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Neufeld PM, Nettersheim RA, Matschke V, Vorgerd M, Stahlke S, Theiss C. Unraveling the gut-brain axis: the impact of steroid hormones and nutrition on Parkinson's disease. Neural Regen Res 2024; 19:2219-2228. [PMID: 38488556 PMCID: PMC11034592 DOI: 10.4103/1673-5374.391304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 10/07/2023] [Accepted: 11/24/2023] [Indexed: 04/24/2024] Open
Abstract
This comprehensive review explores the intricate relationship between nutrition, the gut microbiome, steroid hormones, and Parkinson's disease within the context of the gut-brain axis. The gut-brain axis plays a pivotal role in neurodegenerative diseases like Parkinson's disease, encompassing diverse components such as the gut microbiota, immune system, metabolism, and neural pathways. The gut microbiome, profoundly influenced by dietary factors, emerges as a key player. Nutrition during the first 1000 days of life shapes the gut microbiota composition, influencing immune responses and impacting both child development and adult health. High-fat, high-sugar diets can disrupt this delicate balance, contributing to inflammation and immune dysfunction. Exploring nutritional strategies, the Mediterranean diet's anti-inflammatory and antioxidant properties show promise in reducing Parkinson's disease risk. Microbiome-targeted dietary approaches and the ketogenic diet hold the potential in improving brain disorders. Beyond nutrition, emerging research uncovers potential interactions between steroid hormones, nutrition, and Parkinson's disease. Progesterone, with its anti-inflammatory properties and presence in the nervous system, offers a novel option for Parkinson's disease therapy. Its ability to enhance neuroprotection within the enteric nervous system presents exciting prospects. The review addresses the hypothesis that α-synuclein aggregates originate from the gut and may enter the brain via the vagus nerve. Gastrointestinal symptoms preceding motor symptoms support this hypothesis. Dysfunctional gut-brain signaling during gut dysbiosis contributes to inflammation and neurotransmitter imbalances, emphasizing the potential of microbiota-based interventions. In summary, this review uncovers the complex web of interactions between nutrition, the gut microbiome, steroid hormones, and Parkinson's disease within the gut-brain axis framework. Understanding these connections not only offers novel therapeutic insights but also illuminates the origins of neurodegenerative diseases such as Parkinson's disease.
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Affiliation(s)
- Paula Maria Neufeld
- Department of Cytology, Institute of Anatomy, Medical Faculty, Ruhr-University Bochum, Bochum, Germany
| | - Ralf A. Nettersheim
- Department of Visceral Surgery, University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Veronika Matschke
- Department of Cytology, Institute of Anatomy, Medical Faculty, Ruhr-University Bochum, Bochum, Germany
| | - Matthias Vorgerd
- Department of Neurology, Heimer Institute for Muscle Research, University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Sarah Stahlke
- Department of Cytology, Institute of Anatomy, Medical Faculty, Ruhr-University Bochum, Bochum, Germany
| | - Carsten Theiss
- Department of Cytology, Institute of Anatomy, Medical Faculty, Ruhr-University Bochum, Bochum, Germany
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Corsello A, Paragliola RM, Salvatori R. Diagnosing and treating the elderly individual with hypopituitarism. Rev Endocr Metab Disord 2024; 25:575-597. [PMID: 38150092 DOI: 10.1007/s11154-023-09870-w] [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] [Accepted: 12/18/2023] [Indexed: 12/28/2023]
Abstract
Hypopituitarism in the elderly is an underestimated condition mainly due to the non-specific presentation that can be attributed to the effects of aging and the presence of comorbidities. Diagnosis and treatment of hypopituitarism often represent a challenging task and this is even more significant in the elderly. Diagnosis can be insidious due to the physiological changes occurring with aging that complicate the interpretation of hormonal investigations, and the need to avoid some provocative tests that carry higher risks of side effects in this population. Treatment of hypopituitarism has generally the goal to replace the hormonal deficiencies to restore a physiological balance as close as possible to that of healthy individuals but in the elderly this must be balanced with the risks of over-replacement and worsening of comorbidities. Moreover, the benefit of some hormonal replacement therapies in the elderly, including sex hormones and growth hormone, remains controversial.
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Affiliation(s)
- Andrea Corsello
- Unità di Chirurgia Endocrina, Ospedale Isola Tiberina - Gemelli Isola, 00186, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Rosa Maria Paragliola
- Unicamillus-Saint Camillus International University of Health Sciences, 00131, Rome, Italy
| | - Roberto Salvatori
- Division of Endocrinology, Department of Medicine, and Pituitary Center, Johns Hopkins University, Baltimore, MD, 2187, USA.
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Oh YI, An JH, Lim GH, Park SM, Kim TH, Seo KW, Youn HY. Pamidronate-induced irreversible symptomatic hypocalcemia in a dog with hypercalcemia after glucocorticoid withdrawal: a case report. BMC Vet Res 2024; 20:227. [PMID: 38790012 PMCID: PMC11127328 DOI: 10.1186/s12917-024-04030-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Pamidronate is used for the treatment of hypercalcemia. However, a rare but potential adverse event of pamidronate treatment is hypocalcemia. This report describes an unusual case of severe, irreversible hypocalcemia after a single injection of pamidronate for the treatment of hypercalcemia due to glucocorticoid withdrawal in a dog. CASE PRESENTATION An 11-year-old castrated male Maltese dog presented with anorexia, vomiting, and diarrhea (day 0). The patient had calcinosis cutis throughout the body, calcification of intraabdominal organs, mild azotemia, and severe hypercalcemia. The severe calcification was attributed to long-term glucocorticoid administration, which was discontinued 1 month before presentation. Fluid therapy, diuretics, calcitonin, and a single intravenous injection of pamidronate were used for the treatment of hypercalcemia. On day 14, normocalcemia was achieved, but renal failure occurred. On day 20, severe and irreversible hypocalcemia occurred, and on day 42, the patient was euthanized at the owner's request because of worsened hypocalcemia and renal failure. CONCLUSIONS Although hypocalcemia is an extremely rare adverse event of bisphosphonate treatment, bisphosphonates like pamidronate can result in potentially life-threatening conditions according to the patient's underlying conditions. Therefore, the patient's condition should be closely monitored and any underlying conditions should be carefully evaluated before initiating the treatment for hypercalcemia using pamidronate.
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Affiliation(s)
- Ye-In Oh
- Department of Veterinary Internal Medicine, College of Veterinary Medicine & Institute for Veterinary Biomedical Science, Kyungpook National University, Daegu, 41566, Republic of Korea
| | - Ju-Hyun An
- Department of Veterinary Emergency and Critical Care Medicine, Institute of Veterinary Science, College of Veterinary Medicine, Kangwon National University, Chuncheon-si, 24341, Republic of Korea
| | - Ga-Hyun Lim
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, 08826, Republic of Korea
| | - Su-Min Park
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, 08826, Republic of Korea
| | - Tae-Hee Kim
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, 08826, Republic of Korea
| | - Kyoung-Won Seo
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, 08826, Republic of Korea
| | - Hwa-Young Youn
- Laboratory of Veterinary Internal Medicine, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul, 08826, Republic of Korea.
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Tizianel I, Ruggiero E, Torchio M, Simonato M, Seresin C, Bigolin F, Botta IP, Bano G, Lo Storto MR, Scaroni C, Ceccato F. A schedule for tapering glucocorticoid treatment in patients with severe SARS-CoV 2 infection can prevent acute adrenal insufficiency in the geriatric population. Hormones (Athens) 2024:10.1007/s42000-024-00564-9. [PMID: 38758491 DOI: 10.1007/s42000-024-00564-9] [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: 01/01/2024] [Accepted: 04/23/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE AND DESIGN Glucocorticoids (GCs) have been widely used in symptomatic patients for the treatment of COVID-19. The risk for adrenal insufficiency must be considered after GC withdrawal given that it is a life-threatening condition if left unrecognized and untreated. Our study aimed to diagnose adrenal insufficiency early on through a GC reduction schedule in patients with COVID-19 infection. PATIENTS AND MEASUREMENTS From November 2021 to May 2022, 233 patients were admitted to the Geriatric Division of the University Hospital of Padova with COVID-19 infection. A total of 122 patients were treated with dexamethasone, after which the GC tapering was performed according to a structured schedule. It consists of step-by-step GC tapering with prednisone, from 25 mg to 2.5 mg over 2 weeks. Morning serum sodium, potassium, and cortisol levels were assessed 3 days after the last dose of prednisone. RESULTS At the end of GC withdrawal, no adrenal crisis or signs/symptoms of acute adrenal insufficiency were reported. Median serum cortisol, sodium, and potassium levels after GC discontinuation were, respectively, 427 nmol/L, 140 nmol/L, and 4 nmol/L (interquartile range 395-479, 138-142, and 3.7-4.3). A morning serum cortisol level below the selected threshold of 270 nmol/L was observed in two asymptomatic cases (respectively, 173 and 239 nmol/L, reference range 138-690 nmol/L). Mild hyponatremia (serum sodium 132 to 134 nmol/L, reference range 135-145 nmol/L) was detected in five patients, without being related to cortisol levels. CONCLUSIONS A structured schedule for the tapering of GC treatment used in patients with severe COVID-19 can reduce the risk of adrenal crisis and acute adrenal insufficiency.
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Affiliation(s)
- Irene Tizianel
- Endocrine Unit-Department of Medicine DIMED, Via Ospedale Civile, Padova, 105 - 35128, Italy
- Endocrine Unit, University Hospital of Padova, Padova, Italy
| | - Elena Ruggiero
- Geriatric Division, University Hospital of Padova, Padova, Italy
- Pain Therapy and Palliative Care, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | | | - Matteo Simonato
- Geriatric Division, University Hospital of Padova, Padova, Italy
| | - Chiara Seresin
- Geriatric Division, University Hospital of Padova, Padova, Italy
| | | | | | - Giulia Bano
- Geriatric Division, University Hospital of Padova, Padova, Italy
| | | | - Carla Scaroni
- Endocrine Unit-Department of Medicine DIMED, Via Ospedale Civile, Padova, 105 - 35128, Italy
- Endocrine Unit, University Hospital of Padova, Padova, Italy
| | - Filippo Ceccato
- Endocrine Unit-Department of Medicine DIMED, Via Ospedale Civile, Padova, 105 - 35128, Italy.
- Endocrine Unit, University Hospital of Padova, Padova, Italy.
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Beuschlein F, Else T, Bancos I, Hahner S, Hamidi O, van Hulsteijn L, Husebye ES, Karavitaki N, Prete A, Vaidya A, Yedinak C, Dekkers OM. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. Eur J Endocrinol 2024; 190:G25-G51. [PMID: 38714321 DOI: 10.1093/ejendo/lvae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/18/2024] [Indexed: 05/09/2024]
Abstract
Glucocorticoids are widely prescribed as anti-inflammatory and immunosuppressive agents. This results in at least 1% of the population using chronic glucocorticoid therapy, being at risk for glucocorticoid-induced adrenal insufficiency. This risk is dependent on the dose, duration and potency of the glucocorticoid, route of administration, and individual susceptibility. Once glucocorticoid-induced adrenal insufficiency develops or is suspected, it necessitates careful education and management of affected patients. Tapering glucocorticoids can be challenging when symptoms of glucocorticoid withdrawal develop, which overlap with those of adrenal insufficiency. In general, tapering of glucocorticoids can be more rapidly within a supraphysiological range, followed by a slower taper when on physiological glucocorticoid dosing. The degree and persistence of HPA axis suppression after cessation of glucocorticoid therapy are dependent on overall exposure and recovery of adrenal function varies greatly amongst individuals. This first European Society of Endocrinology/Endocrine Society joint clinical practice guideline provides guidance on this clinically relevant condition to aid clinicians involved in the care of patients on chronic glucocorticoid therapy.
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Affiliation(s)
- Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University of Zürich (USZ) and University of Zürich (UZH), Zürich, Switzerland
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität, Munich, Germany
- The LOOP Zurich Medical Research Center, Zurich, Switzerland
| | - Tobias Else
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic Rocheste r, MN 55905, US
- Joint appointment in Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, MN 55905, US
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Leonie van Hulsteijn
- European Society of Endocrinology, Bristol, UK
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, N-5021 Bergen
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christine Yedinak
- Department of Neurological Surgery, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [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] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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Einarsdottir MJ, Bankvall M, Robledo-Sierra J, Rödström PO, Bergthorsdottir R, Trimpou P, Hasséus B, Ragnarsson O. Topical clobetasol treatment for oral lichen planus can cause adrenal insufficiency. Oral Dis 2024; 30:1304-1312. [PMID: 37103329 DOI: 10.1111/odi.14588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 03/13/2023] [Accepted: 04/06/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVE Glucocorticoids suppress the hypothalamic-pituitary-adrenal axis, which may lead to glucocorticoid-induced adrenal insufficiency. The study aimed to investigate the prevalence of this state in patients with oral lichen planus treated with topical clobetasol propionate. METHODS In this cross-sectional study, 30 patients with oral lichen planus receiving long-term (>6 weeks) clobetasol propionate gel 0.025% were invited to participate. Adrenal function was assessed by measuring morning plasma cortisol after a 48-h withdrawal of clobetasol treatment. In patients with plasma cortisol <280 nmol/L, a cosyntropin stimulation test was performed. RESULTS Twenty-seven patients were included. Twenty-one (78%) patients presented with plasma cortisol ≥280 nmol/L (range 280-570 nmol/L), and six (22%) <280 nmol/L (range 13-260 nmol/L). Five of these six patients underwent cosyntropin stimulation that revealed severe adrenal insufficiency in two patients (cortisol peak 150 nmol/L and 210 nmol/L) and mild adrenal insufficiency in three patients (cortisol peak 350-388 nmol/L). CONCLUSION In this study, approximately 20% of patients receiving intermittent topical glucocorticoid treatment for oral lichen planus had glucocorticoid-induced adrenal insufficiency. It is essential for clinicians to be aware of this risk and to inform patients about the potential need for glucocorticoid stress doses during intercurrent illness.
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Affiliation(s)
- Margret J Einarsdottir
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Bankvall
- Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden
| | - Jairo Robledo-Sierra
- Department of Oral Medicine and Pathology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Faculty of Dentistry, CES University, Medellin, Colombia
| | - Per-Olof Rödström
- Clinic for Oral Medicine, Public Dental Service, Region Västra Götaland, Gothenburg, Sweden
| | - Ragnhildur Bergthorsdottir
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Penelope Trimpou
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bengt Hasséus
- Department of Oral Medicine and Pathology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Clinic for Oral Medicine, Public Dental Service, Region Västra Götaland, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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8
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Riekhof F, Yan Y, Bennett CL, Sanfilippo KM, Carson KR, Chang SH, Georgantopoulos P, Luo S, Govindan S, Cheranda N, Afzal A, Schoen MW. Hospitalizations Among Veterans Treated for Metastatic Prostate Cancer With Abiraterone or Enzalutamide. Clin Genitourin Cancer 2024; 22:18-26.e3. [PMID: 37495480 DOI: 10.1016/j.clgc.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/24/2023] [Accepted: 07/06/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Abiraterone and enzalutamide are second generation androgen receptor pathway inhibitors (ARPIs) used to treat advanced or metastatic prostate cancer. Without head-to-head comparative studies identifying 1 agent as preferred initial therapy, physician preferences guide initial ARPI choice. This study compares hospitalizations among patients treated initially with abiraterone versus enzalutamide. PATIENTS AND METHODS United States veterans treated with abiraterone or enzalutamide between May 13, 2011 and December 31, 2019; then compared hospitalization rate during first treatment with ARPI in the Veterans Healthcare Administration. Baseline incidence rate of hospitalization was determined from data 1 year prior to ARPI. Incidence Rate Difference (IRD) was calculated using χ2 test and difference in IRD using Poisson Regression. RESULTS 19,775 veterans were identified; 13,527 (68.4%) were initially treated with abiraterone and 6248 (31.6%) initially with enzalutamide. The enzalutamide cohort was older (75.8 vs. 74.5 years, P < .001) and had higher baseline comorbidities at ARPI initiation (4.4 vs. 4.0, P < .001). Patients were treated with enzalutamide longer than abiraterone (median 9.0 vs. 8.0 months, P < .001). Total hospitalizations increased from 465 per 1000 person-years in the year prior to treatment with abiraterone to 567 during treatment. Total hospitalizations increased from 417 per 1000 person-years in the year prior to treatment with enzalutamide to 430 during treatment. Total rate of hospitalization increased 22% for abiraterone compared to a 3% increase for enzalutamide in the 12 months after ARPI initiation (P < .0001). Abiraterone was associated with greater increase in rates of acute heart failure, atrial fibrillation, acute kidney injury, urinary tract infections, sepsis, and pneumonia. CONCLUSION By comparing the rate of hospitalization before vs. during treatment, real world analyses identified a 22% versus 3% increase in hospitalizations with abiraterone compared to enzalutamide respectively, despite being used in a younger population with less comorbid disease. Abiraterone was also associated with higher risk of infections, a novel finding.
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Affiliation(s)
- Forest Riekhof
- Saint Louis Veterans Affairs Medical Center, Saint Louis, MO; Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO
| | - Yan Yan
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Charles L Bennett
- Department of Clinical Pharmacy and Outcomes Sciences (CPOS), College of Pharmacy, University of South Carolina, Columbia, SC
| | - Kristen M Sanfilippo
- Saint Louis Veterans Affairs Medical Center, Saint Louis, MO; Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Kenneth R Carson
- Department of Medicine, Northwestern University Feinberg School of Medicine
| | - Su-Hsin Chang
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Peter Georgantopoulos
- Department of Clinical Pharmacy and Outcomes Sciences (CPOS), College of Pharmacy, University of South Carolina, Columbia, SC
| | - Suhong Luo
- Saint Louis Veterans Affairs Medical Center, Saint Louis, MO; Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Srinivas Govindan
- Saint Louis Veterans Affairs Medical Center, Saint Louis, MO; Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO
| | - Nina Cheranda
- Saint Louis Veterans Affairs Medical Center, Saint Louis, MO; Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO
| | - Amber Afzal
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Martin W Schoen
- Saint Louis Veterans Affairs Medical Center, Saint Louis, MO; Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO.
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9
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Tucci L, Fanelli F, Improta I, Bissi V, Lena C, Galante G, Mezzullo M, Magagnoli M, Lalumera AB, Colombin G, Coscia K, Rotolo L, Vicennati V, Pagotto U, Di Dalmazi G. Monitoring adrenal insufficiency through salivary steroids: a pilot study. Eur J Endocrinol 2024; 190:327-337. [PMID: 38571387 DOI: 10.1093/ejendo/lvae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/21/2024] [Accepted: 03/11/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Various glucocorticoid replacement therapies (GRTs) are available for adrenal insufficiency (AI). However, their effectiveness in restoring glucocorticoid rhythm and exposure lacks adequate biochemical markers. We described the diurnal salivary cortisol (SalF) and cortisone (SalE) rhythm among different GRTs and analysed the associations between saliva-derived parameters and life quality questionnaires. METHODS Control subjects (CSs, n = 28) and AI patients receiving hydrocortisone (HC, n = 9), cortisone acetate (CA, n = 23), and dual-release hydrocortisone once (DRHC-od, n = 10) and twice a day (DRHC-td, n = 6) collected 9 saliva samples from 07:00 to 23:00. Patients compiled Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Scale, and Addison disease-specific quality-of-life questionnaires. SalE and SalF were measured by liquid chromatography-mass spectrometry. Exposure was monitored using SalE for HC and DRHC and SalF for CA. Area under the curve (AUC) was computed. Different GRTs were compared by Z-scores calculated from saliva-derived parameters. Questionnaire results predictors were evaluated with multiple regression analysis. RESULTS Compared with controls, all GRTs resulted in glucocorticoid overexposure in the morning. Hydrocortisone, CA, and DRHC-td caused overexposure also in afternoon and evening. Compared with other treatments, CA determined increased Z-score-07:00 (P < .001), DRHC-td determined increased Z-score-AUC07:00→14:00 (P = .007), and DRHC-od induced lower Z-score-AUC14:00→23:00 (P = .015). Z-scores-AUC14:00→16:00 ≥ .619 best predicted questionnaire scores. CONCLUSIONS None of the GRTs mimics normal glucocorticoid rhythmicity and exposure. SalE, SalF, and Z-score may be useful markers for monitoring and comparing different GRTs. Excess glucocorticoid in early afternoon best associated with depressive symptoms and worse life and sleep quality.
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Affiliation(s)
- Lorenzo Tucci
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Flaminia Fanelli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Ilaria Improta
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Valentina Bissi
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Claudia Lena
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Greta Galante
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Marco Mezzullo
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Matteo Magagnoli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Anna Bianca Lalumera
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Giacomo Colombin
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Kimberly Coscia
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Laura Rotolo
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Valentina Vicennati
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Uberto Pagotto
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Guido Di Dalmazi
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
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10
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Baek SW, Noh JH, Heo YS. Prevalence of Adrenal Insufficiency in Korean Patients undergoing Total Knee Arthroplasty. Ann Geriatr Med Res 2024; 28:20-26. [PMID: 37984965 PMCID: PMC10982440 DOI: 10.4235/agmr.23.0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/29/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND This study investigated the prevalence of adrenal insufficiency among patients admitted for total knee arthroplasty (TKA) due to osteoarthritis and identified factors contributing to adrenal insufficiency. METHODS We divided the patients into two groups based on the results of preoperative standard-dose short synchronous stimulation tests: group 1 (adrenal insufficiency) and group 2 (normal adrenal function). We also assessed the prevalence of adrenal insufficiency and compared the numbers of patients who received oral steroids, the frequency of previous steroid injection use, and the frequency of systemic symptoms of steroid depletion such as fatigue and loss of appetite between the two groups. Multiple regression analysis was performed to identify factors related to adrenal insufficiency. RESULTS The prevalence of adrenal insufficiency was 60.0% (120/200). Group 1 had higher numbers of previous steroid injections (12.8±10.2 vs. 6.8±7.9) and patients taking oral steroids (18/120 vs. 3/80) (p<0.001 and p=0.011, respectively). The frequency of systemic symptoms of steroid depletion, such as fatigue and loss of appetite, was also higher in group 1 (94/120 vs. 42/80, p<0.001). Recent steroid injections and loss of appetite were associated with adrenal insufficiency (p=0.002 and p=0.009, respectively). CONCLUSION The results of this study revealed a high prevalence of adrenal insufficiency in Korean patients hospitalized for TKA due to end-stage osteoarthritis. Recent steroid injections were causally related to the development of adrenal insufficiency. Therefore, adrenal function should be assessed preoperatively to prevent postoperative complications related to adrenal insufficiency.
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Affiliation(s)
- So Won Baek
- Nursing Department, Kangwon National University Hospital, Chuncheon, Republic of Korea
| | - Jung Ho Noh
- Department of Orthopaedic Surgery, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Yeon Sik Heo
- Department of Orthopaedic Surgery, Kangwon National University Hospital, Chuncheon, Republic of Korea
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11
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Tavares LCP, Caetano LDVN, Ianhez M. Side effects of chronic systemic glucocorticoid therapy: what dermatologists should know. An Bras Dermatol 2024; 99:259-268. [PMID: 38007314 PMCID: PMC10943326 DOI: 10.1016/j.abd.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/26/2023] [Accepted: 05/31/2023] [Indexed: 11/27/2023] Open
Abstract
In dermatologists' clinical practice, the use of systemic glucocorticoids is recurrent for the management of different comorbidities that require chronic immunosuppression. The prescription of this medication requires caution and basic clinical knowledge due to the several adverse effects inherent to the treatment. However, different doubts may arise or inappropriate conduct may be adopted due to the lack of objective and specific guidelines for the screening, prophylaxis and management of complications from chronic corticosteroid therapy. Considering this problem, the authors carried out a narrative review of the literature to gather up-to-date data on adverse effects secondary to the chronic use of systemic glucocorticoids. The broad approach to this topic made it possible to review the pathophysiology and risk factors for these complications, as well as to develop updated orientation that can be used as a learning tool and quick reference for dermatologists during their clinical practice with glucocorticoids.
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Affiliation(s)
- Lucas Campos Prudente Tavares
- Department of Tropical Medicine and Dermatology, Hospital das Clínicas da Universidade Federal de Goiás, Goiânia, Goiás, Brazil.
| | | | - Mayra Ianhez
- Department of Tropical Medicine and Dermatology, Hospital das Clínicas da Universidade Federal de Goiás, Goiânia, Goiás, Brazil
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12
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Bonaventura I, Tomaselli A, Angelini F, Ferrari D, De Alcubierre D, Hasenmajer V, Sbardella E, Cozzolino A, Paganini AM, Isidori AM, Minnetti M, Pofi R. Predicting postoperative hypocortisolism in patients with non-aldosterone-producing adrenocortical adenoma: a retrospective single-centre study. J Endocrinol Invest 2024:10.1007/s40618-023-02283-1. [PMID: 38386266 DOI: 10.1007/s40618-023-02283-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 12/14/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Limited information exists on postoperative hypocortisolism and hypothalamus-pituitary-adrenal axis recovery in patients with adrenal incidentaloma following unilateral adrenalectomy. We evaluated frequency of postoperative hypocortisolism and predictors for recovery in non-aldosterone-producing adrenocortical adenoma patients after unilateral adrenalectomy. METHODS A retrospective analysis of 32 adrenal incidentaloma patients originally included in the ITACA trial (NCT04127552) with confirmed non-aldosterone-producing adrenocortical adenoma undergoing unilateral adrenalectomy from September 2019 to April 2023 was conducted. Preoperative assessments included adrenal MRI, anthropometrics, evaluation of comorbidities, adrenal function assessed via ACTH, urinary free cortisol, and 1 mg dexamethasone suppression test. ACTH and serum cortisol or Short Synacthen test were performed within 6 days, 6 weeks, 6 months, and a year after surgery. RESULTS Six days postoperative, 18.8% of patients had normal adrenal function. Among those with postoperative hypocortisolism, 53.8% recovered by 6 weeks. Patients with earlier adrenal recovery (6 weeks) had lower preoperative 1 mg dexamethasone suppression test (median 1 mg dexamethasone suppression test 76.2 [61.8-111.0] nmol/L vs 260.0 [113.0-288.5] nmol/L, p < 0.001). Univariate analysis showed preoperative 1 mg dexamethasone suppression test negatively related with baseline ACTH levels (r = - 0.376; p = 0.041) and negatively associated with the 6-week baseline (r = - 0.395, p = 0.034) and 30-min cortisol levels during Short Synacthen test (r = - 0.534, p = 0.023). Logistic regression analysis demonstrated preoperative 1 mg dexamethasone suppression test as the only biochemical predictor for 6-week adrenal recovery: ROC curve identified a 1 mg dexamethasone suppression test threshold of 131 nmol/L predicting 6-week recovery with 89.5% sensitivity and 72.7% specificity (AUC 0.87; 95% CI 66.9-98.7, p < 0.001). Other preoperative assessments (tumor size, ACTH levels and anthropometrics) were not associated with postoperative hypothalamus-pituitary-adrenal axis function, but the presence of diabetes was associated with a lower probability of recovery (OR = 24.55, p = 0.036). ACTH levels increased postoperatively in all patients but did not predict hypothalamus-pituitary-adrenal axis recovery. CONCLUSIONS The preoperative 1 mg dexamethasone suppression test cortisol value and presence of diabetes are the only relevant predictor of hypothalamus-pituitary-adrenal axis recovery in patients with non-aldosterone- producing adrenocortical adenoma undergoing surgery, regardless other clinical and biochemical variables. Notably, pre- and postoperative ACTH levels did not predict hypothalamus-pituitary-adrenal axis recovery. These findings point towards the potential for saving resources by optimizing their allocation during follow-up assessments for patients with non-aldosterone-producing adrenocortical adenoma undergoing unilateral adrenalectomy.
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Affiliation(s)
- I Bonaventura
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A Tomaselli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - F Angelini
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - D Ferrari
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - D De Alcubierre
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Cancer Research Center of Lyon, Inserm U1052, CNRS UMR5286, Claude Bernard Lyon 1 University, Lyon, France
| | - V Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A M Paganini
- Department of General Surgery, Surgical Specialties and Organ Transplantation "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Policlinico Umberto I, Centre for Rare Diseases (Endo-ERN Accredited), Rome, Italy
| | - M Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - R Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK.
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13
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Charoensri S, Auchus RJ. A Contemporary Approach to the Diagnosis and Management of Adrenal Insufficiency. Endocrinol Metab (Seoul) 2024; 39:73-82. [PMID: 38253474 PMCID: PMC10901672 DOI: 10.3803/enm.2024.1894] [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: 11/29/2023] [Revised: 12/18/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024] Open
Abstract
Adrenal insufficiency (AI) can be classified into three distinct categories based on its underlying causes: primary adrenal disorders, secondary deficiencies in adrenocorticotropin, or hypothalamic suppression from external factors, most commonly glucocorticoid medications used for anti-inflammatory therapy. The hallmark clinical features of AI include fatigue, appetite loss, unintentional weight loss, low blood pressure, and hyponatremia. Individuals with primary AI additionally manifest skin hyperpigmentation, hyperkalemia, and salt craving. The diagnosis of AI is frequently delayed due to the non-specific symptoms and signs early in the disease course, which poses a significant challenge to its early detection prior to an adrenal crisis. Despite the widespread availability of lifesaving glucocorticoid medications for decades, notable challenges persist, particularly in the domains of timely diagnosis while simultaneously avoiding misdiagnosis, patient education for averting adrenal crises, and the determination of optimal replacement therapies. This article reviews recent advancements in the contemporary diagnostic strategy and approaches to optimal treatment for AI.
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Affiliation(s)
- Suranut Charoensri
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Richard J. Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA
- Endocrinology & Metabolism Section, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA
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Arshad MF, Elder C, Newell-Price J, Ross R, Debono M. A retrospective study on weaning glucocorticoids and recovery of the hypothalamic-pituitary-adrenal axis. J Clin Endocrinol Metab 2024:dgae059. [PMID: 38298131 DOI: 10.1210/clinem/dgae059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/09/2024] [Accepted: 01/26/2024] [Indexed: 02/02/2024]
Abstract
CONTEXT Glucocorticoids suppress the hypothalamic-pituitary-adrenal (HPA) axis resulting in tertiary adrenal insufficiency (AI). When weaning patients off glucocorticoids there is no consensus on whether to maintain patients on prednisolone or convert to hydrocortisone. OBJECTIVE Investigate HPA axis recovery in patients on long-term prednisolone and assess outcome after hydrocortisone conversion. DESIGN Retrospective cohort study. SETTING Outpatient endocrine steroid clinic. PATIENTS Patients on long-term prednisolone referred for HPA axis testing between 2015-2022. MAIN OUTCOMES MEASURED 1) HPA axis recovery rate in patients on prednisolone demonstrated by normal ACTH stimulation test (AST).2) HPA axis recovery rate sub-analysis of dose-matched patients with confirmed tertiary AI on prednisolone or hydrocortisone. RESULTS 206 patients on prednisolone were tested for tertiary AI. Of these 176 remained on prednisolone while 30 were converted to hydrocortisone. The overall HPA axis recovery rate for patients on prednisolone after interval testing was 137/206 (66.5%). HPA axis recovery rate in dose-matched prednisolone and hydrocortisone conversion groups was 7/10 (70%) and 2/13 (15%) (p=0.008), respectively. There was no difference in mean (SD) age (67.1(12.2) v 63.4(11.1) years; p=0.464) and baseline cortisol (5.3(4.2) v 4.6(3.1)µg/dL; p=0.648) and median [IQR] glucocorticoids duration (1213[1114] v 2316[4808] days; p=0.693) and baseline ACTH (20.5[29.0] v 16.3[14.8]ng/L; p=0.905) between dose-matched prednisolone and hydrocortisone groups. Follow-up duration in prednisolone group was significantly lower (median [IQR] 348[975] v 667[884] days; p=0.012). CONCLUSIONS Patients with glucocorticoid induced AI maintained on once-daily prednisolone can recover HPA axis function when weaning. There is no apparent advantage to recover HPA axis function in converting to multiple dosing hydrocortisone.
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Affiliation(s)
- Muhammad Fahad Arshad
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Charlotte Elder
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - John Newell-Price
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Richard Ross
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
| | - Miguel Debono
- Division of Clinical Medicine, School of Medicine & Population Health, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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15
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Gordon H, Burisch J, Ellul P, Karmiris K, Katsanos K, Allocca M, Bamias G, Barreiro-de Acosta M, Braithwaite T, Greuter T, Harwood C, Juillerat P, Lobaton T, Müller-Ladner U, Noor N, Pellino G, Savarino E, Schramm C, Soriano A, Michael Stein J, Uzzan M, van Rheenen PF, Vavricka SR, Vecchi M, Zuily S, Kucharzik T. ECCO Guidelines on Extraintestinal Manifestations in Inflammatory Bowel Disease. J Crohns Colitis 2024; 18:1-37. [PMID: 37351850 DOI: 10.1093/ecco-jcc/jjad108] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, London, Centre for Immunobiology, Blizard Institute, Faculty of Medicine, Barts & The London Medical School, Queen Mary University of London, UK
| | - Johan Burisch
- Gastrounit, medical division, Hvidovre Hospital, University of Copenhagen, Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, Division of Internal Medicine, University and Medical School of Ioannina, Ioannina, Greece
| | - Mariangela Allocca
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Giorgos Bamias
- GI Unit, 3rd Academic Department of Internal Medicine, National and Kapodistrian University of Athens, Sotiria Hospital, Athens, Greece
| | - Manuel Barreiro-de Acosta
- University Hospital Santiago De Compostela CHUS, Department of Gastroenterology - IBD Unit, Santiago De Compostela, Spain
| | - Tasanee Braithwaite
- School of Immunology and Microbiology, King's College London, The Medical Eye Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, GZO - Zurich Regional Health Center, Wetzikon, Division of Gastroenterology and Hepatology, University Hospital Lausanne - CHUV, Lausanne, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Catherine Harwood
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Department of Dermatology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Pascal Juillerat
- Gastroenterology, Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland; Crohn and Colitis Center, Gastro-entérologie Beaulieu SA, Lausanne, Switzerland
| | - Triana Lobaton
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent; Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus Liebig University Giessen, Bad Nauheim, Germany
| | - Nurulamin Noor
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gianluca Pellino
- Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain; Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Christoph Schramm
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandra Soriano
- Gastroenterology Division and IBD Center, Internal Medicine Department, Azienda Unità Sanitaria Locale - IRCCS, 42122 Reggio Emilia, Italy
| | - Jürgen Michael Stein
- Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/Main, Department of Gastroenterology and Clinical Nutrition, DGD Clinics Sachsenhausen, Frankfurt/Main, Germany
| | - Mathieu Uzzan
- Department of Gastroenterology, Hôpital Henri Mondor, APHP, Créteil, France
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital, Zurich, Switzerland
| | - Maurizio Vecchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stephane Zuily
- Vascular Medicine Division and French Referral Center for Rare Auto-Immune Diseases, Université de Lorraine, INSERM, DCAC and CHRU-Nancy, Nancy, France
| | - Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Münster, Lüneburg, Germany
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Welch MR. Management of Complications in Neuro-oncology Patients. Continuum (Minneap Minn) 2023; 29:1844-1871. [PMID: 38085901 DOI: 10.1212/con.0000000000001359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE The purpose of this article is to familiarize the reader with the spectrum of neurologic and medical complications relevant to the care of patients with neurologic cancer while highlighting best practices to prevent morbidity and mortality. Topics include tumor-related epilepsy, vasogenic edema, complications of corticosteroid use, disruption of the hypothalamic-pituitary axis, venous thromboembolism, and opportunistic infection. LATEST DEVELOPMENTS In 2021, a joint guideline from the Society for Neuro-Oncology and the European Association of Neuro-Oncology reaffirmed recommendations first established in 2000 that patients with newly diagnosed brain tumors should not be prescribed an antiseizure medication prophylactically. For those with tumor-related epilepsy, monotherapy with a non-enzyme-inducing anticonvulsant is the preferred initial treatment, and levetiracetam remains the preferred first choice. Surveys of physician practice continue to demonstrate excessive use of glucocorticoids in the management of patients with both primary and metastatic central nervous system malignancy. This is particularly concerning among patients who require checkpoint inhibitors as the efficacy of these agents is blunted by concomitant glucocorticoid use, resulting in a reduction in overall survival. Finally, direct oral anticoagulants have been shown to be safe in patients with brain tumors and are now favored as first-line treatment among those who require treatment for venous thromboembolism. ESSENTIAL POINTS Medical care for patients impacted by primary and secondary central nervous system malignancy is complex and requires a committed team-based approach that routinely calls upon the expertise of physicians across multiple fields. Neurologists have an important role to play and should be familiar with the spectrum of complications impacting these patients as well as the latest recommendations for management.
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17
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Lawrence NR, Arshad MF, Pofi R, Ashby S, Dawson J, Tomlinson JW, Newell-Price J, Ross RJ, Elder CJ, Debono M. Multivariable Model to Predict an ACTH Stimulation Test to Diagnose Adrenal Insufficiency Using Previous Test Results. J Endocr Soc 2023; 7:bvad127. [PMID: 37942292 PMCID: PMC10628819 DOI: 10.1210/jendso/bvad127] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Indexed: 11/10/2023] Open
Abstract
Context The adrenocorticotropin hormone stimulation test (AST) is used to diagnose adrenal insufficiency, and is often repeated in patients when monitoring recovery of the hypothalamo-pituitary-adrenal axis. Objective To develop and validate a prediction model that uses previous AST results with new baseline cortisol to predict the result of a new AST. Methods This was a retrospective, longitudinal cohort study in patients who had undergone at least 2 ASTs, using polynomial regression with backwards variable selection, at a Tertiary UK adult endocrinology center. Model was developed from 258 paired ASTs over 5 years in 175 adults (mean age 52.4 years, SD 16.4), then validated on data from 111 patients over 1 year (51.8, 17.5) from the same center, data collected after model development. Candidate prediction variables included previous test baseline adrenocorticotropin hormone (ACTH), previous test baseline and 30-minute cortisol, days between tests, and new baseline ACTH and cortisol used with calculated cortisol/ACTH ratios to assess 8 candidate predictors. The main outcome measure was a new test cortisol measured 30 minutes after Synacthen administration. Results Using 258 sequential ASTs from 175 patients for model development and 111 patient tests for model validation, previous baseline cortisol, previous 30-minute cortisol and new baseline cortisol were superior at predicting new 30-minute cortisol (R2 = 0.71 [0.49-0.93], area under the curve [AUC] = 0.97 [0.94-1.0]) than new baseline cortisol alone (R2 = 0.53 [0.22-0.84], AUC = 0.88 [0.81-0.95]). Conclusion Results of a previous AST can be objectively combined with new early-morning cortisol to predict the results of a new AST better than new early-morning cortisol alone. An online calculator is available at https://endocrinology.shinyapps.io/sheffield_sst_calculator/ for external validation.
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Affiliation(s)
- Neil Richard Lawrence
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
- Paediatric Endocrinology Department, Sheffield Children's NHS Foundation Trust, Sheffield S10 2TH, UK
| | - Muhammad Fahad Arshad
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
- Endocrinology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
| | - Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Sean Ashby
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
| | - Jeremy Dawson
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University Hospitals NHS Trust, Oxford OX3 9DU, UK
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 9DU, UK
| | - John Newell-Price
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
- Endocrinology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
| | - Richard J Ross
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
| | - Charlotte J Elder
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
- Paediatric Endocrinology Department, Sheffield Children's NHS Foundation Trust, Sheffield S10 2TH, UK
| | - Miguel Debono
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
- Endocrinology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
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Choo YH, Kim M, Kim JH, Jeon H, Jung HW, Ha EJ, Oh J, Shim Y, Kim SB, Jung HG, Park SH, Kim JO, Kim J, Kim H, Lee S. The Unique Relationship between Neuro-Critical Care and Critical Illness-Related Corticosteroid Insufficiency : Implications for Neurosurgeons in Neuro-Critical Care. J Korean Neurosurg Soc 2023; 66:618-631. [PMID: 37840243 PMCID: PMC10641414 DOI: 10.3340/jkns.2023.0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/07/2023] [Indexed: 10/17/2023] Open
Abstract
The brain houses vital hormonal regulatory structures such as the hypothalamus and pituitary gland, which may confer unique susceptibilities to critical illness-related corticosteroid insufficiency (CIRCI) in patients with neurological disorders. In addition, the frequent use of steroids for therapeutic purposes in various neurological conditions may lead to the development of steroid insufficiency. This abstract aims to highlight the significance of understanding these relationships in the context of patient care and management for physicians. Neurological disorders may predispose patients to CIRCI due to the role of the brain in hormonal regulation. Early recognition of CIRCI in the context of neurological diseases is essential to ensure prompt and appropriate intervention. Moreover, the frequent use of steroids for treating neurological conditions can contribute to the development of steroid insufficiency, further complicating the clinical picture. Physicians must be aware of these unique interactions and be prepared to evaluate and manage patients with CIRCI and steroid insufficiency in the context of neurological disorders. This includes timely diagnosis, appropriate steroid administration, and careful monitoring for potential adverse effects. A comprehensive understanding of the interplay between neurological disease, CIRCI, and steroid insufficiency is critical for optimizing patient care and outcomes in this complex patient population.
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Affiliation(s)
- Yoon Hee Choo
- Department of Neurological Surgery and Critical Care Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Moinay Kim
- Department of Neurological Surgery and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hyun Kim
- Department of Neurological Surgery and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hanwool Jeon
- Department of Neurological Surgery and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee-Won Jung
- Department of Neurological Surgery and Critical Care Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Eun Jin Ha
- Department of Neurological Surgery and Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jiwoong Oh
- Department of Neurological Surgery and Critical Care Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Youngbo Shim
- Department of Neurological Surgery and Critical Care Medicine, Kangbuk Samsung Hospital, Seoul, Korea
| | - Seung Bin Kim
- Department of Neurological Surgery and Critical Care Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Han-Gil Jung
- Department of Neurological Surgery and Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - So Hee Park
- Department of Neurological Surgery and Critical Care Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Jung Ook Kim
- Department of Neurological Surgery and Critical Care Medicine, Gachon University Gil Hospital Regional Trauma Center, Incheon, Korea
| | - Junhyung Kim
- Department of Neurological Surgery and Critical Care Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Hyeseon Kim
- Department of Neurological Surgery and Critical Care Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, Korea
| | - Seungjoo Lee
- Department of Neurological Surgery and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Nils HJ, Arce Recatala C, Castano A, Ribas D, Flores-Fraile J. Efficacy/Safety of the Use of Glucocorticoids in Oral and Maxillofacial Surgery. Dent J (Basel) 2023; 11:239. [PMID: 37886924 PMCID: PMC10606022 DOI: 10.3390/dj11100239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/08/2023] [Accepted: 09/28/2023] [Indexed: 10/28/2023] Open
Abstract
INTRODUCTION Glucocorticoids, also known as corticosteroids or steroids, are drugs derived from cholesterol. They are synthesized by the adrenal cortex, along with other hormones, such as cortisol and aldosterone. Glucocorticoids are drugs recommended for patients undergoing surgery on the oral cavity, facial skeleton, and related cervical structures due to their high efficacy against inflammatory and immune processes. However, these drugs are restricted due to their multiple and serious adverse effects. The objective of this study was to verify the efficacy of corticosteroids administered in major surgeries of the oral cavity, as well as of the cervical and facial structures, based on the characteristics of the patient so as to select the best therapeutic strategy. METHODS Articles in the databases of PubMed, Nature Portfolio, Medline, Cochrane Library, and Google Scholar were thoroughly examined. RESULTS A total of 54 articles were selected to address the proposed objectives. The results obtained show that it is effective and safe to use glucocorticoids as pre- or postsurgical therapy in oral and maxillofacial surgery to control the processes of inflammation, pain, lockjaw, and edema. However, when referring to the use of these drugs, one must proceed with caution and pay particular attention when handling them. The concentration of the glucocorticoids used must be individualized, as well as the selection of the route of administration. Various studies show that, although the oral route is the most used route, the most effective route is the intramuscular route due to its easy absorption. However, for patients who have recurrent inflammatory and vesiculobullous ulcerative lesions, the topical route should be chosen to mitigate side effects, considering that recurrent applications must be made to prevent the worsening of the lesion and to avoid having to use medications enterally. In patients with cervicofacial infections, antibiotics continue to be the main drugs used to manage the condition in conjunction with corticosteroids. It is important to know the possible interactions of glucocorticoids with other medicines or food: it has been described that the interaction between Ritonavir, an antiretroviral drug that inhibits human immunodeficiency virus (HIV) proteases, and prednisone causes an increase in the concentration of prednisone, leading to possible toxicity in normally safe doses and, in many cases, iatrogenic Cushing's syndrome. It is also important to know the systemic or topical adverse effects of the chronic or high-dose use of glucocorticoids. CONCLUSIONS It can be concluded that by making adequate use of glucocorticoid therapy in oral and maxillofacial surgery to manage clinical manifestations, it is possible to attenuate the morbidities of treatment and intervention.
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Affiliation(s)
| | | | | | - David Ribas
- University of Sevilla, 41004 Sevilla, Spain; (A.C.); (D.R.)
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Garg VK, Tickoo V, Prasad VP, Maturu VN. Iatrogenic Cushing's syndrome in a case of allergic bronchopulmonary aspergillosis treated with oral itraconazole and inhaled budesonide. BMJ Case Rep 2023; 16:e256788. [PMID: 37813554 PMCID: PMC10565246 DOI: 10.1136/bcr-2023-256788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus fumigatus that occurs in patients with asthma or cystic fibrosis. Here, we report a case of a young female with bronchial asthma who presented to our hospital with worsening breathlessness on exertion. She was diagnosed to have ABPA and was initiated on oral itraconazole while continuing inhaled long acting beta-2 adrenergic agonist and medium dose inhaled corticosteroid (ICS) for her asthma. Three months after initiation of therapy, the patient had significant improvement in breathlessness. However, she had weight gain, facial puffiness, increased facial hair and development of striae on her inner thighs, calf and lower abdomen. Her serum cortisol levels were found to be suppressed and hence a diagnosis of iatrogenic Cushing's syndrome was made. Our case describes the potentially serious interaction between ICS and oral itraconazole, a treatment very commonly prescribed in patients with ABPA.
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Affiliation(s)
- Vipul Kumar Garg
- Pulmonary Medicine, Yashoda Hospitals, Hyderabad, Telangana, India
| | - Vidya Tickoo
- Endocrinology, Yashoda Hospitals, Hyderabad, Telangana, India
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21
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Pan YA, Roberts D. The not-so-natural herb: a case of exogenous Cushing syndrome. Med J Aust 2023; 219:297-298. [PMID: 37658579 DOI: 10.5694/mja2.52095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 09/03/2023]
Affiliation(s)
- Yi-An Pan
- Logan Hospital, Logan, QLD
- Gold Coast Hospital and Health Service, Gold Coast, QLD
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22
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Hysa E, Vojinovic T, Gotelli E, Alessandri E, Pizzorni C, Paolino S, Sulli A, Smith V, Cutolo M. The dichotomy of glucocorticosteroid treatment in immune-inflammatory rheumatic diseases: an evidence-based perspective and insights from clinical practice. Reumatologia 2023; 61:283-293. [PMID: 37745141 PMCID: PMC10515127 DOI: 10.5114/reum/170845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 08/08/2023] [Indexed: 09/26/2023] Open
Abstract
Objectives Glucocorticosteroids (GCs) are the most used anti-inflammatory and immunosuppressive drugs due to their effectiveness in managing pain and disease modification in many immune-inflammatory rheumatic diseases (IRDs). However, their use is limited because of adverse effects (AEs). Material and methods The authors analyzed recent studies, including randomized controlled trials (RCTs), observational, translational studies and systematic reviews, providing an in-depth viewpoint on the benefits and drawbacks of GC use in rheumatology. Results Glucocorticosteroids are essential in managing life-threatening autoimmune diseases and a cornerstone in many IRDs given their swift onset of action, necessary in flares. Several RCTs and meta-analyses have demonstrated that when administered over a long time and on a low-dose basis, GC can slow the radiographic progression in early rheumatoid arthritis (RA) patients by at least 50%, satisfying the conventional definition of a disease-modifying anti-rheumatic drug (DMARD). In the context of RA treatment, the use of modified-release prednisone formulations at night may offer the option of respecting circadian rhythms of both inflammatory response and HPA activation, thereby enabling low-dose GC administration to mitigate nocturnal inflammation and prolonged morning fatigue and joint stiffness. Long-term GC use should be individualized based on patient characteristics and minimized due to their potential AEs. Their chronic use, especially at medium/high dosages, might cause irreversible organ damage due to the burden of metabolic systemic effects and increased risk of infections. Many international guidelines recommend tapering/withdrawal of GCs in sustained remission. Treat-to-target (T2T) strategies are critical in setting targets for disease activity and reducing/discontinuing GCs once control is achieved. Conclusions Glucocorticosteroids' use in treating IRDs should be judicious, focused on minimizing use, tapering and discontinuing treatment, when possible, to improve long-term safety. Glucocorticosteroids remain part of many therapeutic regimens, particularly at low doses, and elderly RA patients, especially with associated chronic comorbidities, may benefit from long-term low-dose GC treatment. A personalized GC therapy is essential for optimal long-term outcomes.
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Affiliation(s)
- Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Tamara Vojinovic
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Elisa Alessandri
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Carmen Pizzorni
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
| | - Vanessa Smith
- Department of Internal Medicine, Department of Rheumatology, University Hospital Ghent, Belgium
- Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
- IRCCS – San Martino Polyclinic Hospital, Genova, Italy
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Salton F, Confalonieri P, Meduri GU, Mondini L, Trotta L, Barbieri M, Bozzi C, Torregiani C, Lerda S, Bellan M, Confalonieri M, Ruaro B, Tavano S, Pozzan R. Theory and Practice of Glucocorticoids in COVID-19: Getting to the Heart of the Matter-A Critical Review and Viewpoints. Pharmaceuticals (Basel) 2023; 16:924. [PMID: 37513836 PMCID: PMC10385094 DOI: 10.3390/ph16070924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
Prolonged, low-dose glucocorticoids (GCs) have shown the highest efficacy among pharmacological and non-pharmacological treatments for COVID-19. Despite the World Health Organization's recommendation against their use at the beginning of the pandemic, GCs at a dose equivalent to dexamethasone 6 mg/day for 10 days are now indicated in all COVID-19 cases who require respiratory support. However, the efficacy of the intervention depends on the timing of initiation, the dose, and other individual factors. Indeed, patients treated with similar GC protocols often experience different outcomes, which do not always correlate with the presence of comorbidities or with the severity of respiratory involvement at baseline. This prompted us to critically review the literature on the rationale, pharmacological principles, and clinical evidence that should guide GC treatment. Based on these data, the best treatment protocol probably involves an initial bolus dose to saturate the glucocorticoid receptors, followed by a continuous infusion to maintain constant plasma levels, and eventually a slow tapering to interruption. Methylprednisolone has shown the highest efficacy among different GC molecules, most likely thanks to its higher ability to penetrate the lung. Decreased tissue sensitivity to glucocorticoids is thought to be the main mechanism accounting for the lower response to the treatment in some individuals. We do not have a readily available test to identify GC resistance; therefore, to address inter-individual variability, future research should aim at investigating clinical, physiological, and laboratory markers to guide a personalized GC treatment approach.
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Affiliation(s)
- Francesco Salton
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Paola Confalonieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Gianfranco Umberto Meduri
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Lucrezia Mondini
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Liliana Trotta
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Mariangela Barbieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Chiara Bozzi
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Chiara Torregiani
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Selene Lerda
- Business School, University of Milano, 20149 Milano, Italy
| | - Mattia Bellan
- Department of Translational Medicine, Università del Piemonte Orientale (UPO), 28100 Novara, Italy
- Center for Autoimmune and Allergic Disease (CAAD), Università del Piemonte Orientale (UPO), 28100 Novara, Italy
- A.O.U. Maggiore della Carità, 28100 Novara, Italy
| | - Marco Confalonieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Barbara Ruaro
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Stefano Tavano
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Riccardo Pozzan
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
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Bilha SC, Hogas S, Hogas M, Marcu S, Leustean L, Ungureanu MC, Branisteanu DD, Preda C. Thyroid, Gonadal and Adrenal Dysfunction in Kidney Transplant Recipients: A Review for the Clinician. Biomolecules 2023; 13:920. [PMID: 37371500 DOI: 10.3390/biom13060920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/13/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
While chronic kidney disease-associated mineral and bone disorders (CKD-MBD) prevail in the endocrinological assessment of CKD patients, other endocrine abnormalities are usually overlooked. CKD is associated with significant thyroid, adrenal and gonadal dysfunction, while persistent and de novo endocrinological abnormalities are frequent among kidney transplant recipients (KTR). Low T3 levels prior to transplantation may help identify those at risk for delayed graft function and are often found in KTR. Thyroid surveillance after kidney transplantation should be considered due to structural anomalies that may occur. Despite the rapid recovery of gonadal hormonal secretion after renal transplantation, fertility is not completely restored. Testosterone may improve anemia and general symptoms in KTR with persistent hypogonadism. Female KTR may still experience abnormal uterine bleeding, for which estroprogestative administration may be beneficial. Glucocorticoid administration suppresses the hypothalamic-pituitary-adrenal axis in KTR, leading to metabolic syndrome. Patients should be informed about signs and symptoms of hypoadrenalism that may occur after glucocorticoid withdrawal, prompting adrenal function assessment. Clinicians should be more aware of the endocrine abnormalities experienced by their KTR patients, as these may significantly impact the quality of life. In clinical practice, awareness of the specific endocrine dysfunctions experienced by KTR patients ensures the correct management of these complications in a multidisciplinary team, while avoiding unnecessary treatment.
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Affiliation(s)
- Stefana Catalina Bilha
- Endocrinology Department, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Simona Hogas
- Nephrology Department, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihai Hogas
- Physiology Department, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Stefan Marcu
- Nephrology Department, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Letitia Leustean
- Endocrinology Department, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Maria-Christina Ungureanu
- Endocrinology Department, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Dumitru D Branisteanu
- Department of Medicine, Charles E. Smith College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Cristina Preda
- Endocrinology Department, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iasi, Romania
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Fan HP, Zhou Y, Zhou Y, Jin J, Hu TY. Association between short-term systemic use of glucocorticoids and prognosis of cardiogenic shock: a retrospective analysis. BMC Anesthesiol 2023; 23:169. [PMID: 37202727 PMCID: PMC10193317 DOI: 10.1186/s12871-023-02131-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/09/2023] [Indexed: 05/20/2023] Open
Abstract
OBJECTIVE To investigate the prescription rate of short-term systemic use of glucocorticoids during hospitalization in patients with cardiogenic shock (CS), and outcomes related with glucocorticoid use. METHODS We extracted patients' information from the Medical Information Mart for Intensive Care IV version 2.0 (MIMIC-IV v2.0) database. The primary endpoint was 90-day all-cause mortality. Secondary safety endpoints were infection identified by bacterial culture and at least one episode of hyperglycemia after ICU admission. Propensity score matching (PSM) was used to balance baseline characteristics. The difference in cumulative mortality rate between these treated with and without glucocorticoids was assessed by Kaplan-Meier curve with log-rank test. Independent risk factors for endpoints were identified by Cox or Logistic regression analysis. RESULTS A total of 1528 patients were enrolled, and one-sixth of these patients received short-term systemic therapy of glucocorticoids during hospitalization. These conditions, including rapid heart rate, the presence of rheumatic disease, chronic pulmonary disease and septic shock, high lactate level, the requirements of mechanical ventilation and continuous renal replacement therapy, were associated with an increase in glucocorticoid administration (all P ≤ 0.024). During a follow-up of 90 days, the cumulative mortality rate in patients treated with glucocorticoids was significantly higher than that in these untreated with glucocorticoids (log-rank test, P < 0.001). Multivariable Cox regression analysis showed that glucocorticoid use (hazard ratio 1.48, 95% confidence interval [CI] 1.22-1.81; P < 0.001) was independently associated with an increased risk for 90-day all-cause mortality. This result was consistent irrespective of age, gender, the presence of myocardial infarction, acute decompensated heart failure and septic shock, and inotrope therapy, but was more evident in low-risk patients as assessed by ICU scoring systems. Additionally, multivariable Logistic regression analysis showed that glucocorticoid exposure was an independent predictor of hyperglycemia (odds ratio 2.14, 95% CI 1.48-3.10; P < 0.001), but not infection (odds ratio 1.23, 95% CI 0.88-1.73; P = 0.221). After PSM, glucocorticoid therapy was also significantly related with increased risks of 90-day mortality and hyperglycemia. CONCLUSIONS Real-world data showed that short-term systemic use of glucocorticoids was common in CS patients. Importantly, these prescriptions were associated with increased risks of adverse events.
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Affiliation(s)
- Hua-Ping Fan
- Department of Cardiology, 63650 Military Hospital, Urumqi, Xinjiang, 841700, China
| | - Yan Zhou
- Department of Ophthalmology, The First People's Hospital of Ziyang, Sichuan, 641300, China
| | - Yu Zhou
- Department of Cardiology, 63650 Military Hospital, Urumqi, Xinjiang, 841700, China
| | - Jun Jin
- Institute of Cardiovascular Diseases, Xinqiao Hospital, Army Medical University, Chongqing, 400038, China
| | - Tian-Yang Hu
- Precision Medicine Center, The Second Affiliated Hospital of Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, 400010, China.
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Ballerini MG, Freire AV, Rodríguez ME, Suco Valle S, Castro S, Arcari A, Bergadá I, Ropelato MG. Diagnostic Accuracy of Morning Salivary Cortisol in the Assessment of the Hypothalamic-Pituitary-Adrenal Axis Recovery after Prolonged Corticosteroid Therapy in Children. Horm Res Paediatr 2023; 97:53-61. [PMID: 37231892 DOI: 10.1159/000530939] [Citation(s) in RCA: 1] [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: 10/28/2022] [Accepted: 04/25/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Assessment of the hypothalamic-pituitary-adrenal (HPA) axis is necessary after prolonged glucocorticoid therapy withdrawal. Salivary cortisol reflects 65% of the free circulating cortisol fraction. Saliva collection is non-invasive and child friendly. OBJECTIVE We aimed to evaluate the diagnostic accuracy of morning salivary cortisol (mSAF) to determine HPA recovery after prolonged corticosteroid therapy in children. METHODS We conducted a prospective, validation study in 171 paediatric patients (mean ± SD age: 13.0 ± 4.4 years) who received glucocorticoids for >4 weeks (median and interquartile range: 11 [7-14] months) and were referred for therapy withdrawal. Serum and saliva samples were collected between 8 and 9 a.m. on the same day. Cortisol was measured by an electrochemiluminescence immunoassay (ECLIA) 48 h after cessation of glucocorticoid therapy. Serum cortisol ≥193 nmol/L was used as the reference cut-off value for HPA recovery after glucocorticoid withdrawal and mSAF as the index test. RESULTS The cut-off concentration obtained by ROC for mSAF was ≥5.0 nmol/L. True positive and true negative results were observed in 85/171 and 40/171 children, respectively. The false-positive rate was low (3/171, 1.7%); however, false-negative results were observed in 43/171 (25%) children. The main ROC results (95% CI) were area under curve: 0.98 (0.96-0.99), sensitivity: 0.66 (0.57-0.75), specificity: 0.93 (0.81-0.99), positive predictive value: 0.97 (0.90-0.99), negative predictive value: 0.48 (0.37-0.59), LR+: 9.5, and diagnostic accuracy: 73.1%. CONCLUSION The present study supports that mSAF ≥5.0 nmol/L by ECLIA is a non-invasive biomarker for the assessment of HPA recovery after prolonged glucocorticoid therapy in paediatric patients, with a positive predictive value of 97%. This proposed cut-off should be further validated using gold standard techniques for steroid quantification such as liquid chromatography-tandem mass spectrometry.
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Affiliation(s)
- María Gabriela Ballerini
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Analía Verónica Freire
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - María Eugenia Rodríguez
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Sofía Suco Valle
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Sebastián Castro
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Andrea Arcari
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ignacio Bergadá
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - María Gabriela Ropelato
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
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Monge Chacón AG, Wang C, Waqar D, Syeda SA, Kumar R, Meghana DR. Long-Term Usage of Oral Glucocorticoids Leading to Adrenal Insufficiency: A Comprehensive Review of the Literature. Cureus 2023; 15:e38948. [PMID: 37309331 PMCID: PMC10257969 DOI: 10.7759/cureus.38948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/14/2023] Open
Abstract
Systemic glucocorticoid therapy is used worldwide by one to three percent of the general population and 0.5-1.8% on long-term oral glucocorticoid use. It is widely used in conditions such as inflammation, autoimmune diseases, and cancer to inhibit inflammatory responses. One of the possible undesirable side effects of exogenous corticosteroid treatment is adrenal suppression upon discontinuation of the medication and adrenal insufficiency after utilizing the supraphysiologic doses for more than one month. To prevent patients from the unwanted signs and symptoms of adrenal insufficiency, including fatigue, gastrointestinal upset, anorexia/weight loss, etc., better management of the quantity and frequency of exogenous corticosteroid use, as well as better education before starting its use, is needed. For patients actively on exogenous corticosteroids, a close follow-up must be in place to avoid adrenal suppression after the eventual discontinuation of their use. This review article summarizes the important studies to date on this subject, especially oral glucocorticoid use, and analyzes risks such as dose, duration of exposure, and comorbidities of adrenal insufficiency associated with oral glucocorticoid use. We comprehensively include information on those with primary adrenal insufficiency and pediatric patients, hoping to provide better insight and clinical reference.
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Affiliation(s)
| | - Chen Wang
- Medicine, China Medical University, Taichung, TWN
| | - Danish Waqar
- Internal Medicine, Nephrology, Loyola University Medical Center, Chicago, USA
| | | | - Rohan Kumar
- Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
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Kane WJ, Berry PS. Perioperative Assessment and Optimization in Major Colorectal Surgery: Medication Management. Clin Colon Rectal Surg 2023; 36:210-217. [PMID: 37113275 PMCID: PMC10125279 DOI: 10.1055/s-0043-1761156] [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: 04/29/2023]
Abstract
The colorectal surgeon is often faced with medications that can be challenging to manage in the perioperative period. In the era of novel agents for anticoagulation and immunotherapies for inflammatory bowel disease and malignancy, understanding how to advise patients about these medications has become increasingly complex. Here, we aim to provide clarity regarding the use of these agents and their perioperative management, with a particular focus on when to stop and restart them perioperatively. This review will begin with the management of both nonbiologic and biologic therapies used in the treatment of inflammatory bowel disease and malignancy. Then, discussion will shift to anticoagulant and antiplatelet medications, including their associated reversal agents. Upon finishing this review, the reader will have gained an increased familiarity with the management of common medications requiring modification by colorectal surgeons in the perioperative period.
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Affiliation(s)
- William J. Kane
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Puja Shah Berry
- Department of General and Colorectal Surgery, WellSpan Surgical Specialists, York, Pennsylvania
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Debono M, Elder CJ, Lewis J, Fearnside J, Caunt S, Dixon S, Jacques RM, Newell-Price J, Whitaker MJ, Keevil B, Ross RJ. Home Waking Salivary Cortisone to Screen for Adrenal Insufficiency. NEJM EVIDENCE 2023; 2:EVIDoa2200182. [PMID: 38320034 DOI: 10.1056/evidoa2200182] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Worldwide, adults and children are at risk of adrenal insufficiency as a result of adrenal suppression from use of anti-inflammatory glucocorticoids and opiates, as well as infectious diseases. The adrenocorticotropin (ACTH) stimulation test is the reference standard for diagnosis of adrenal insufficiency but requires clinic attendance and venesection. Salivary cortisone reflects free serum cortisol, and samples can be collected at home and posted to a laboratory. We tested whether home waking salivary cortisone level could be used to screen for adrenal insufficiency. METHODS: A prospective, diagnostic accuracy study was performed in patients at high risk of adrenal insufficiency. Patients collected a home salivary sample on waking and then attended the clinical facility for an ACTH stimulation test. Salivary cortisone was measured by liquid chromatography–tandem mass spectrometry. Receiver-operating characteristic curves were computed, and positive and negative predictive values were calculated. RESULTS: Two hundred twenty patients were recruited. As measured by an ACTH stimulation test, the prevalence of adrenal insufficiency was 44%. The area under the receiver-operating characteristic curve for waking salivary cortisone as a predictor of adrenal insufficiency was 0.95 (95% confidence interval [CI], 0.92 to 0.97). Cutoffs to ensure a minimum of 95% sensitivity and specificity gave a negative predictive value of 96% (95% CI, 90 to 99) and a positive predictive value of 95% (95% CI, 87 to 99) to exclude and confirm adrenal insufficiency, respectively. Waking salivary cortisone data provided information similar to that of an ACTH stimulation test in 70% of participants. Eighty-three percent of patients preferred home salivary collection to clinic attendance. CONCLUSIONS: Home waking salivary cortisone sampling has accuracy for the diagnosis of adrenal insufficiency similar to that of a standard ACTH stimulation test. Patients found the at-home test to be more convenient than the hospital-based test. (Funded by the National Institute for Health Research.)
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Affiliation(s)
- Miguel Debono
- Department of Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Charlotte J Elder
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Jen Lewis
- Medical Statistics and Health Economics, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Jane Fearnside
- Medical Statistics and Health Economics, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Sharon Caunt
- Department of Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Simon Dixon
- Medical Statistics and Health Economics, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Richard M Jacques
- Medical Statistics and Health Economics, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - John Newell-Price
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Martin J Whitaker
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Brian Keevil
- Department of Biochemistry, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Richard J Ross
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
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Raff H, Zhang CD. A New Approach - Home Waking Salivary Cortisone to Screen for Adrenal Insufficiency. NEJM EVIDENCE 2023; 2:EVIDe2200306. [PMID: 38320042 DOI: 10.1056/evide2200306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Adrenal insufficiency is a common and potentially life-threatening endocrine disorder that can be drug induced or endogenous and of adrenal (primary) or pituitary/hypothalamic (secondary/tertiary) origin.1,2 Of particular concern in drug-induced disease is the patient with glucocorticoid- or opioid-induced adrenal insufficiency. Adrenal insufficiency of any cause is typically diagnosed biochemically with a subnormal morning serum cortisol (the circadian, awakening peak) and serum dehydroepiandrosterone sulfate, followed by or simultaneously with an assessment of the acute (30 and 60 minutes) serum cortisol response to injected synthetic corticotropin (ACTH[1-24]), if clinically indicated.
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Affiliation(s)
- Hershel Raff
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee
- Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Milwaukee
| | - Catherine D Zhang
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee
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Paragliola RM, Locantore P, Corsello SM, Salvatori R. Treating Hypopituitarism in the Over 65s: Review of Clinical Studies. Clin Interv Aging 2023; 18:423-439. [PMID: 36974195 PMCID: PMC10039666 DOI: 10.2147/cia.s370782] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/02/2023] [Indexed: 03/29/2023] Open
Abstract
The current increase of life expectancy is associated with the presence of endocrine diseases in the elderly. The management of hypopituitarism in this group of patients is a challenging task. A correct diagnosis, which represents an essential requisite for an appropriate medical treatment, can be difficult because of the physiological changes occurring in pituitary function with aging, which may lead to challenges in the interpretation of laboratory results. Furthermore, the treatment requires several careful considerations: the need to restore the hormonal physiology with replacement therapies must be balanced with the need to avoid the risks of the over-replacement, especially in the presence of concomitant cardiovascular and metabolic disease. Interactions with other drugs able to modify the absorption and/or the metabolism of hormonal replacement therapies should be considered, in particular for the treatment of hypoadrenalism and hypothyroidism. The most important challenges stem from the lack of specific studies focused on the management of hypopituitarism in older people.
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Affiliation(s)
- Rosa Maria Paragliola
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
- Unicamillus-Saint Camillus International University of Health Sciences, Rome, Italy
| | - Pietro Locantore
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Salvatore Maria Corsello
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
- Unicamillus-Saint Camillus International University of Health Sciences, Rome, Italy
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine and Pituitary Center Johns Hopkins University, Baltimore, MD, USA
- Correspondence: Roberto Salvatori, Johns Hopkins University, Division of Endocrinology, Diabetes and Metabolism, 1830 East Monument Street #333, Baltimore, MD, 21287, USA, Tel +1- 410 955-3921, Fax +1-410 367-2042, Email
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Prencipe N, Marinelli L, Varaldo E, Cuboni D, Berton AM, Bioletto F, Bona C, Gasco V, Grottoli S. Isolated anterior pituitary dysfunction in adulthood. Front Endocrinol (Lausanne) 2023; 14:1100007. [PMID: 36967769 PMCID: PMC10032221 DOI: 10.3389/fendo.2023.1100007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/21/2023] [Indexed: 03/29/2023] Open
Abstract
Hypopituitarism is defined as a complete or partial deficiency in one or more pituitary hormones. Anterior hypopituitarism includes secondary adrenal insufficiency, central hypothyroidism, hypogonadotropic hypogonadism, growth hormone deficiency and prolactin deficiency. Patients with hypopituitarism suffer from an increased disability and sick days, resulting in lower health status, higher cost of care and an increased mortality. In particular during adulthood, isolated pituitary deficits are not an uncommon finding; their clinical picture is represented by vague symptoms and unclear signs, which can be difficult to properly diagnose. This often becomes a challenge for the physician. Aim of this narrative review is to analyse, for each anterior pituitary deficit, the main related etiologies, the characteristic signs and symptoms, how to properly diagnose them (suggesting an easy and reproducible step-based approach), and eventually the treatment. In adulthood, the vast majority of isolated pituitary deficits are due to pituitary tumours, head trauma, pituitary surgery and brain radiotherapy. Immune-related dysfunctions represent a growing cause of isolated pituitary deficiencies, above all secondary to use of oncological drugs such as immune checkpoint inhibitors. The diagnosis of isolated pituitary deficiencies should be based on baseline hormonal assessments and/or dynamic tests. Establishing a proper diagnosis can be quite challenging: in fact, even if the diagnostic methods are becoming increasingly refined, a considerable proportion of isolated pituitary deficits still remains without a certain cause. While isolated ACTH and TSH deficiencies always require a prompt replacement treatment, gonadal replacement therapy requires a benefit-risk evaluation based on the presence of comorbidities, age and gender of the patient; finally, the need of growth hormone replacement therapies is still a matter of debate. On the other side, prolactin replacement therapy is still not available. In conclusion, our purpose is to offer a broad evaluation from causes to therapies of isolated anterior pituitary deficits in adulthood. This review will also include the evaluation of uncommon symptoms and main etiologies, the elements of suspicion of a genetic cause and protocols for diagnosis, follow-up and treatment.
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Chen Cardenas SM, Santhanam P, Morris-Wiseman L, Salvatori R, Hamrahian AH. Perioperative Evaluation and Management of Patients on Glucocorticoids. J Endocr Soc 2022; 7:bvac185. [PMID: 36545644 PMCID: PMC9760550 DOI: 10.1210/jendso/bvac185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Indexed: 12/04/2022] Open
Abstract
Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.
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Affiliation(s)
- Stanley M Chen Cardenas
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Prasanna Santhanam
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lilah Morris-Wiseman
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Amir H Hamrahian
- Correspondence: Amir Hamrahian, MD, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 E Monument St, Ste 333, Baltimore, MD 21287, USA.
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Li D. Quality of Life in Patients with Adrenal Insufficiency. Endocrinol Metab Clin North Am 2022; 51:741-753. [PMID: 36244690 DOI: 10.1016/j.ecl.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients with adrenal insufficiency, despite standard glucocorticoid replacement therapy, continue to experience and report impaired self-perceived health status and quality of life. In this review, we will describe quality of life in this patient population, and summarize the determinants of quality of life, based on previous survey-based studies and clinical trials. In addition, some new emerging data during the still ongoing coronavirus disease pandemic are also reviewed in the present article.
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Affiliation(s)
- Dingfeng Li
- Department of Endocrinology, Endocrine and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, F20, Cleveland, OH 44195, USA.
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Affiliation(s)
- Aoife Garrahy
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Aparna Pal
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK
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36
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Chiarella SE, Bancos I, Ortega VE. Inhaled Corticosteroid-Induced Adrenal Suppression in Patients With Asthma Detected by Metabolomic Profiling. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2774-2775. [PMID: 36444000 PMCID: PMC10041941 DOI: 10.1016/j.jaip.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 07/24/2022] [Accepted: 08/01/2022] [Indexed: 11/21/2022]
Affiliation(s)
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minn
| | - Victor E Ortega
- Division of Respiratory Medicine, Mayo Clinic, Scottsdale, Ariz
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Brennan V, Martin-Grace J, Greene G, Heverin K, Mulvey C, McCartan T, Lombard L, Walsh J, Hale EM, Srinivasan S, O'Reilly MW, Thompson CJ, Costello RW, Sherlock M. The Contribution of Oral and Inhaled Glucocorticoids to Adrenal Insufficiency in Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2614-2623. [PMID: 35697207 DOI: 10.1016/j.jaip.2022.05.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/25/2022] [Accepted: 05/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Exposure to any form of glucocorticoid preparation is associated with a risk of adrenal insufficiency (AI). OBJECTIVE To establish the contribution of oral corticosteroid (OCS) and inhaled corticosteroid (ICS) exposure to the risk of AI in a cohort of patients (n = 80) with severe, uncontrolled asthma. METHODS We compiled individualized cumulative OCS and ICS exposure data using a combination of health care records and electronic inhaler monitoring using an Inhaler Compliance Assessment device and estimated the risk of AI for each participant using a morning serum cortisol concentration. RESULTS The predicted prevalence of AI based on morning cortisol concentrations was 25% (20 of 80). Participants on maintenance OCS therapy had the highest risk of AI at 60% (6 of 10) compared with 17% (11 of 65) in those with no recent OCS exposure. Morning serum cortisol correlated negatively with both OCS exposure (mg/kg prednisolone) (r = -0.4; P < .0002) and ICS exposure (mg/kg fluticasone propionate) (r = -0.26; P = .019). Logistic regression of risk of AI against the number of standard treatment courses of OCS demonstrated a positive relationship although this did not reach statistical significance (odds ratio, 1.41; 95% CI, 0.97-2.05; P = .073). Logistic regression analysis, categorizing patients as high-risk AI (cortisol <130 nmol/L) or not (cortisol >130 nmol/L), showed that cumulative ICS exposure remained a significant predictor of AI, even when exposure to OCS was controlled for (odds ratio, 2.17 per 1 mg/kg increase in cumulative fluticasone propionate exposure; 95% CI, 1.06-4.42; P = .033). CONCLUSIONS Our data suggest that AI is common among patients with asthma and highlights that the risk of AI is associated with both high-dose ICS therapy and intermittent treatment courses of OCS.
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Affiliation(s)
- Vincent Brennan
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Julie Martin-Grace
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Garrett Greene
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Karen Heverin
- Department of Clinical Biochemistry, Beaumont Hospital, Dublin, Ireland
| | - Christopher Mulvey
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Tom McCartan
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Lorna Lombard
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Joanne Walsh
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Elaine Mac Hale
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland
| | - Shari Srinivasan
- Department of Clinical Biochemistry, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland; Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Chris J Thompson
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland; Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Richard W Costello
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland; Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Medicine, Royal College of Surgeons in Ireland Beaumont Campus, Dublin, Ireland; Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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Fedotcheva TA, Fedotcheva NI, Shimanovsky NL. Progesterone as an Anti-Inflammatory Drug and Immunomodulator: New Aspects in Hormonal Regulation of the Inflammation. Biomolecules 2022; 12:biom12091299. [PMID: 36139138 PMCID: PMC9496164 DOI: 10.3390/biom12091299] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/10/2022] [Accepted: 09/11/2022] [Indexed: 11/25/2022] Open
Abstract
The specific regulation of inflammatory processes by steroid hormones has been actively studied in recent years, especially by progesterone (P4) and progestins. The mechanisms of the anti-inflammatory and immunomodulatory P4 action are not fully clear. The anti-inflammatory effects of P4 can be defined as nonspecific, associated with the inhibition of NF-κB and COX, as well as the inhibition of prostaglandin synthesis, or as specific, associated with the regulation of T-cell activation, the regulation of the production of pro- and anti-inflammatory cytokines, and the phenomenon of immune tolerance. The specific anti-inflammatory effects of P4 and its derivatives (progestins) can also include the inhibition of proliferative signaling pathways and the antagonistic action against estrogen receptor beta-mediated signaling as a proinflammatory and mitogenic factor. The anti-inflammatory action of P4 is accomplished through the participation of progesterone receptor (PR) chaperones HSP90, as well as immunophilins FKBP51 and FKBP52, which are the validated targets of clinically approved immunosuppressive drugs. The immunomodulatory and anti-inflammatory effects of HSP90 inhibitors, tacrolimus and cyclosporine, are manifested, among other factors, due to their participation in the formation of an active ligand–receptor complex of P4 and their interaction with its constituent immunophilins. Pharmacological agents such as HSP90 inhibitors can restore the lost anti-inflammatory effect of glucocorticoids and P4 in chronic inflammatory and autoimmune diseases. By regulating the activity of FKBP51 and FKBP52, it is possible to increase or decrease hormonal signaling, as well as restore it during the development of hormone resistance. The combined action of immunophilin suppressors with steroid hormones may be a promising strategy in the treatment of chronic inflammatory and autoimmune diseases, including endometriosis, stress-related disorders, rheumatoid arthritis, and miscarriages. Presumably, the hormone receptor- and immunophilin-targeted drugs may act synergistically, allowing for a lower dose of each.
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Affiliation(s)
- Tatiana A. Fedotcheva
- Science Research Laboratory of Molecular Pharmacology, Medical Biological Faculty, Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation, Ostrovityanova St. 1, Moscow 117997, Russia
- Correspondence: ; Tel.: +7-9169353196
| | - Nadezhda I. Fedotcheva
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, Institutskaya Str. 3, Pushchino 142290, Russia
| | - Nikolai L. Shimanovsky
- Science Research Laboratory of Molecular Pharmacology, Medical Biological Faculty, Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation, Ostrovityanova St. 1, Moscow 117997, Russia
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Investigation of the 12-month efficacy and safety of low-dose mifepristone in the treatment of painful adenomyosis. REPRODUCTIVE AND DEVELOPMENTAL MEDICINE 2022. [DOI: 10.1097/rd9.0000000000000031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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40
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Lentz S, Collier KC, Willis G, Long B. Diagnosis and Management of Adrenal Insufficiency and Adrenal Crisis in the Emergency Department. J Emerg Med 2022; 63:212-220. [PMID: 36038436 DOI: 10.1016/j.jemermed.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/24/2022] [Accepted: 06/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Adrenal insufficiency can result in significant patient morbidity and mortality, but due to the range of symptoms and variable clinical course and etiologies, it can be a challenging condition to diagnose and manage. OBJECTIVE This narrative review will discuss the evaluation of an adult patient at risk for a new diagnosis of adrenal insufficiency and the management of a patient with known or suspected adrenal insufficiency. DISCUSSION A new presentation of adrenal insufficiency can range from nonspecific, minor symptoms including fatigue, to a life-threatening adrenal crisis with hemodynamic instability. Due to the variety of signs and symptoms, the diagnosis is often missed. Those with known adrenal insufficiency are at risk for adrenal crisis, which may occur due to a variety of triggers. Initial evaluation includes assessment for the underlying etiology or concomitant condition, laboratory analysis, and imaging, when clinically indicated. Although not necessary for evaluation in the emergency department setting, the diagnosis is confirmed by specific testing such as the cosyntropin stimulation test. The mainstay of treatment in adrenal crisis is hydrocortisone, intravenous fluid, glucose repletion, and treatment of the underlying acute trigger. CONCLUSIONS Emergency clinicians must be prepared to recognize, evaluate, and manage those with known or suspected adrenal insufficiency or adrenal crisis.
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Affiliation(s)
- Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, The University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Kathryn C Collier
- Emergency Medicine Residency, The University of Vermont Larner College of Medicine, Burlington, Vermont
| | - George Willis
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Brit Long
- Emergency Medicine, San Antonio Uniformed Services Health Education Consortium (SAUSHEC), Brooke Army Medical Center, Fort Sam Houston, Texas
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41
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Kim JH. Time to Care for Adrenal Insufficiency in Cancer Patients. J Korean Med Sci 2022; 37:e232. [PMID: 35851865 PMCID: PMC9294499 DOI: 10.3346/jkms.2022.37.e232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Raschi E, Fusaroli M, Massari F, Mollica V, Repaci A, Ardizzoni A, Poluzzi E, Pagotto U, Di Dalmazi G. The Changing Face of Drug-induced Adrenal Insufficiency in the Food and Drug Administration Adverse Event Reporting System. J Clin Endocrinol Metab 2022; 107:e3107-e3114. [PMID: 35704533 PMCID: PMC9282361 DOI: 10.1210/clinem/dgac359] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Indexed: 12/18/2022]
Abstract
CONTEXT Adrenal insufficiency (AI) is a life-threatening condition complicating heterogeneous disorders across various disciplines, with challenging diagnosis and a notable drug-induced component. OBJECTIVE This work aimed to describe the spectrum of drug-induced AI through adverse drug event reports received by the US Food and Drug Administration (FDA). METHODS A retrospective disproportionality analysis reporting trends of drug-induced AI was conducted on the FDA Adverse Event Reporting System (FAERS) (> 15 000 000 reports since 2004). AE reports were extracted from FAERS over the past 2 decades. Interventions included cases containing any of the preferred terms in the Medical Dictionary for Regulatory Activities describing AI, and signals of disproportionate reporting for drugs recorded in 10 or more cases as primary suspect. RESULTS We identified 8496 cases of AI: 97.5% serious, 41.1% requiring hospitalization. AI showed an exponential increase throughout the years, with 5282 (62.2%) cases in 2015 to 2020. We identified 56 compounds associated with substantial disproportionality: glucocorticoids (N = 1971), monoclonal antibodies (N = 1644, of which N = 1330 were associated with immune checkpoint inhibitors-ICIs), hormone therapy (N = 291), anti-infectives (N = 252), drugs for hypercortisolism or adrenocortical cancer diagnosis/treatment (N = 169), and protein kinase inhibitors (N = 138). Cases of AI by glucocorticoids were stable in each 5-year period (22%-27%), whereas those by monoclonal antibodies, largely ICIs, peaked from 13% in 2010 to 2015 to 33% in 2015 to 2020. CONCLUSION We provide a comprehensive insight into the evolution of drug-induced AI, highlighting the heterogeneous spectrum of culprit drug classes and the emerging increased reporting of ICIs. We claim for the urgent identification of predictive factors for drug-induced AI, and the establishment of screening and educational protocols for patients and caregivers.
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Affiliation(s)
- Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum–University of Bologna, Bologna 40138, Italy
| | - Michele Fusaroli
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum–University of Bologna, Bologna 40138, Italy
| | - Francesco Massari
- Medical Oncology Unit, IRCCS Azienda Ospedaliero–Universitaria di Bologna, Bologna 40138, Italy
| | - Veronica Mollica
- Medical Oncology Unit, IRCCS Azienda Ospedaliero–Universitaria di Bologna, Bologna 40138, Italy
| | - Andrea Repaci
- Division of Endocrinology and Diabetes Prevention and Care Unit, IRCCS Azienda Ospedaliero–Universitaria di Bologna, Bologna 40138, Italy
| | - Andrea Ardizzoni
- Medical Oncology Unit, IRCCS Azienda Ospedaliero–Universitaria di Bologna, Bologna 40138, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum–University of Bologna, Bologna 40138, Italy
| | - Elisabetta Poluzzi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum–University of Bologna, Bologna 40138, Italy
| | - Uberto Pagotto
- Division of Endocrinology and Diabetes Prevention and Care Unit, IRCCS Azienda Ospedaliero–Universitaria di Bologna, Bologna 40138, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum–University of Bologna, Bologna 40138, Italy
| | - Guido Di Dalmazi
- Correspondence: Guido Di Dalmazi, MD, Division of Endocrinology and Diabetes Prevention and Care Unit, IRCCS Azienda Ospedaliero–Universitaria di Bologna, Department of Medical and Surgical Sciences, Alma Mater Studiorum–University of Bologna, via Massarenti, 9, 40138 Bologna, Italy.
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Duncan PJ, McClafferty H, Nolan O, Ding Q, Homer NZM, Le Tissier P, Walker BR, Shipston MJ, Romanò N, Chambers TJG. Corticotroph isolation from Pomc-eGFP mice reveals sustained transcriptional dysregulation characterising a mouse model of glucocorticoid-induced suppression of the hypothalamus-pituitary-adrenal axis. J Neuroendocrinol 2022; 34:e13165. [PMID: 35833423 PMCID: PMC9539609 DOI: 10.1111/jne.13165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 04/16/2022] [Accepted: 04/18/2022] [Indexed: 11/27/2022]
Abstract
Glucocorticoids (GC) are prescribed for periods > 3 months to 1%-3% of the UK population; 10%-50% of these patients develop hypothalamus-pituitary-adrenal (HPA) axis suppression, which may last over 6 months and is associated with morbidity and mortality. Recovery of the pituitary and hypothalamus is necessary for recovery of adrenal function. We developed a mouse model of dexamethasone (DEX)-induced HPA axis dysfunction aiming to further explore recovery in the pituitary. Adult male wild-type C57BL6/J or Pomc-eGFP transgenic mice were randomly assigned to receive DEX (approximately 0.4 mg kg-1 bodyweight day-1 ) or vehicle via drinking water for 4 weeks following which treatment was withdrawn and tissues were harvested after another 0, 1, and 4 weeks. Corticotrophs were isolated from Pomc-eGFP pituitaries using fluorescence-activated cell sorting, and RNA extracted for RNA-sequencing. DEX treatment suppressed corticosterone production, which remained partially suppressed at least 1 week following DEX withdrawal. In the adrenal, Hsd3b2, Cyp11a1, and Mc2r mRNA levels were significantly reduced at time 0, with Mc2r and Cyp11a1 remaining reduced 1 week following DEX withdrawal. The corticotroph transcriptome was modified by DEX treatment, with some differences between groups persisting 4 weeks following withdrawal. No genes supressed by DEX exhibited ongoing attenuation 1 and 4 weeks following withdrawal, whereas only two genes were upregulated and remained so following withdrawal. A pattern of rebound at 1 and 4 weeks was observed in 14 genes that increased following suppression, and in six genes that were reduced by DEX and then increased. Chronic GC treatment may induce persistent changes in the pituitary that may influence future response to GC treatment or stress.
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Affiliation(s)
- Peter J. Duncan
- Centre for Discovery Brain SciencesUniversity of EdinburghEdinburghUK
| | | | - Oscar Nolan
- Centre for Discovery Brain SciencesUniversity of EdinburghEdinburghUK
| | - Qinghui Ding
- Centre for Discovery Brain SciencesUniversity of EdinburghEdinburghUK
| | - Natalie Z. M. Homer
- Centre for Cardiovascular ScienceUniversity of Edinburgh, Queen's Medical Research InstituteEdinburghUK
| | - Paul Le Tissier
- Centre for Discovery Brain SciencesUniversity of EdinburghEdinburghUK
| | - Brian R. Walker
- Centre for Cardiovascular ScienceUniversity of Edinburgh, Queen's Medical Research InstituteEdinburghUK
- Translational & Clinical Research InstituteNewcastle UniversityNewcastle upon TyneUK
| | | | - Nicola Romanò
- Centre for Discovery Brain SciencesUniversity of EdinburghEdinburghUK
| | - Thomas J. G. Chambers
- Centre for Discovery Brain SciencesUniversity of EdinburghEdinburghUK
- Edinburgh Centre for Endocrinology and DiabetesNHS Lothian, Metabolic Unit, Western General HospitalEdinburghUK
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Abstract
Severe asthma is a heterogeneous syndrome with several clinical variants and often represents a complex disease requiring a specialized and multidisciplinary approach, as well as the use of multiple drugs. The prevalence of severe asthma varies from one country to another, and it is estimated that 50% of these patients present a poor control of their disease. For the best management of the patient, it is necessary a correct diagnosis, an adequate follow-up and undoubtedly to offer the best available treatment, including biologic treatments with monoclonal antibodies. With this objective, this consensus process was born, which began in its first version in 2018, whose goal is to offer the patient the best possible management of their disease in order to minimize their symptomatology. For this 2020 consensus update, a literature review was conducted by the authors. Subsequently, through a two-round interactive Delphi process, a broad panel of asthma experts from SEPAR and the regional pulmonology societies proposed the recommendations and conclusions contained in this document.
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Jensterle M, Herman R, Janež A, Mahmeed WA, Al-Rasadi K, Al-Alawi K, Banach M, Banerjee Y, Ceriello A, Cesur M, Cosentino F, Galia M, Goh SY, Kalra S, Kempler P, Lessan N, Lotufo P, Papanas N, Rizvi AA, Santos RD, Stoian AP, Toth PP, Viswanathan V, Rizzo M. The Relationship between COVID-19 and Hypothalamic–Pituitary–Adrenal Axis: A Large Spectrum from Glucocorticoid Insufficiency to Excess—The CAPISCO International Expert Panel. Int J Mol Sci 2022; 23:ijms23137326. [PMID: 35806331 PMCID: PMC9266848 DOI: 10.3390/ijms23137326] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 12/12/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a highly heterogeneous disease regarding severity, vulnerability to infection due to comorbidities, and treatment approaches. The hypothalamic–pituitary–adrenal (HPA) axis has been identified as one of the most critical endocrine targets of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that might significantly impact outcomes after infection. Herein we review the rationale for glucocorticoid use in the setting of COVID-19 and emphasize the need to have a low index of suspicion for glucocorticoid-induced adrenal insufficiency, adjusting for the glucocorticoid formulation used, dose, treatment duration, and underlying health problems. We also address several additional mechanisms that may cause HPA axis dysfunction, including critical illness-related corticosteroid insufficiency, the direct cytopathic impacts of SARS-CoV-2 infection on the adrenals, pituitary, and hypothalamus, immune-mediated inflammations, small vessel vasculitis, microthrombotic events, the resistance of cortisol receptors, and impaired post-receptor signaling, as well as the dissociation of ACTH and cortisol regulation. We also discuss the increased risk of infection and more severe illness in COVID-19 patients with pre-existing disorders of the HPA axis, from insufficiency to excess. These insights into the complex regulation of the HPA axis reveal how well the body performs in its adaptive survival mechanism during a severe infection, such as SARS-CoV-2, and how many parameters might disbalance the outcomes of this adaptation.
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Affiliation(s)
- Mojca Jensterle
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (M.J.); (R.H.)
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Rok Herman
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (M.J.); (R.H.)
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Andrej Janež
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (M.J.); (R.H.)
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence: ; Tel.: +386-1-522-35-64
| | - Wael Al Mahmeed
- Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi P.O. Box 112412, United Arab Emirates;
| | - Khalid Al-Rasadi
- Medical Research Center, Sultan Qaboos University, Muscat 113, Oman;
| | - Kamila Al-Alawi
- Department of Training and Studies, Royal Hospital, Ministry of Health, Muscat 113, Oman;
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), 90-419 Lodz, Poland;
- Polish Mother’s Memorial Hospital Research Institute (PMMHRI), 93-338 Lodz, Poland
- Cardiovascular Research Centre, University of Zielona Gora, 65-417 Zielona Gora, Poland
| | - Yajnavalka Banerjee
- Department of Biochemistry, Mohamed Bin Rashid University, Dubai P.O. Box 505055, United Arab Emirates;
| | | | - Mustafa Cesur
- Clinic of Endocrinology, Ankara Güven Hospital, 06540 Ankara, Turkey;
| | - Francesco Cosentino
- Unit of Cardiology, Karolinska Institute and Karolinska University Hospital, University of Stockholm, 171 77 Stockholm, Sweden;
| | - Massimo Galia
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bind), University of Palermo, 90127 Palermo, Italy;
| | - Su-Yen Goh
- Department of Endocrinology, Singapore General Hospital, Singapore 169856, Singapore;
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital & BRIDE, Karnal 132001, India;
| | - Peter Kempler
- Department of Medicine and Oncology, Semmelweis University, 1085 Budapest, Hungary;
| | - Nader Lessan
- The Research Institute, Imperial College London Diabetes Centre, Abu Dhabi P.O. Box 48338, United Arab Emirates;
| | - Paulo Lotufo
- Center for Clinical and Epidemiological Research, University Hospital, University of São Paulo, São Paulo 05403-000, Brazil;
| | - Nikolaos Papanas
- Diabetes Center, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, 68100 Alexandroupoli, Greece;
| | - Ali A. Rizvi
- Department of Medicine, University of Central Florida College of Medicine, Orlando, FL 32827, USA;
| | - Raul D. Santos
- The Heart Institute (InCor), University of Sao Paulo Medical School Hospital, São Paulo 05403-000, Brazil;
- Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Anca P. Stoian
- Faculty of Medicine, Diabetes, Nutrition and Metabolic Diseases, Carol Davila University, 050474 Bucharest, Romania;
| | - Peter P. Toth
- Cicarrone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | | | - Manfredi Rizzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (Promise), University of Palermo, 90127 Palermo, Italy;
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Li D, Brand S, Hamidi O, Westfall AA, Suresh M, Else T, Vaidya A, Bancos I. Quality of Life and its Determinants in Patients With Adrenal Insufficiency: A Survey Study at 3 Centers in the United States. J Clin Endocrinol Metab 2022; 107:e2851-e2861. [PMID: 35350067 PMCID: PMC9202727 DOI: 10.1210/clinem/dgac175] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Current evidence on determinants of quality of life (QoL) in patients with adrenal insufficiency (AI) is limited. OBJECTIVE This work aimed to identify the determinants of QoL in different subtypes of AI. METHODS This multicenter cross-sectional survey study was conducted using a patient-centered questionnaire, the Short Form-36. RESULTS Of 529 participants, 223 (42.2%) had primary AI, 190 (35.9%) had secondary AI, and 116 (21.9%) had glucocorticoid-induced AI. Median age was 58 years (interquartile range: 43-68 years) and 342 (64.8%) were women. In multivariable analyses, patients were more likely to report worse physical scores if they were women (odds ratio [OR]: 3.3; 95% CI, 1.8-6.0), had secondary AI or glucocorticoid-induced AI (OR: 2.5; 95% CI, 1.4-4.3), had shorter duration of AI (OR: 2.0; 95% CI, 1.1-3.6), were treated with more than 25 mg hydrocortisone equivalent daily (OR: 2.3; 95% CI, 1.2-4.6), had more comorbidities related to glucocorticoid excess (OR: 2.3; 95% CI, 1.3-4.0), reported a higher financial burden from AI (OR: 2.1; 95% CI, 1.3-3.6), and reported difficulties with AI management (OR: 2.5; 95% CI, 1.2-5.2). Women (OR: 2.1; 95% CI, 1.08-4.0), shorter duration of AI (OR: 2.4; 95% CI, 1.4-4.3), higher financial burden (OR: 2.3; 95% CI, 1.3-4.0), difficulties with AI management (OR: 2.6; 95% CI, 1.4-4.9), and lack of family support (OR: 9.1; 95% CI, 2.3-33.3) were associated with worse mental component scores. CONCLUSION In patients with AI, QoL could be improved by addressing certain determinants, such as avoiding GC overreplacement, providing in-depth education on self-management, offering more comprehensive insurance coverage, and ensuring better family support.
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Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Sarah Brand
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA
| | - Ashleigh A Westfall
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA
| | - Malavika Suresh
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Tobias Else
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts 02115, USA
| | - Irina Bancos
- Correspondence: Irina Bancos, MD, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Heuer JG, Meyer CM, Baker HE, Geiser A, Lucchesi J, Xu D, Hamang M, Martin JA, Hu C, Roth KD, Thirunavukkarasu K, Alsina-Fernandez J, Ma YL. Pharmacological Evaluation of a Pegylated Urocortin-1 Peptide in Experimental Autoimmune Disease Models. J Pharmacol Exp Ther 2022; 382:287-298. [PMID: 35688476 DOI: 10.1124/jpet.122.001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/25/2022] [Indexed: 11/22/2022] Open
Abstract
Urocortin-1 (UCN1) is a member of the corticotropin releasing hormone (CRH) family of peptides that acts through CRH-receptor 1 (CRHR1) and CRH-receptor 2 (CRHR2). UCN1 can induce adrenocorticotropin hormone (ACTH) and downstream glucocorticoids through CRHR1 and promote beneficial metabolic effects through CRHR2. UCN1 has a short half-life and has been shown to improve experimental autoimmune disease. A pegylated UCN1 peptide (PEG-hUCN1) was generated to extend half-life and was tested in multiple experimental autoimmune disease models and in healthy mice to determine effects on corticosterone induction, autoimmune disease, and glucocorticoid induced adverse effects. Cardiovascular effects were also assessed by telemetry. PEG-hUCN1 demonstrated a dose dependent 4-to-6-fold elevation of serum corticosterone and significantly improved autoimmune disease comparable to prednisolone in several experimental models. In healthy mice, PEG-hUCN1 showed less adverse effects compared to corticosterone treatment. PEG-hUCN1 peptide induced an initial 30% reduction in blood pressure that was followed by a gradual and sustained 30% increase in blood pressure at the highest dose. Additionally, an adeno-associated viral 8 (AAV8) UCN1 was used to assess adverse effects of chronic elevation of UCN1 in wild type and CRHR2 knockout mice. Chronic UCN1 expression by an AAV8 approach in wild type and CRHR2 knockout mice demonstrated an important role of CRHR2 in countering the adverse metabolic effects of elevated corticosterone from UCN1. Our findings demonstrate that PEG-hUCN1 shows profound effects in treating autoimmune disease with an improved safety profile relative to corticosterone and that CRHR2 activity is important in metabolic regulation. Significance Statement This study reports the generation and characterization of a pegylated UCN1 peptide and the role of CRHR2 in UCN1-induced metabolic effects. The potency/selectivity, pharmacokinetic properties, pharmacodynamic effects and efficacy in four autoimmune models and safety profiles are presented. This pegylated UCN1 shows potential for treating autoimmune diseases with reduced adverse effects compared to corticosterone treatment. Continuous exposure to UCN1 through an AAV8 approach demonstrates some glucocorticoid mediated adverse metabolic effects that are exacerbated in the absence of the CRHR2 receptor.
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Affiliation(s)
- Josef G Heuer
- Biotherapeutic Discovery Research, Eli Lilly and Company, United States
| | - Catalina M Meyer
- Biotherapeutic Discovery Research, Eli Lilly and Company, United States
| | - Hana E Baker
- Lilly Research Laboratories, Eli Lilly and Company, United States
| | - Andrea Geiser
- New Therapeutic Modalities, Eli Lilly and Company, United States
| | - Jonathan Lucchesi
- Biotechnology & Immunology Res, Eli Lilly and Company, United States
| | - Daniel Xu
- Biotechnology & Immunology Res, Eli Lilly and Company, United States
| | - Matthew Hamang
- Biotechnology & Immunology Res, Eli Lilly and Company, United States
| | | | - Charlie Hu
- Biotherapeutic Discovery Research, Eli Lilly and Company, United States
| | - Kenneth D Roth
- Molecular Pharmacology, Eli Lilly and Company, United States
| | | | | | - Yanfei L Ma
- Biotechnology & Immunology Res, Eli Lilly and Company, United States
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Abstract
Adrenal insufficiency (AI), first described by Thomas Addison in 1855, is characterised by inadequate hormonal production by the adrenal gland, which could either be primary, due to destruction of the adrenal cortex, or secondary/tertiary, due to lack of adrenocorticotropic hormone or its stimulation by corticotropin-releasing hormone. This was an invariably fatal condition in Addison's days with most patients dying within a few years of diagnosis. However, discovery of cortisone in the 1940s not only improved the life expectancy of these patients but also had a dramatic effect on their overall quality of life. The diagnosis, easily confirmed by demonstrating inappropriately low cortisol secretion, is often delayed by months, and many patients present with acute adrenal crisis. Sudden withdrawal from chronic glucocorticoid therapy is the most common cause of AI. Currently, there remains a wide variation in the management of this condition across Europe. As primary AI is a relatively rare condition, most medical specialists will only manage a handful of these patients in their career. Despite many advances in recent years, there is currently no curative option, and modern cortisol replacement regimens fail to adequately mimic physiological cortisol rhythm. A number of new approaches including allograft of adrenocortical tissue and stem cell therapy are being tried but remain largely experimental.
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Affiliation(s)
- Rajeev Kumar
- Diabetes and Endocrinology, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - W S Wassif
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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Stam SP, Vulto A, Vos MJ, Kerstens MN, Rutgers A, Kema I, Touw DJ, Bakker SJ, van Beek AP. Rationale and design of the CORE (COrticosteroids REvised) study: protocol. BMJ Open 2022; 12:e061678. [PMID: 35473729 PMCID: PMC9045047 DOI: 10.1136/bmjopen-2022-061678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Corticosteroids are an important pillar in many anti-inflammatory and immunosuppressive treatment regimens and are available in natural and synthetic forms, which are considered equipotent if clinical bioequivalence data are used. Current clinical bioequivalence data are however based on animal studies or studies with subjective endpoints. Furthermore, advancement in steroid physiology with regard to metabolism, intracellular handling and receptor activation have not yet been incorporated. Therefore, this study aims to re-examine the clinical bioequivalence and dose effects of the most widely used synthetic corticosteroids, prednisolone and dexamethasone. METHODS AND ANALYSIS In this double-blind, randomised cross-over clinical trial, 24 healthy male and female volunteers aged 18-75 years, will be included. All volunteers will randomly receive either first a daily dose of 7.5 mg prednisolone for 1 week, immediately followed by a daily dose of 30 mg prednisolone for 1 week, or first a presumed clinical bioequivalent dose of 1.125 mg dexamethasone per day, immediately followed by 4.5 mg of dexamethasone per day for 1 week. After a wash-out period of 4-8 weeks, the other treatment will be applied. The primary study endpoint is the difference in free cortisol excretion in 24 hours urine. Secondary endpoints will include differences in immunological parameters, blood pressure and metabolic measurements. ETHICS AND DISSEMINATION This study has been approved by the Medical Ethics Committee of the University Medical Center Groningen (METC 2020.398). The results of this study will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (Identifier: NCT04733144), and in the Dutch trial registry (NL9138).
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Affiliation(s)
- Suzanne P Stam
- Internal Medicine, Division of Nephrology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Annet Vulto
- Internal Medicine, Division of Endocrinology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Michel J Vos
- Laboratory Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Michiel N Kerstens
- Internal Medicine, Division of Endocrinology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Abraham Rutgers
- Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Ido Kema
- Laboratory Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Clincal Pharmacy and Pharmacology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stephan Jl Bakker
- Internal Medicine, Division of Nephrology, University Medical Centre Groningen, Groningen, The Netherlands
| | - André P van Beek
- Internal Medicine, Division of Endocrinology, University Medical Centre Groningen, Groningen, The Netherlands
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Zheng K, Lv B, Wu L, Wang C, Xu H, Li X, Wu Z, Zhao Y, Zheng Z. Protecting effect of emodin in experimental autoimmune encephalomyelitis mice by inhibiting microglia activation and inflammation via Myd88/PI3K/Akt/NF-κB signalling pathway. Bioengineered 2022; 13:9322-9344. [PMID: 35287559 PMCID: PMC9161934 DOI: 10.1080/21655979.2022.2052671] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Experimental autoimmune encephalomyelitis (EAE) is characterised by demyelination of the central nervous system. Emodin is an anthraquinone derivative with comprehensive anti-inflammatory, anti-cancer, and immunomodulatory effects and is widely used in the treatment of inflammatory, tumour, and immune system diseases. However, none of the clinical or experimental studies have explored the therapeutic efficacy of emodin in EAE/multiple sclerosis (MS). Thus, we evaluated the protective effect of emodin on EAE mediated via inhibition of microglia activation and inflammation. Wild-type mice were randomly divided into the normal control, EAE, low-dose emodin, and high-dose emodin groups. Clinical scores and pathological changes were assessed 21 days after immunisation. The network pharmacology approach was used to elucidate underlying mechanisms by using an online database. Molecular docking, polymerase chain reaction tests, western blotting, and immunofluorescence were performed to verify the network pharmacology results. An in vivo experiment showed that high-dose emodin ameliorated clinical symptoms, inflammatory cell infiltration, and myelination. Pharmacological network analysis showed AKT1 was the main target and that emodin played a key role in MS treatment mainly via the PI3K-Akt pathway. Molecular docking showed that emodin bound well with PI3K, AKT1, and NFKB1. Emodin decreased the expression of phosphorylated(p)-PI3K, p-Akt, NF-κB, and myeloid differentiation factor 88 and the levels of markers (CD86 and CD206) in M1- and M2-phenotype microglia in EAE. Thus, emodin inhibited microglial activation and exhibited anti-inflammatory and neuroprotective effects against EAE via the Myd88/PI3K/Akt/NF-κB signalling pathway. In conclusion, emodin has a promising role in EAE/MS treatment, warranting further detailed studies.
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Affiliation(s)
- Kenan Zheng
- The First Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, China.,Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Baojiang Lv
- The First Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, China.,Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lulu Wu
- The First Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, China.,Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Chen Wang
- Department of Traditional Chinese Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Haoyou Xu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, China
| | - Xiaojun Li
- The Second Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhibing Wu
- Department of Neurology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuanqi Zhao
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, China
| | - Zequan Zheng
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, China.,Doctoral candidates with the same academic level of Guangzhou University of Chinese Medicine, Guangzhou, China
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