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Fraga NR, Minaeian N, Kim MS. Congenital Adrenal Hyperplasia. Pediatr Rev 2024; 45:74-84. [PMID: 38296783 DOI: 10.1542/pir.2022-005617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
We describe congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, which is the most common primary adrenal insufficiency in children and adolescents. In this comprehensive review of CAH, we describe presentations at different life stages depending on disease severity. CAH is characterized by androgen excess secondary to impaired steroidogenesis in the adrenal glands. Diagnosis of CAH is most common during infancy with elevated 17-hydroxyprogesterone levels on the newborn screen in the United States. However, CAH can also present in childhood, with late-onset symptoms such as premature adrenarche, growth acceleration, hirsutism, and irregular menses. The growing child with CAH is treated with hydrocortisone for glucocorticoid replacement, along with increased stress doses for acute illness, trauma, and procedures. Mineralocorticoid and salt replacement may also be necessary. Although 21-hydroxylase deficiency is the most common type of CAH, there are other rare types, such as 11β-hydroxylase and 3β-hydroxysteroid dehydrogenase deficiency. In addition, classic CAH is associated with long-term comorbidities, including cardiometabolic risk factors, impaired cognitive function, adrenal rest tumors, and bone health effects. Overall, early identification and treatment of CAH is important for the pediatric patient.
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Affiliation(s)
- Nicole R Fraga
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA
| | - Nare Minaeian
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Mimi S Kim
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine of University of Southern California, Los Angeles, CA
- The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, CA
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2
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Jacob M, Lin-Su K, Catarozoli C, Thomas C, Poppas D, Lekarev O. Screening for Anxiety and Depression in Children with Congenital Adrenal Hyperplasia. J Clin Res Pediatr Endocrinol 2023; 15:406-416. [PMID: 37470306 PMCID: PMC10683541 DOI: 10.4274/jcrpe.galenos.2023.2023-2-10] [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: 02/21/2023] [Accepted: 07/18/2023] [Indexed: 07/21/2023] Open
Abstract
Objective Congenital adrenal hyperplasia (CAH) is an inherited condition in which individuals require multiple daily doses of medication and are at risk for life-threatening adrenal crisis. The chronic nature and severity of CAH place children at risk for psychiatric morbidity. The aim was to assess the degree of anxiety and depressive symptoms in children with CAH. Methods A cross-sectional cohort study of children (7-17 years) with CAH and their caregivers were recruited between May and December 2021. Children with hypothyroidism (HT) and their caregivers served as unaffected controls. Validated mental health questionnaires [Children’s Depression Inventory 2 Self Report-Short (CDI-2), Screen for Child Anxiety Related Disorders (SCARED), Patient Health Questionnaire modified for Adolescents (PHQ-A); self and proxy] were completed by participants at one clinic visit. Higher scores indicated greater symptoms of anxiety and depression. Results A total of 60 children and 56 parents participated. Among the children 34 had CAH (68% female, mean age 11.41±2.5, CAH duration 8.5±4.1) and 26 had HT (73% female, mean age 12.7±2.9 years, HT duration 6.0±4.2 years). There was no increase in anxiety and depression symptoms in children with CAH compared to controls. In sub-analyses, children with CAH and controls reported a greater number of anxiety and depression symptoms than their caregivers on the SCARED and CDI-2, respectively. There was no association between adrenal control and the degree of anxiety or depression symptoms. Conclusion Children with CAH do not have more symptoms of anxiety or depression compared to controls. Child and caregiver-proxy responses lack agreement, suggesting that children with CAH may continue to benefit from routine mental health evaluation, regardless of voiced caregiver concern.
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Affiliation(s)
- Marianne Jacob
- Cooperman Barnabas Medical Center, Division of Pediatric Endocrinology, New Jersey, USA
| | - Karen Lin-Su
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, Division of Pediatric Endocrinology, New York, USA
| | - Corinne Catarozoli
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, Department of Child and Adolescent Psychiatry, New York, USA
| | - Charlene Thomas
- Weill Cornell Medicine, Department of Population Health Sciences, New York, USA
| | - Dix Poppas
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, Division of Pediatric Urology, New York, USA
| | - Oksana Lekarev
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, Division of Pediatric Endocrinology, New York, USA
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Galderisi A, Kariyawasam D, Stoupa A, Quoc AN, Pinto G, Viaud M, Brabant S, Beltrand J, Polak M, Samara-Boustani D. Glucose pattern in children with classical congenital adrenal hyperplasia: evidence from continuous glucose monitoring. Eur J Endocrinol 2023; 189:K19-K24. [PMID: 37952170 DOI: 10.1093/ejendo/lvad147] [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: 07/27/2023] [Revised: 10/01/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND While the risk for hypoglycemia during acute illness is well described in children with classical congenital adrenal hyperplasia (CAH), there is little evidence for the prevalence of asymptomatic hypoglycemia and the daily glucose patterns in CAH. Herein, we explored the daytime glucose profile of children with classical CAH. METHODS We conducted an observational study in 11 children (6 female; age 3.1 years [1.4, 5.1]; body mass index 17.3 kg/m2 [15.6, 17.9]) with a genetic diagnosis of classical CAH receiving hydrocortisone and fludrocortisone replacement therapy. Participants underwent 2 14-day continuous glucose monitoring (CGM) sessions and an inpatient 24 h series cortisol and adrenocorticotropic hormone (ACTH) measures. Data were analyzed for 3 daytime lags (7 Am-4 Pm, 4 Pm-10pm, 10 Pm-7 Am) corresponding to the hydrocortisone dosing period with cortisol and ACTH measured before the hydrocortisone dose. RESULTS Eleven participants completed at least 1 CGM session, and 7 out of 11 underwent both the CGM session and the cortisol/ACTH serial measures. In the whole cohort, the percentage of time of sensor glucose values <70 mg/dL was higher during the 10 Pm-7 Am and the 7 Am-4 Pm time slots than in the late afternoon period (17% [7, 54] and 15% [6.8, 24] vs 2% [1.1, 16.7] during the periods 7 Am-4 Pm and 4 Pm-10 Pm, respectively [P = .006 and P = .003]). Nighttime hypoglycemia was mostly spent below the 65 mg/dL (10.9% [4.1, 34]). The glycemic pattern paralleled the nadir of daily cortisol at 7 Am (10.3±4.4 μg/dL). A greater percentage of time in hypoglycemia was associated with lower cortisol concentration at 7 Am and 10 Pm (P < .001 and P = .005). CONCLUSIONS Continuous glucose monitoring demonstrated a disrupted daily glucose pattern in children with CAH, paralleled by a lower cortisol concentration. CLINICALTRIALS.GOV REGISTRATION NCT04322435.
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Affiliation(s)
- Alfonso Galderisi
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
- Department of Pediatrics, Pediatric Endocrinology, Yale University, New Haven, CT, United States
| | - Dulanjalee Kariyawasam
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
- Faculty of Medicine, Université Paris Cité, Paris, France
- Cochin Institute, INSERM U1016, Paris, France
- IMAGINE Institute Affiliate, INSERM U1163, Paris, France
| | - Athanasia Stoupa
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
- Faculty of Medicine, Université Paris Cité, Paris, France
- Cochin Institute, INSERM U1016, Paris, France
- IMAGINE Institute Affiliate, INSERM U1163, Paris, France
| | - Adrien Nguyen Quoc
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
- Faculty of Medicine, Université Paris Cité, Paris, France
| | - Graziella Pinto
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
| | - Magali Viaud
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
| | - Severine Brabant
- Department of Functional Explorations, Necker-Enfants Malades University Hospital, AP-HP Centre, Paris, France
| | - Jacques Beltrand
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
- Faculty of Medicine, Université Paris Cité, Paris, France
- Cochin Institute, INSERM U1016, Paris, France
- IMAGINE Institute Affiliate, INSERM U1163, Paris, France
| | - Michel Polak
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
- Faculty of Medicine, Université Paris Cité, Paris, France
- Cochin Institute, INSERM U1016, Paris, France
- IMAGINE Institute Affiliate, INSERM U1163, Paris, France
| | - Dinane Samara-Boustani
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
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Bacila IA, Lawrence NR, Badrinath SG, Balagamage C, Krone NP. Biomarkers in congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2023. [PMID: 37608608 DOI: 10.1111/cen.14960] [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: 05/09/2023] [Revised: 07/25/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
Monitoring of hormone replacement therapy represents a major challenge in the management of congenital adrenal hyperplasia (CAH). In the absence of clear guidance and standardised monitoring strategies, there is no consensus among clinicians regarding the relevance of various biochemical markers used in practice, leading to wide variability in their application and interpretation. In this review, we summarise the published evidence on biochemical monitoring of CAH. We discuss temporal variations of the most commonly measured biomarkers throughout the day, the interrelationship between different biomarkers, as well as their relationship with different glucocorticoid and mineralocorticoid treatment regimens and clinical outcomes. Our review highlights significant heterogeneity across studies in both aims and methodology. However, we identified key messages for the management of patients with CAH. The approach to hormone replacement therapy should be individualised, based on the individual hormonal profile throughout the day in relation to medication. There are limitations to using 17-hydroxyprogesterone, androstenedione and testosterone, and the role of additional biomarkers such 11-oxygenated androgens which are more disease specific should be further established. Noninvasive monitoring via salivary and urinary steroid measurements is becoming increasingly available and should be considered, especially in the management of children with CAH. Additionally, this review indicates the need for large scale longitudinal studies analysing the interrelation between different monitoring strategies used in clinical practice and health outcomes in children and adults with CAH.
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Affiliation(s)
| | - Neil R Lawrence
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Chamila Balagamage
- Department of Endocrinology, Birmingham Women's & Children's Hospital, Birmingham, UK
- Department of Endocrinology, Sheffield Children's Hospital, Sheffield, UK
| | - Nils P Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Endocrinology, Sheffield Children's Hospital, Sheffield, UK
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Åkerman AK, Sævik ÅB, Thorsby PM, Methlie P, Quinkler M, Jørgensen AP, Höybye C, Debowska AJ, Nedrebø BG, Dahle AL, Carlsen S, Tomkowicz A, Sollid ST, Nermoen I, Grønning K, Dahlqvist P, Grimnes G, Skov J, Finnes T, Wahlberg J, Holte SE, Simunkova K, Kämpe O, Husebye ES, Øksnes M, Bensing S. Plasma-Metanephrines in Patients with Autoimmune Addison's Disease with and without Residual Adrenocortical Function. J Clin Med 2023; 12:jcm12103602. [PMID: 37240708 DOI: 10.3390/jcm12103602] [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: 03/03/2023] [Revised: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
PURPOSE Residual adrenocortical function, RAF, has recently been demonstrated in one-third of patients with autoimmune Addison's disease (AAD). Here, we set out to explore any influence of RAF on the levels of plasma metanephrines and any changes following stimulation with cosyntropin. METHODS We included 50 patients with verified RAF and 20 patients without RAF who served as controls upon cosyntropin stimulation testing. The patients had abstained from glucocorticoid and fludrocortisone replacement > 18 and 24 h, respectively, prior to morning blood sampling. The samples were obtained before and 30 and 60 min after cosyntropin stimulation and analyzed for serum cortisol, plasma metanephrine (MN), and normetanephrine (NMN) by liquid-chromatography tandem-mass pectrometry (LC-MS/MS). RESULTS Among the 70 patients with AAD, MN was detectable in 33%, 25%, and 26% at baseline, 30 min, and 60 min after cosyntropin stimulation, respectively. Patients with RAF were more likely to have detectable MN at baseline (p = 0.035) and at the time of 60 min (p = 0.048) compared to patients without RAF. There was a positive correlation between detectable MN and the level of cortisol at all time points (p = 0.02, p = 0.04, p < 0.001). No difference was noted for NMN levels, which remained within the normal reference ranges. CONCLUSION Even very small amounts of endogenous cortisol production affect MN levels in patients with AAD.
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Affiliation(s)
- Anna-Karin Åkerman
- Department of Medicine, Örebro University Hospital, 701 85 Örebro, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Åse Bjorvatn Sævik
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, 7804 Bergen, Norway
| | - Per Medbøe Thorsby
- Hormone Laboratory, Department of Medical Biochemistry and Biochemical Endocrinology and Metabolism Research Group, Oslo University Hospital, 0372 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0372 Oslo, Norway
| | - Paal Methlie
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, 7804 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, 5009 Bergen, Norway
| | | | | | - Charlotte Höybye
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | | | - Bjørn Gunnar Nedrebø
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- Department of Internal Medicine, Haugesund Hospital, 5528 Haugesund, Norway
| | - Anne Lise Dahle
- Department of Internal Medicine, Haugesund Hospital, 5528 Haugesund, Norway
| | - Siri Carlsen
- Department of Endocrinology, Stavanger University Hospital, 4068 Stavanger, Norway
| | - Aneta Tomkowicz
- Department of Medicine, Sørlandet Hospital, 4604 Kristiansand, Norway
| | - Stina Therese Sollid
- Department of Medicine, Drammen Hospital, Vestre Viken Health Trust, 3004 Drammen, Norway
| | - Ingrid Nermoen
- Department of Endocrinology, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Kaja Grønning
- Department of Endocrinology, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Guri Grimnes
- Division of Internal Medicine, University Hospital of North Norway, 9038 Tromsø, Norway
- Tromsø Endocrine Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, 9037 Tromsø, Norway
| | - Jakob Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Trine Finnes
- Section of Endocrinology, Innlandet Hospital Trust, 2381 Hamar, Norway
| | - Jeanette Wahlberg
- Department of Medicine, Örebro University Hospital, 701 85 Örebro, Sweden
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, 702 81 Örebro, Sweden
| | | | - Katerina Simunkova
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
| | - Olle Kämpe
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, 171 76 Stockholm, Sweden
- Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Eystein Sverre Husebye
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, 7804 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, 5009 Bergen, Norway
- Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Marianne Øksnes
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, 7804 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, 5009 Bergen, Norway
- Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, 171 76 Stockholm, Sweden
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Tseng T, Seagroves A, Tanawattanacharoen VK, Liang MC, Koppin CM, Keenan M, Davidowitz E, Nguyen E, Chand S, Geffner ME, Chang TP, Kim MS. Electrolyte abnormalities and stress dosing predict illness-related hospitalizations among infants and toddlers with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2023; 98:536-542. [PMID: 36593179 PMCID: PMC10006318 DOI: 10.1111/cen.14876] [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: 08/28/2022] [Revised: 12/22/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Infants and toddlers with classical congenital adrenal hyperplasia (CAH) are at high risk for morbidity/mortality arising from life-threatening adrenal crisis. Management of acute illnesses in CAH requires an understanding of factors leading to emergency department (ED) visits and hospitalizations in the first few years of life. We, therefore, examined adrenal crisis at prehospital and ED stages of illness in young children with CAH as they related to medical outcomes. PATIENTS AND DESIGN Retrospective cohort study of 39 children with CAH due to 21-hydroxylase deficiency (0-4 years of age) and 27 age-matched controls. MEASUREMENTS ED visit, acute illness symptoms (fever, vomiting, diarrhoea) and other characteristics (hospitalizations, administration of stress-dose hydrocortisone, electrolyte abnormalities). RESULTS CAH infants and toddlers had significantly higher rates of ED visits (0.50 [0.25-0.88] per person-year) than controls (0 [0-0] per person-year; p < .001). Moreover, CAH children under 6 months old had significantly higher rates of ED visits compared with older ages. Only 50% (51/102) of illness-related ED visits in CAH children were preceded by the administration of either oral (46/51) or intramuscular (11/51) stress dosing by parents. A total of 10.8% of ED visits resulted in hospital admission. Controlling for age and 17-hydroxyprogesterone at diagnosis, electrolyte abnormalities and administration of parenteral hydrocortisone in the ED significantly predicted hospital admission. Receiving a hydrocortisone injection before the ED was a significant predictor of having electrolyte abnormalities. CONCLUSIONS Infants and toddlers with classical CAH are at high risk for acute illness and hospitalizations and often do not receive adequate stress dosing before the ED.
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Affiliation(s)
- Teresa Tseng
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Amy Seagroves
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Veeraya K Tanawattanacharoen
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Mark C Liang
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Christina M Koppin
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Madison Keenan
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Elana Davidowitz
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Eugene Nguyen
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Sanjay Chand
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Mitchell E Geffner
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
- The Saban Research Institute, Los Angeles, California, USA
- Division of Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Todd P Chang
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
- The Saban Research Institute, Los Angeles, California, USA
- Division of Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Mimi S Kim
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
- The Saban Research Institute, Los Angeles, California, USA
- Division of Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
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7
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Abstract
Treatment for congenital adrenal hyperplasia (CAH) was introduced in the 1950s following the discovery of the structure and function of adrenocortical hormones. Although major advances in molecular biology have delineated steroidogenic mechanisms and the genetics of CAH, management and treatment of this condition continue to present challenges. Management is complicated by a combination of comorbidities that arise from disease-related hormonal derangements and treatment-related adverse effects. The clinical outcomes of CAH can include life-threatening adrenal crises, altered growth and early puberty, and adverse effects on metabolic, cardiovascular, bone and reproductive health. Standard-of-care glucocorticoid formulations fall short of replicating the circadian rhythm of cortisol and controlling efficient adrenocorticotrophic hormone-driven adrenal androgen production. Adrenal-derived 11-oxygenated androgens have emerged as potential new biomarkers for CAH, as traditional biomarkers are subject to variability and are not adrenal-specific, contributing to management challenges. Multiple alternative treatment approaches are being developed with the aim of tailoring therapy for improved patient outcomes. This Review focuses on challenges and advances in the management and treatment of CAH due to 21-hydroxylase deficiency, the most common type of CAH. Furthermore, we examine new therapeutic developments, including treatments designed to replace cortisol in a physiological manner and adjunct agents intended to control excess androgens and thereby enable reductions in glucocorticoid doses.
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Affiliation(s)
- Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, MD, USA.
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
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