
Collapse
Affiliation(s)
- Clemens Kamrath
- Department of Pediatrics, Division of Pediatric Endocrinology, Johann Wolfgang Goethe-University, Frankfurt, Germany.
| | | |
Collapse
|
44
|
Reh CS, Geffner ME. Somatotropin in the treatment of growth hormone deficiency and Turner syndrome in pediatric patients: a review. Clin Pharmacol 2010; 2:111-22. [PMID: 22291494 PMCID: PMC3262362 DOI: 10.2147/cpaa.s6525] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Growth hormone (GH), also known as somatotropin, is a peptide hormone that is synthesized and secreted by the somatotrophs of the anterior pituitary gland. The main action of GH is to stimulate linear growth in children; however, it also fosters a healthy body composition by increasing muscle and reducing fat mass, maintains normal blood glucose levels, and promotes a favorable lipid profile. This article provides an overview of the normal pathophysiology of GH production and action. We discuss the history of GH therapy and the development of the current formulation of recombinant human GH given as daily subcutaneous injections. This paper reviews two of the longest standing FDA-approved indications for GH treatment, GH deficiency and Turner syndrome. We will highlight the pathogenesis of these disorders, including presentations, presumed mechanism(s) for the associated short stature, and diagnostic criteria, with a review of stimulation test benefits and pitfalls. This review also includes current recommendations for GH therapy to help maximize final height in these children, as well as data demonstrating the efficacy and safety of GH treatment in these populations.
Collapse
Affiliation(s)
- Christina Southern Reh
- Childrens Hospital Los Angeles, Keck School of Medicine of USC, Division of Endocrinology, Diabetes, and Metabolism, Los Angeles, CA, USA.
| | | |
Collapse
|
45
|
Tseng LL, Lue HC, Huang CH, Niu DM. Severe hyponatremia due to ACTH insufficiency in a 14 year-old girl with growth hormone deficiency. J Pediatr Endocrinol Metab 2010; 23:197-201. [PMID: 20432824 DOI: 10.1515/jpem.2010.23.1-2.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
SIADH-like hyponatremia as the presenting manifestation of ACTH deficiency is rare in childhood. Here we report a 14 year-old girl who, after 8 years of GH replacement and subsequent treatment for subclinical secondary hypothyroidism, presented with confusion and disorientation due to severe hyponatremia. When her pituitary axis was re-assessed, she was diagnosed as having ACTH deficiency associated with multiple pituitary hormone deficiencies (MPHD) (including GH, FSH, LH, and subclinical TSH deficiencies). She responded poorly to treatment with only hypertonic fluid, but improved after addition of hydrocortisone replacement. The purpose of this paper is to emphasize the importance of suspecting ACTH insufficiency in children with GH deficiency if hyponatremia develops.
Collapse
Affiliation(s)
- Lo-Lin Tseng
- Department of Pediatrics, Lo-Tung St. Mary's Hospital, Taipei, Taiwan
| | | | | | | |
Collapse
|
46
|
Patterson BC, Truxillo L, Wasilewski-Masker K, Mertens AC, Meacham LR. Adrenal function testing in pediatric cancer survivors. Pediatr Blood Cancer 2009; 53:1302-7. [PMID: 19637328 DOI: 10.1002/pbc.22208] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Central adrenal insufficiency is observed after cranial radiation therapy for cancer. Screening at risk patients is recommended, but the best screening strategy is unknown. METHODS A retrospective review of pediatric cancer survivors who underwent hypothalamic/pituitary/adrenal axis testing was conducted. Data included: cancer diagnosis, radiotherapy dose, other endocrinopathies, and adrenal function testing. Adrenal testing included sequential low-dose corticotropin test (LDCT) and standard-dose corticotropin test (SDCT). 8 a.m. serum cortisol levels were compared to LDCT results. LDCT results were compared by radiotheroapy dose and according to the presence of endocrine comorbidities. RESULTS Seventy-eight subjects (56% male, mean age at diagnosis 6.5 years) underwent testing. 67.9% had been treated with radiotherapy to the hypothalamus/pituitary. Mean time to diagnosis of adrenal insufficiency was 6.8 years after cancer diagnosis. Adequate adrenal function was found in 65% of patients by LDCT and 89% by SDCT. Only 21% of patients had basal serum cortisols collected at 8 a.m. Agreement between 8 a.m. baseline cortisol and LDCT was fair. Agreement between random baseline cortisol and LDCT was poor. Prevalence of central adrenal insufficiency diagnosed by LDCT increased with radiotherapy dose (8% for 10-19.9 Gy; 83% for >or=40 Gy) and the number of endocrine comorbidities. CONCLUSIONS In pediatric cancer survivors, central adrenal insufficiency was common even in patients receiving <40 Gy to the hypothalamus/pituitary. We recommend use of LDCT, not 8 a.m. serum cortisol to screen patients who received >30 Gy of radiotherapy and those with other central endocrinopathies.
Collapse
Affiliation(s)
- Briana C Patterson
- Division of Endocrinology, Department of Pediatrics, Emory University, Atlanta, Georgia, USA.
| | | | | | | | | |
Collapse
|
47
|
Gupta A, Cheetham T, Jaffray C, Ullman D, Gibb I, Spencer DA. Repeatability of the low-dose ACTH test in asthmatic children on inhaled corticosteroids. Acta Paediatr 2009; 98:1945-9. [PMID: 19694623 DOI: 10.1111/j.1651-2227.2009.01479.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To assess the repeatability of low-dose Synacthen test (LDST) in asthmatic children receiving high-dose fluticasone propionate (FP). METHODS Low-dose Synacthen test was performed on 18 children with stable chronic asthma treated with FP at a constant daily dose of > or =500 microg and repeated 1 month later. Repeatability was assessed using the Kappa statistic for categorical variables. RESULTS Fifteen patients had consistent results (either two normal or two abnormal responses) and three patients had inconsistent results (one normal and one abnormal response). The Kappa statistic was 0.56 indicating fair to good agreement between the tests. CONCLUSION The results of adrenal function testing in patients on inhaled steroids can have major implications for patient management, making it important to use a test with excellent repeatability. The LDST conducted using our protocol does not fulfil this criterion.
Collapse
Affiliation(s)
- Atul Gupta
- Department of Respiratory Paediatrics, Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | | | | | | | | | | |
Collapse
|
48
|
Binder G, Brämswig J, Kratzsch J, Pfäffle R, Woelfle J. Leitlinie zur Diagnostik des Wachstumshormonmangels im Kindes- und Jugendalter. Monatsschr Kinderheilkd 2009. [DOI: 10.1007/s00112-009-2049-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
49
|
Franklin SL, Geffner ME. Growth hormone: the expansion of available products and indications. Endocrinol Metab Clin North Am 2009; 38:587-611. [PMID: 19717006 DOI: 10.1016/j.ecl.2009.06.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Growth hormone is a widely used hormone. This article describes its historical use, current indications and studies for possible future uses.
Collapse
Affiliation(s)
- Sherry L Franklin
- University of California San Diego School of Medicine, Rady Childrens Hospital of San Diego, 7910 Frost Street, Suite 435, San Diego, CA 92123, USA.
| | | |
Collapse
|
50
|
Yuen KCJ, Biller BMK, Molitch ME, Cook DM. Clinical review: Is lack of recombinant growth hormone (GH)-releasing hormone in the United States a setback or time to consider glucagon testing for adult GH deficiency? J Clin Endocrinol Metab 2009; 94:2702-7. [PMID: 19509104 DOI: 10.1210/jc.2009-0299] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The use of the combined GHRH and arginine (GHRH-ARG) test has gained increasing acceptance in the United States as a reliable alternative test to the insulin tolerance test (ITT) for diagnosing adult GH deficiency (GHD). In July 2008, the only manufacturer of recombinant GHRH in the United States, EMD Serono, Inc., announced the discontinuation of Geref, thus raising the question of which reliable alternative GH stimulation test should practicing endocrinologists be considering in place of the GHRH-ARG test. In this article, we review the existing published data and consensus guidelines and provide recommendations for alternative stimulation tests to the GHRH-ARG test. EVIDENCE ACQUISITION The major source of data acquisition included PubMed search strategies and personal experience of the authors from clinical experience. EVIDENCE SYNTHESIS Previous consensus guidelines and previous data assessing the reliability and discriminatory value of the GHRH-ARG, glucagon, ARG, and GH secretagogues on assessing GH reserve are discussed. Our recommendations for performing the glucagon stimulation test, potential drawbacks in conducting this test, and caveats in interpreting this test are also discussed. CONCLUSIONS The ITT should remain the test of choice in diagnosing adult GHD. However, when the ITT is not desirable and recombinant GHRH remains unavailable in the United States, we recommend the alternative to the GHRH-ARG test to be the glucagon stimulation test, based on its reliability and availability. Nevertheless, further studies into alternative GH stimulation tests that are available in the United States, comparable, and simpler to perform than the ITT in diagnosing adult GHD are still needed.
Collapse
Affiliation(s)
- Kevin C J Yuen
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098, USA.
| | | | | | | |
Collapse
|