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Leszczyńska D, Szatko A, Papierska L, Zgliczyński W, Glinicki P. Musculoskeletal complications of Cushing syndrome. Reumatologia 2023; 61:271-282. [PMID: 37745145 PMCID: PMC10515123 DOI: 10.5114/reum/169889] [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: 03/08/2023] [Accepted: 07/22/2023] [Indexed: 09/26/2023] Open
Abstract
Prolonged exposure to an excess of glucocorticosteroids (GCs), both endogenous and exogenous, leads to a wide range of comorbidities, including cardiovascular, metabolic, psychiatric, and musculoskeletal disorders. The latter comprise osteopenia and osteoporosis leading to skeletal fractures and myopathy. Although endogenous hypercortisolemia is a rare disorder, GCs are among the most frequently prescribed drugs, often administered chronically and despite multiple side effects, impossible to taper off due to therapeutic reasons. The pathophysiology of the effect of GC excess on bone often leads to fractures despite normal or low-normal bone mineral density and it includes direct (mainly disturbance in bone formation processes, through inactivation of the Wnt/β-catenin signalling pathway) and indirect mechanisms (through suppressing the gonadal and somatotrophic axis, and also through antagonizing vitamin D actions). Glucocorticosteroid-induced fast-twitch, glycolytic muscles atrophy occurs due to increased protein catabolism and impaired synthesis. Protein degradation is a result of activation of the ubiquitin proteasome and the lysosomes stimulated through overexpression of several atrogenes (such as FOXO-1 and atrogin-1). This review will discuss pathophysiology, clinical presentation, prevention, and management of GC-induced osteoporosis (including calcium and vitamin D supplementation, and bisphosphonates) and myopathy associated with GC excess.
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Affiliation(s)
- Dorota Leszczyńska
- Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
| | - Alicja Szatko
- Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
| | - Lucyna Papierska
- Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
| | - Wojciech Zgliczyński
- Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
| | - Piotr Glinicki
- Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
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2
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Li D, Zhang CD, Saini J, Singh S, Nathani R, Thangamuthu K, Suresh M, Atkinson EJ, Achenbach SJ, Van Gompel J, Young WF, Bancos I. Determinants of muscle function and health-related quality of life in patients with endogenous hypercortisolism: a cross-sectional study. Eur J Endocrinol 2023; 188:603-612. [PMID: 37327378 PMCID: PMC10376436 DOI: 10.1093/ejendo/lvad069] [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: 04/04/2023] [Revised: 04/21/2023] [Accepted: 05/02/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Prospective data on determinants of muscle strength impairment and quality of life in patients with various subtypes and severity of endogenous hypercortisolism are lacking. DESIGN Single-center cross-sectional study, 2019 to 2022. METHODS Patients with Cushing syndrome (CS) and mild autonomous cortisol secretion (MACS) were assessed with clinical and biochemical severity scores, muscle function (nondominant hand grip strength and sit-to-stand test), and quality of life (Short Form-36 [SF36] and CushingQoL). Referent subjects were recruited from the local population undergoing abdominal imaging for reasons other than suspected adrenal disorder. RESULTS Of 164 patients, 81 (49%) had MACS, 14 (9%) had adrenal CS, 60 (37%) had pituitary CS, and 9 (5%) had ectopic CS. Median age was 53 years (interquartile range: 42-63 years), and 126 (77%) were women. The SF36 mental component score was similarly low in patients with MACS vs CS, but physical component score was lower in CS when compared to MACS (mean of 34.0 vs 40.5, P = .001). Compared to MACS, patients with CS had lower scores on the standardized CushingQoL (mean of 47.1 vs 34.2, P < .001). Compared to referent subjects, patients with MACS demonstrated reduced muscle strength, similar to patients with CS (mean sit to stand Z-score of -0.47 vs -0.54, P = .822). Clinical severity (r = -0.22, P = .004) but not biochemical severity was associated with sit-to-stand test performance. CONCLUSIONS Both patients with overt CS and MACS demonstrate reduced muscle strength and low quality of life. The clinical severity score utilized is associated with both physical and psychosocial components of CushingQoL and with the physical component of SF36.
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Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, United States
- Department of Endocrinology, Endocrinology and Metabolism Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Catherine D Zhang
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, United States
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jasmine Saini
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, United States
| | - Sumitabh Singh
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, United States
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USTW 75390, United States
| | - Rohit Nathani
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, United States
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USTW 75390, United States
| | - Karthik Thangamuthu
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, United States
| | - Malavika Suresh
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, United States
- Department of Internal Medicine, Medstar Health, Baltimore, MD, medstar: 21230, United States
| | - Elizabeth J Atkinson
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, United States
| | - Sara J Achenbach
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, United States
| | - Jamie Van Gompel
- Department of Neurosurgery, Mayo Clinic, Rochester, MN 55905, United States
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, United States
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, United States
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Бровкина СС, Джериева ИС, Волкова НИ, Шкурат ТП, Гончарова ЗА, Машкина ЕВ, Решетников ИБ. [Association of the structure of the glucocorticoid receptor and single nucleotide NR3C1 gene polymorphisms with metabolic disorders]. PROBLEMY ENDOKRINOLOGII 2023; 69:50-58. [PMID: 36842077 PMCID: PMC9978877 DOI: 10.14341/probl13160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/21/2022] [Accepted: 11/09/2022] [Indexed: 02/27/2023]
Abstract
Glucocorticoid therapy is widely used in the treatment of various pathologies. Sensitivity to glucocorticoids (GC) has a serious impact not only on the effectiveness of their action, but also on the severity of side effects, the formation of risk factors and the development of cardiovascular diseases (CVD). Variability of sensitivity to GC causes different phenotypes and severity of metabolic disorders underlying CVD. Among them, one can distinguish a decrease in muscle mass and strength, obesity, glucose and lipid metabolism impairment, and others. Glucocorticoids carry out their effects by binding to the glucocorticoid receptor (GR), and therefore this is considered a critical point in their action. This review presents data on the significance of the glucocorticoid receptor structure, examines the main single nucleotide polymorphisms (SNP) of the NR3C1 gene associated with hypersensitivity or relative resistance to glucocorticoids in the context of metabolic disorders and the development of CVD. The association of the four most studied SNP of the GR gene with metabolic risks is described in detail: BclI (rs41423247), N363S (rs56149945), ER22/23EK (rs6189/rs6190), GR-9ß (rs6198). Their determination can contribute to clarifying the prognosis of both the effectiveness of GC and the development of metabolic disorders, and subsequent early correction of CVD risk factors.
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Braun LT, Vogel F, Reincke M. Long-term morbidity and mortality in patients with Cushing's syndrome. J Neuroendocrinol 2022; 34:e13113. [PMID: 35312199 DOI: 10.1111/jne.13113] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 11/28/2022]
Abstract
Increased multisystem morbidity and mortality in patients with Cushing's syndrome comprise clinical problems and challenges, both at the time of diagnosis and in remission. Relevant comorbidities and clinical problems include hypertension, diabetes, overweight, myopathy and a high risk for acute complications such as infections and venous thrombembolism. Although there are therapy recommendations for most of these comorbidities, there is a lack of large, prospective studies to confirm and optimise them. Mortality is especially high during active disease and within the first year after diagnosis, as a result of cardiovascular events, infections and suicide. All in all, interdisciplinary therapy management is important for reducing morbidity and mortality over the long-term.
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Affiliation(s)
- Leah T Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Frederick Vogel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
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Li S, Schönke M, Buurstede JC, Moll TJ, Gentenaar M, Schilperoort M, Visser JA, Kaikaew K, van de Vijver D, Abbassi-Daloii T, Raz V, Aartsma-Rus A, van Putten M, Meijer OC, Kroon J. Sexual Dimorphism in Transcriptional and Functional Glucocorticoid Effects on Mouse Skeletal Muscle. Front Endocrinol (Lausanne) 2022; 13:907908. [PMID: 35898460 PMCID: PMC9309696 DOI: 10.3389/fendo.2022.907908] [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] [Received: 03/30/2022] [Accepted: 06/17/2022] [Indexed: 11/23/2022] Open
Abstract
Muscle atrophy is common in patients with increased glucocorticoid exposure. Glucocorticoid effects are often sex-specific, and while different glucocorticoid responses between male and female subjects are reported, it is unclear why this is. In this study, we evaluated the effects of corticosterone and synthetic glucocorticoid treatment on muscle atrophy in male and female mice. We found that corticosterone treatment reduced grip strength in female mice only, whereas muscle mass was reduced in both sexes. Skeletal muscle transcriptional responses to corticosterone treatment were more pronounced and widespread in male mice. Synthetic glucocorticoid treatment reduced grip strength in both sexes, while female mice were more sensitive to muscle atrophy than male mice. To evaluate the role of androgens, chemically-castrated male mice were treated with synthetic glucocorticoids. We observed additively reduced muscle mass, but did not observe any interaction effects. Although sex differences in glucocorticoid responses in skeletal muscle are partly influenced by androgen signaling, further studies are warranted to fully delineate the underlying mechanisms.
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Affiliation(s)
- Sheng Li
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Milena Schönke
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Jacobus C. Buurstede
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Tijmen J.A. Moll
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Max Gentenaar
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Maaike Schilperoort
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Jenny A. Visser
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Kasiphak Kaikaew
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Physiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Davy van de Vijver
- Department of Human Genetics, Leiden University Medical Center, Leiden, Netherlands
| | - Tooba Abbassi-Daloii
- Department of Human Genetics, Leiden University Medical Center, Leiden, Netherlands
| | - Vered Raz
- Department of Human Genetics, Leiden University Medical Center, Leiden, Netherlands
| | | | - Maaike van Putten
- Department of Human Genetics, Leiden University Medical Center, Leiden, Netherlands
| | - Onno C. Meijer
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Jan Kroon
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: Jan Kroon,
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Motavalli R, Majidi T, Pourlak T, Abediazar S, Shoja MM, Zununi Vahed S, Etemadi J. The clinical significance of the glucocorticoid receptors: Genetics and epigenetics. J Steroid Biochem Mol Biol 2021; 213:105952. [PMID: 34274458 DOI: 10.1016/j.jsbmb.2021.105952] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 07/04/2021] [Accepted: 07/11/2021] [Indexed: 12/14/2022]
Abstract
The impacts of glucocorticoids (GCs) are mainly mediated by a nuclear receptor (GR) existing in almost every tissue. The GR regulates a wide range of physiological functions, including inflammation, cell metabolism, and differentiation playing a major role in cellular responses to GCs and stress. Therefore, the dysregulation or disruption of GR can cause deficiencies in the adaptation to stress and the preservation of homeostasis. The number of GR polymorphisms associated with different diseases has been mounting per year. Tackling these clinical complications obliges a comprehensive understanding of the molecular network action of GCs at the level of the GR structure and its signaling pathways. Beyond genetic variation in the GR gene, epigenetic changes can enhance our understanding of causal factors involved in the development of diseases and identifying biomarkers. In this review, we highlight the relationships of GC receptor gene polymorphisms and epigenetics with different diseases.
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Affiliation(s)
- Roza Motavalli
- Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Taraneh Majidi
- Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Tala Pourlak
- Department of Pathology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sima Abediazar
- Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammadali M Shoja
- Clinical Academy of Teaching and Learning, Ross University School of Medicine, Miramar, FL, USA
| | | | - Jalal Etemadi
- Kidney Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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Dutta A, Gupta N, Walia R, Bhansali A, Dutta P, Bhadada SK, Pivonello R, Ahuja CK, Dhandapani S, Hajela A, Simeoli C, Sachdeva N, Saikia UN. Remission in Cushing's disease is predicted by cortisol burden and its withdrawal following pituitary surgery. J Endocrinol Invest 2021; 44:1869-1878. [PMID: 33453019 DOI: 10.1007/s40618-020-01495-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/26/2020] [Indexed: 12/16/2022]
Abstract
AIM To ascertain the predictors of remission and relapse in patients of Cushing's disease (CD) undergoing pituitary transsphenoidal surgery (TSS). METHODS Patients with CD subjected to TSS over 35 years at a tertiary care center were included. Patients were grouped into remission and persistent disease at 1 year after surgery, and were further followed up for relapse. Demographic, clinical, biochemical, histological, radiological and post-operative follow-up parameters were analyzed. RESULTS Of the 152 patients of CD, 145 underwent TSS. Remission was achieved in 95 (65.5%) patients at 1 year. Patients in remission had shorter duration of symptoms prior to presentation (p = 0.009), more frequent presence of proximal myopathy (p = 0.038) and a tumor size of < 2.05 cm (p = 0.016) in comparison to those with persistent disease. Post-TSS, immediate post-operative 0800-h cortisol (< 159.85 nmol/L; p = 0.001), histological confirmation of tumor (p = 0.045), duration of glucocorticoid replacement (median 90 days; p = 0.001), non-visualization of tumor on MRI (p = 0.003), new-onset hypogonadism (p = 0.001), 3-month 0800-h cortisol (< 384.9 nmol/L; p = 0.001), resolution of diabetes (p = 0.001) and hypertension (p = 0.001), and recovery of hypothalamic-pituitary-adrenal axis (p = 0.018) favored remission. In logistic regression model, requirement of glucocorticoid replacement (p = 0.033), and resolution of hypertension post-TSS (p = 0.003) predicted remission. None of the parameters could predict relapse. CONCLUSION The study could ascertain the predictors of remission in CD. Apart from the tumor characteristics, surgical aspects and low post-operative 0800-h cortisol, the results suggest that baseline clinical parameters, longer glucocorticoid replacement, and resolution of metabolic complications post-TSS predict remission in CD. Long-term follow-up is essential to look for relapse.
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Affiliation(s)
- A Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - N Gupta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - R Walia
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India.
| | - A Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - P Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - S K Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - C K Ahuja
- Department of Radiology, PGIMER, Chandigarh, India
| | - S Dhandapani
- Department of Neurosurgery, PGIMER, Chandigarh, India
| | - A Hajela
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - C Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - N Sachdeva
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - U N Saikia
- Department of Histopathology, PGIMER, Chandigarh, India
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Abstract
Synthetic glucocorticoids are widely used for their anti-inflammatory and immunosuppressive actions. A possible unwanted effect of glucocorticoid treatment is suppression of the hypothalamic-pituitary-adrenal axis, which can lead to adrenal insufficiency. Factors affecting the risk of glucocorticoid induced adrenal insufficiency (GI-AI) include the duration of glucocorticoid therapy, mode of administration, glucocorticoid dose and potency, concomitant drugs that interfere with glucocorticoid metabolism, and individual susceptibility. Patients with exogenous glucocorticoid use may develop features of Cushing's syndrome and, subsequently, glucocorticoid withdrawal syndrome when the treatment is tapered down. Symptoms of glucocorticoid withdrawal can overlap with those of the underlying disorder, as well as of GI-AI. A careful approach to the glucocorticoid taper and appropriate patient counseling are needed to assure a successful taper. Glucocorticoid therapy should not be completely stopped until recovery of adrenal function is achieved. In this review, we discuss the factors affecting the risk of GI-AI, propose a regimen for the glucocorticoid taper, and make suggestions for assessment of adrenal function recovery. We also describe current gaps in the management of patients with GI-AI and make suggestions for an approach to the glucocorticoid withdrawal syndrome, chronic management of glucocorticoid therapy, and education on GI-AI for patients and providers.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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9
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Martins CS, de Castro M. Generalized and tissue specific glucocorticoid resistance. Mol Cell Endocrinol 2021; 530:111277. [PMID: 33864884 DOI: 10.1016/j.mce.2021.111277] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 12/20/2022]
Abstract
Glucocorticoids (GCs) are steroid hormones that influence several physiologic functions and are among the most frequently prescribed drugs worldwide. Resistance to GCs has been observed in the context of the familial generalized GC resistance (Chrousos' syndrome) or tissue specific GC resistance in chronic inflammatory states. In this review, we have summarized the major factors that influence individual glucocorticoid sensitivity/resistance. The fine-tuning of GC action is determined in a tissue-specific fashion that includes the combination of different GC receptor promoters, translation initiation sites, splice isoforms, interacting proteins, post-translational modifications, and alternative mechanisms of signal transduction.
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Affiliation(s)
- Clarissa Silva Martins
- Department of Internal Medicine - Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, SP, Brazil; School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil
| | - Margaret de Castro
- Department of Internal Medicine - Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, SP, Brazil.
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Reincke M. Cushing Syndrome Associated Myopathy: It Is Time for a Change. Endocrinol Metab (Seoul) 2021; 36:564-571. [PMID: 34139801 PMCID: PMC8258338 DOI: 10.3803/enm.2021.1069] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/25/2021] [Indexed: 12/27/2022] Open
Abstract
Cushing syndrome is the result of excessive levels of glucocorticoids. Endogenous Cushing syndrome is rare with an incidence of two to three cases per million per year. Clinically, the presentation consists of a characteristic phenotype including skin symptoms and metabolic manifestations. A frequent co-morbidity with high impact on quality of life is Cushing syndrome associated myopathy. It characteristically affects the proximal myopathy, impairing stair climbing and straightening up. The pathophysiology is complex and involves protein degradation via the forkhead box O3 (FOXO3) pathway, intramuscular fat accumulation, and inactivity-associated muscle atrophy. Surgical remission of Cushing syndrome is the most important step for recovery of muscle function. Restoration depends on age, co-morbidities and postoperative insulin-like growth factor concentrations. At average, functionality remains impaired during the long-term compared to age and sex matched control persons. Growth hormone therapy in individuals with impaired growth hormone secretion could be an option but has not been proved in a randomized trial.
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Affiliation(s)
- Martin Reincke
- Medical Department IV, LMU-University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
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11
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Zervas A, Chrousos G, Livadas S. Snow White and the Seven Dwarfs: a fairytale for endocrinologists. Endocr Connect 2021; 10:R189-R199. [PMID: 33878729 PMCID: PMC8183629 DOI: 10.1530/ec-20-0615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/16/2021] [Indexed: 11/16/2022]
Abstract
'Snow White and the Seven Dwarfs', a fairytale that is widely known across the Western world, was originally written by the Brothers Grimm, and published in 1812 as 'Snow White'. Though each dwarf was first given an individual name in the 1912 Broadway play, in Walt Disney's 1937 film 'Snow White and the Seven Dwarfs', they were renamed, and the dwarfs have become household names. It is well known that myths, fables, and fairytales, though appearing to be merely children's tales about fictional magical beings and places, have, more often than not, originated from real facts. Therefore, the presence of the seven brothers with short stature in the story is, from an endocrinological point of view, highly intriguing, in fact, thrilling. The diversity of the phenotypes among the seven dwarfs is also stimulating, although puzzling. We undertook a differential diagnosis of their common underlying disorder based on the original Disney production's drawings and the unique characteristics of these little gentlemen, while we additionally evaluated several causes of short stature and, focusing on endocrine disorders that could lead to these clinical features among siblings, we have, we believe, been able to reveal the underlying disease depicted in this archetypal tale.
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Affiliation(s)
| | - George Chrousos
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, University Research Institute of Maternal and Child Health and Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Athens, Greece
- National and Kapodistrian University of Athens Medical School, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Sarantis Livadas
- Endocrine Unit, Athens Medical Centre, Athens, Greece
- Correspondence should be addressed to S Livadas:
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12
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Vogel F, Braun LT, Rubinstein G, Zopp S, Künzel H, Strasding F, Albani A, Riester A, Schmidmaier R, Bidlingmaier M, Quinkler M, Deutschbein T, Beuschlein F, Reincke M. Persisting Muscle Dysfunction in Cushing's Syndrome Despite Biochemical Remission. J Clin Endocrinol Metab 2020; 105:dgaa625. [PMID: 32882010 PMCID: PMC7538105 DOI: 10.1210/clinem/dgaa625] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/31/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT Glucocorticoid-induced myopathy is a characteristic symptom of endogenous Cushing's syndrome (CS). Its long-term outcome is largely unknown. OBJECTIVE To evaluate long-term muscle function following the remission of endogenous CS. STUDY DESIGN Observational longitudinal cohort study. SETTING Tertiary care hospitals and a specialized outpatient clinic. PATIENTS As part of the prospective multicenter German Cushing's Registry, we assessed muscle strength in patients with overt endogenous CS. We studied the patients at the time of diagnosis (n = 88), after 6 months (n = 69), and thereafter annually, following surgical remission over a period of up to 4 years (1 year: n = 55; 2 years: n = 34; 3 years: n = 29; 4 years: n = 22). Muscle function was evaluated by hand grip strength and by chair rising test. RESULTS Grip strength was decreased to 83% of normal controls (100%) at the time of diagnosis. It further decreased to 71% after 6 months in remission (P ≤ 0.001) and showed no improvement during further follow-up compared with baseline. Chair rising test performance improved initially (8 seconds at baseline vs 7 seconds after 6 months, P = 0.004) but remained at this reduced level thereafter (7 seconds after 3 years vs 5 seconds in controls, P = 0.038). In multivariate analysis, we identified, as predictors for long-term muscle dysfunction, age, waist-to-hip ratio, and hemoglobin A1c at baseline. Furthermore, muscle strength during follow-up was strongly correlated with quality of life. CONCLUSION This study shows that CS-associated myopathy does not spontaneously resolve during remission. This calls for action to identify effective interventions to improve muscle dysfunction in this setting.
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Affiliation(s)
- Frederick Vogel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Leah T Braun
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - German Rubinstein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Stephanie Zopp
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Heike Künzel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Finn Strasding
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Adriana Albani
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Anna Riester
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Ralf Schmidmaier
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Martin Bidlingmaier
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | | | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Felix Beuschlein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
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