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Yalovitsky G, Shaki D, Hershkovitz E, Friger M, Haim A. Comparison of glucagon stimulation test and low dose ACTH test in assessing hypothalamic-pituitary-adrenal (HPA) axis in children. Clin Endocrinol (Oxf) 2023; 98:678-681. [PMID: 36750758 DOI: 10.1111/cen.14887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/27/2023] [Accepted: 02/05/2023] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Children with a pituitary hormone deficiency are at risk for secondary adrenal insufficiency (AI). A stimulation test is usually performed for diagnosing AI, evaluating both the hypothalamic-pituitary-adrenal and growth hormone (GH)-IGF-1 axes. This single test is preferred by clinicians and is considerably more tolerable by patients. The objective of this study was to evaluate the glucagon stimulation test (GST), which is commonly used to assess both axes. Its diagnostic capability for GH deficiency is high and well accepted, however its utility for determining secondary AI has not been well established. METHODS This retrospective study involved 120 patients under 18 years of age with short stature who had undergone both a GST and low dose ACTH stimulation test (LDACTH test). Twenty-six children who had more than 6 months elapsed between the two tests were excluded from the study. The study was conducted on patients of the Pediatric Endocrinology Department at Soroka University Hospital, a tertiary medical centre in Beer Sheva, Israel. Statistical analyses were carried out via IBM SPSS (v. 22), with a significance level determined at p < .05. RESULTS Different cortisol cut-off values were assessed for GST and it was determined that the highest combined sensitivity and specificity yielded a cut-off point of 320 nmol/L (56% sensitivity and 83% specificity) while the currently accepted cut-off value (500 nmol/L) yielded 100% sensitivity and 6% specificity. CONCLUSION The results of this study show that GST is not an optimal tool for diagnosing secondary AI. Therefore, clinicians using this test should interpret its results with caution.
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Affiliation(s)
- Guy Yalovitsky
- Goldman Medical School at the Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - David Shaki
- Goldman Medical School at the Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Pediatric Endocrinology Unit, Soroka University Medical Center, Be'er Sheva, Israel
| | - Eli Hershkovitz
- Goldman Medical School at the Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Pediatric Endocrinology Unit, Soroka University Medical Center, Be'er Sheva, Israel
| | - Michael Friger
- Goldman Medical School at the Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Alon Haim
- Goldman Medical School at the Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Pediatric Endocrinology Unit, Soroka University Medical Center, Be'er Sheva, Israel
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Zöllner EW, Lombard CJ, Zemlin AE. Performance of glucagon stimulation test in diagnosing central adrenal insufficiency in children when utilising the Roche Elecsys ® cortisol II assay: a pilot study. J Pediatr Endocrinol Metab 2022; 35:1272-1277. [PMID: 36062297 DOI: 10.1515/jpem-2022-0252] [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: 05/10/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The glucagon stimulation test (GST) is used for the simultaneous assessment of central adrenal insufficiency (CAI) and growth hormone deficiency. The new Roche cortisol II (C II) assay was recently introduced, confounding interpretation of the GST. The performance of the GST in diagnosing central adrenal insufficiency (CAI), utilising the C II assay, was therefore compared with that of the overnight metyrapone test (ONMTPT). METHODS A diagnostic accuracy study was performed by retrospectively analysing folders and laboratory records of 25 children and adolescents investigated for hypopituitarism with the GST and the ONMTPT between September 2016 and December 2019. The peak serum cortisol (C) of the GST, the post-metyrapone serum 11-deoxycortisol and adrenocorticotropin levels of the ONMTPT were recorded. Diagnostic performance of the GST at a previously suggested cut-off of 374 nmol/L was evaluated. RESULTS Seventeen boys and 8 girls, aged 1.7-16.3 years (median 7.3 years) were identified. The sensitivity of the post-GST C-level at 374 nmol/L was 0.40 (95% confidence interval [CI] 0.17-0.69), specificity 0.64 (95% CI 0.39-0.84), positive predictive value 0.44 (95% CI 0.19-0.73), negative predictive value 0.60 (95% CI 0.36-0.80), accuracy 0.54 (95% CI 0.35-0.72), positive likelihood ratio (+LR) 0.93 (95% CI 0.49-1.77) and negative LR 1.12 (95% CI 0.40-3.15). The area under the receiver of operating characteristics (ROC) curve was 0.379 (95% CI 0.142-0.615). CONCLUSIONS This study suggests that the GST at any C II cut-off cannot replace the ONMTPT as a diagnostic test for CAI in children. Findings should be confirmed in a larger study.
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Affiliation(s)
- Ekkehard Werner Zöllner
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Carl J Lombard
- Biostatistics Unit, South African Medical Research Council and Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, Cape Town, South Africa
| | - Annalise E Zemlin
- Division of Chemical Pathology, National Health Laboratory Service (NHLS) and Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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Hanukoglu A, Weisglass R. Is the fear from insulin tolerance test in the evaluation of short stature justified? Eur J Pediatr 2022; 181:2867-2871. [PMID: 35459965 DOI: 10.1007/s00431-021-04364-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 11/24/2022]
Abstract
UNLABELLED Among growth hormone (GH) provocative tests, insulin tolerance test (ITT) is considered a valuable test in children with short stature to diagnose GH deficiency. However, many pediatric endocrinologists are reluctant to perform it. We conducted a nationwide survey among all the pediatric endocrine clinics' heads in Israel regarding their position on this issue. We found that the number of endocrine units performing ITT is almost nil. Sense of fear from severe hypoglycemia was a dominating cause for not performing ITT. We review the pros and cons of performing ITT versus other tests, especially glucagon test. Glucagon tolerance test is not considered the test of choice by some endocrinologists but recommended by others including in Israel. We also note the influence of a widely cited report published in 1992 (many times inaccurately) on endocrinologists' views. CONCLUSION A nationwide survey in Israel revealed a high rate of reluctance to perform ITT. The rationale behind this attitude was a sense of fear of performing the test by many endocrinologists. We discuss the preferences for choosing GH stimulation tests and the pros and cons of alternatives to ITT. The fear of not performing ITT was not always justified. WHAT IS KNOWN • ITT test is considered a gold standard in the evaluation of short stature to diagnose GH deficiency by many endocrinologists. WHAT IS NEW • High reluctance rate found in Israel to perform ITT, prompted us to evaluate the attitudes of pediatric endocrinologists around the world showing conflicting ideas. • The role of a single paper sometimes misquoted also contributed to these conflicting results.
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Affiliation(s)
- Aaron Hanukoglu
- Division of Pediatric Endocrinology, E. Wolfson Medical Center, Holon, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Regina Weisglass
- Division of Pediatric Endocrinology, E. Wolfson Medical Center, Holon, Israel
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Ach T, Abdelkrim AB, Hasni Y, Saad G, Kacem M, Chaieb M, Zaouali M, Maaroufi A, Ach K. Safety assessment and potential risks of the glucagon stimulation test in the diagnosis of secondary adrenal insufficiency. Curr Drug Saf 2021; 17:59-63. [PMID: 34315384 DOI: 10.2174/1574886316666210727152000] [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: 11/20/2020] [Revised: 04/29/2021] [Accepted: 05/07/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although it takes more time, the glucagon stimulation test (GST) is a reliable measure for assessing growth hormone (GH) and adrenocorticotropic hormone (ACTH) secretion. The GST is considered to be a safe test, however, it still has mild side effects and potential risks. OBJECTIVE The objective of this study was to analyze the side effects of the GST while testing adrenal insufficient patients. METHODS This was a prospective study in which GST was performed in eighty-one patients (44 men, 37 women, mean age: 35.83±19.62 years) with pituitary disorder. The GST consisted in an intramuscular injection of 1 mg of glucagon. Blood samples were collected at baseline, and 30, 60, 90, 120, 150, 180 and 210 min after glucagon injection for cortisol measurements. All patients were asked to report side-effects associated with this test. RESULTS The mean peak blood glucose level under GST was 9.01±2.03 mmol/L and the mean glycemic nadir was 4.34±1.75 mmol/L was found most frequently during the 30th minute (p <10-3). During the test, 35 subjects (43.2%) had side effects with a mean age of 42.89 ± 19.75 years. Frequent side effects included: nausea (29.62%), vomiting (27.16%), abdominal cramps (18.51%) and hunger (13.58%). All patients tolerated the test until the end. Adverse effects were significantly more prevalent in patients older than 50 years (p=0.012). CONCLUSIONS The GST is a reliable alternative to assess hypothalamic pituitary adrenal axis but should be cautiously used especially in the elderly although its minor side effects.
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Affiliation(s)
- Taieb Ach
- University Hospital of Farhat Hached Sousse, Endocrinology, Tunisia
| | | | - Yosra Hasni
- University Hospital of Farhat Hached Sousse, Endocrinology, Tunisia
| | - Ghada Saad
- University Hospital of Farhat Hached Sousse, Endocrinology, Tunisia
| | - Maha Kacem
- University Hospital of Farhat Hached Sousse, Endocrinology, Tunisia
| | - Molka Chaieb
- University Hospital of Farhat Hached Sousse, Endocrinology, Tunisia
| | - Monia Zaouali
- University Hospital of Farhat Hached Sousse, Hormonal Physiology, Tunisia
| | - Amel Maaroufi
- University Hospital of Farhat Hached Sousse, Endocrinology, Tunisia
| | - Koussay Ach
- University Hospital of Farhat Hached Sousse, Endocrinology, Tunisia
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Drummond JB, Soares BS, Pedrosa W, Ribeiro-Oliveira A. Revisiting peak serum cortisol response to insulin-induced hypoglycemia in children. J Endocrinol Invest 2021; 44:1291-1299. [PMID: 32959333 DOI: 10.1007/s40618-020-01427-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/14/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE To evaluate factors that could potentially affect the hypothalamic-pituitary adrenal (HPA) axis response to insulin-induced hypoglycemia in children without history or symptoms of adrenal insufficiency and to propose a cut-off value to define a normal response in this population. METHODS Exploratory single-center study involving 78 children that prospectively underwent insulin tolerance test (ITT) for suspected growth hormone (GH) deficiency. METHODS Glucose, cortisol, GH, adrenocorticotrophic hormone (ACTH), epinephrine and norepinephrine levels were measured at baseline and after insulin-induced hypoglycemia. Serum cortisol was measured using Access automated immunoassay. RESULTS Mean (range) basal morning serum cortisol of 8 (2.2-19.5) µg/dL/222 (61-542) nmol/L increased after hypoglycemia to 20.5 (14.6-29.5) µg/dL/570 nmol/L (405-819) nmol/L. Peak serum cortisol levels of 14.6 µg/dL (405 nmol/L) and 15.4 µg/dL (428 nmol/L) corresponded to the 2.5th and 5th percentiles, respectively. Peak serum cortisol correlated with peak plasma epinephrine (r = 0.367; P = 0.0014) but did not correlate with age, BMI-SD or peak serum GH. Children with intact and abnormal GH responses presented similar mean peak serum cortisol levels (20.0 vs. 20.6 µg/dL/555 vs. 572 nmol/L; P = 0.21). CONCLUSION Our data indicate that the current cut-off to define normal HPA axis response in children after insulin-induced hypoglycemia warrants reevaluation to avoid over-diagnosis of adrenal insufficiency. Our results suggest that peak serum cortisol levels ≥ 15.4 µg/dL (428 nmol/L) in children undergoing ITT might represent a normal cortisol response to stress, regardless of age, BMI or GH secretory capacity.
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Affiliation(s)
- J B Drummond
- Laboratory of Endocrinology, Federal University of Minas Gerais, Av. Alfredo Balena, 190, Belo Horizonte, Minas Gerais, 30130-100, Brazil
- Hermes Pardini Institute, Belo Horizonte, Minas Gerais, Brazil
| | - B S Soares
- Laboratory of Endocrinology, Federal University of Minas Gerais, Av. Alfredo Balena, 190, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - W Pedrosa
- Hermes Pardini Institute, Belo Horizonte, Minas Gerais, Brazil
| | - A Ribeiro-Oliveira
- Laboratory of Endocrinology, Federal University of Minas Gerais, Av. Alfredo Balena, 190, Belo Horizonte, Minas Gerais, 30130-100, Brazil.
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Vitebskaya AV, Pisareva EA, Popovich AV. [Comparative study of glucagon and insulin tests for diagnostics of secondary adrenal insufficiency and growth hormone deficiency in children and adolescents]. ACTA ACUST UNITED AC 2020; 66:50-58. [PMID: 33481367 DOI: 10.14341/probl12528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 12/10/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Diagnostics of growth hormone deficiency (GHD) and secondary adrenal insufficiency (SAI) is based on estimation of peak GH and cortisol concentrations in provocation tests. Russian consensus on diagnostics and treatment of hypopituitarism in children and adolescences recommends to measure GH and cortisol concentrations in every time-point of insulin test (IT). Glucagon test (GT) is discussed in literature as alternative to IT. AIMS To estimate the possibility to use provocation GT for diagnostics of SAI and GHD in children and adolescents. MATERIALS AND METHODS We investigated blood and urine cortisol levels, IT, and GT in 20 patients 6.5-17.8 years (Me 13.0 (10.4; 15.3)) after surgery and/or radiology and/or chemical therapy of head and neck tumors; remission for 0.4-7.5 years (Ме 2.1 (1.5; 5.2)). RESULTS With cut-off point 550 nmol/L sensitivity and specifity of IT was 100% and 60%, GT - 100% and 53% respectively. Minimal cortisol cut-off level for GT with sensitivity 100% was 500 nmol/L, maximal with specifity 100% - 400 nmol/L.Early morning cortisol levels did not exceed 250 nmol/l in 2 patients with SAI; and were above 500 nmol/l in 8 patients without SAI while primary or repeated examination.GHD was reviled by IT in all patients. Maximal GH concentrations in GT and IT did not differ significantly (p>0.05) but GT results of 4 patients exceeded or met cut-off for this test (7 ng/ml).GT was characterized by less severity compared with IT. CONCLUSIONS For diagnostics of SAI by GT we can advise cut-off points of cortisol level 500 (sensitivity 100%, specifty 53%) and 400 nmol/L (sensitivity 80%, specifity 100%). Measuring of cortisol levels in 2-3 early morning blood samples allows to exclude or to suspect SAI in half of patients before tests. GH peaks in GT can exceed similarly data in IT that needs future investigation.
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Affiliation(s)
- A V Vitebskaya
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - E A Pisareva
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A V Popovich
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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Yudina AE, Pavlova MG, Sotnikov VM, Tselovalnikova TY, Mazerkina NA, Zheludkova OG, Gerasimov AN, Teryaeva NB, Martynova E, Kim EI. [The glucagon test in diagnosis of secondary adrenal insufficiency after craniospinal irradiation: the feasibility of application, the features of performing the test, and its diagnostic informativity]. ACTA ACUST UNITED AC 2019; 65:227-235. [PMID: 32202724 DOI: 10.14341/probl10219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 07/11/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND The glucagon test (GT) is a promising alternative to the insulin hypoglycemia test (IHT) in diagnosis of secondary adrenal insufficiency (SAI). AIM To study the feasibility of using the GT in patients after craniospinal irradiation and to determine the cut-off value to rule out SAI. METHODS A total of 28 patients (14 males and 14 females) with the median age of 19 years (17; 23) who had undergone combination treatment (surgery, craniospinal irradiation (35 Gy) with boost to the tumor bed, and polychemotherapy) of extrapituitary brain tumors no later than 2 years before study initiation and 10 healthy volunteers of matching sex and age were examined. All the subjects underwent the GT and IHT with an interval of at least 57 days. The cortisol, ACTH, and glucose levels were measured. RESULTS Twelve out of 28 patients were diagnosed with SAI according to the IHT results. ROC analysis revealed that cortisol release during the GT 499 nmol/L ruled out SAI [100% sensitivity (Se); 62% specificity (Sp)], while the absence of a rise 340 nmol/l verified SAI (Sp 100%; 55% Se). For GT, the area under a curve (AUC) was 93.6%, which corresponds to a very good diagnostic informativity. In 19 patients, the IHT and GT results were concordant (in ten patients, the release of cortisol occurred above the cut-off value in both tests; no release was detected in nine patients). In nine cases, the results were discordant: the maximum cortisol level detected in the GT was 500 nmol/l, but the IHT results ruled out SAI (the GT yielded a false positive outcome). Contrariwise, in three (10.7%) patients the release of cortisol detected in the GT was adequate, while being insufficient in the IHT test. Adverse events (nausea) were reported during the GT test in 9 (25%) subjects; one patient had hypoglycemia (1.8 mmol/l). CONCLUSION GT is highly informative and can be used as a first-level stimulation test for ruling out SAI in patients exposed to craniospinal irradiation performed to manage brain tumors. The cortisol level of 500 nmol/L is the best cut-off value for ruling out SAI according to the GT results. The insulin hypoglycemia test is used as the second-level supporting test in patients with positive GT results.
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Affiliation(s)
- A E Yudina
- I.M. Sechenov First Moscow State Medical University
| | - M G Pavlova
- I.M. Sechenov First Moscow State Medical University
| | - V M Sotnikov
- Russian Scientific Center of Roentgeno-Radiology
| | | | - N A Mazerkina
- N.N. Burdenko National Scientific and Practical Center for Neurosurgery
| | | | | | - N B Teryaeva
- N.N. Burdenko National Scientific and Practical Center for Neurosurgery
| | - E Martynova
- I.M. Sechenov First Moscow State Medical University
| | - E I Kim
- I.M. Sechenov First Moscow State Medical University
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Maliachova O, Dimitriadou M, Triantafyllou P, Slavakis A, Christoforidis A. Cortisol Levels in Glucagon Stimulation Test in Children Assessed for Short Stature: Clinical and Laboratorial Correlations. Horm Metab Res 2019; 51:798-804. [PMID: 31745940 DOI: 10.1055/a-1036-6396] [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: 10/25/2022]
Abstract
To assess total cortisol levels in children being evaluating for short stature with normal cortisol reserve and to correlate this response to clinical and laboratory data. Children assessed with glucagon test in our department were recruited in this study retrospectively. Inclusion criteria were: i) age>1 year, ii) absence of chronic illness or medication interfering with ACTH-cortisol axis, iii) GH stimulation levels>3ng/mL at least in one provocation test (glucagon or clonidine), iv) absence of multiple pituitary growth hormone deficiencies, v) normal short Synacthen test in cases of low cortisol response in glucagon test.Two hundred and thirty-seven subjects (160 males, 67.5%) with a mean age of 9.02±3.19 years, were finally included in the analysis. Cortisol peak levels but not cortisol AUC were significantly increased in females compared to males (26.83±7.31 μg/dl vs. 24.04±7.20 μg/dl). When linear correlations were studied, both cortisol peak levels and cortisol AUC were linearly but inversely correlated to age (r=-0.234, p<0.001 and r=-0.315, p<0.001, respectively). Finally, cortisol AUC was inversely correlated to weight Z-scores (r=-0.160, p=0.014). When our analysis was limited only to subjects with intact GH response (GH peak> 7 ng/mL), age was still inversely correlated to cortisol AUC (r=-0.312, p<0.001), and cortisol AUC was linearly correlated to GH AUC assessed with clonidine test (r=0.223, p=0.013). Girls, younger and thinner children exhibit higher cortisol response to glucagon test.
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Affiliation(s)
- Olga Maliachova
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Meropi Dimitriadou
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiota Triantafyllou
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aris Slavakis
- Hormone Assay Laboratory, Department of Biochemistry, Ippokration General Hospital, Thessaloniki, Greece
| | - Athanasios Christoforidis
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Al-Kuraishy HM, Al-Gareeb AI. Effects of rosuvastatin on metabolic profile: Versatility of dose-dependent effect. J Adv Pharm Technol Res 2019; 10:33-38. [PMID: 30815386 PMCID: PMC6383350 DOI: 10.4103/japtr.japtr_330_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Obesity refers to an excess of body fat content causing metabolic and inflammatory disorders. Therefore, the aim of the present study was to investigate dose-dependent effect of rosuvastatin on the metabolic profile of diet-induced obesity in mice model study. A total number of 40 male Albino Swiss mice were used which divided into Group I: Control group, fed normal diet for 8 weeks (n = 10); Group II: High-fat diet (HFD) group, fed on HFD for 8 weeks (n = 10); Group III: HFD + 20 mg/kg rosuvastatin for 8 weeks (n = 10); and Group IV: HFD +40 mg/kg rosuvastatin for 8 weeks (n = 10). Anthropometric and biochemical parameters were estimated, including fasting blood glucose, lipid profile, fasting insulin, and glucose tolerance test (GTT). Mice on HFD fed showed a significant increase in the insulin resistance, body weight, deterioration of lipid profile and significant reduction in the β-cell function, and insulin sensitivity compared to the control P < 0.05. GTT and blood glucose level were significantly high in HFD fed group compared to the control group P < 0.05. Rosuvastatin in a dose of 40 mg/kg illustrated better effect than 20 mg/kg on the glucometabolic profile P < 0.05. Rosuvastatin may has a potential effect on reduction of glucometabolic changes induced by HFD with significant amelioration of pancreatic β-cell function in dose-dependent manner.
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Affiliation(s)
- Hayder M Al-Kuraishy
- Department of Pharmacology, Toxicology and Medicine, College of Medicine, Al-Mustansiriya University, Baghdad, Iraq
| | - Ali I Al-Gareeb
- Department of Pharmacology, Toxicology and Medicine, College of Medicine, Al-Mustansiriya University, Baghdad, Iraq
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Ach T, Yosra H, Jihen M, Abdelkarim Asma B, Maha K, Molka C, Rouatbi S, Monia Z, Ach K. Cortisol cut-points for the glucagon stimulation test in the evaluation of hypothalamic pituitary adrenal axis. Endocr J 2018; 65:935-942. [PMID: 29952338 DOI: 10.1507/endocrj.ej18-0147] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Diagnosis of adrenal insufficiency requires evaluation by dynamic stimulation tests. The insulin tolerance test (ITT) is accepted as the gold-standard test for the evaluation of hypothalamo-pituitary-adrenal (HPA) axis but the test is unpleasant and dangerous. Although it takes more time, glucagon stimulation test (GST) is a good alternative to ITT. The primary aim of this study was to compare the ITT and GSTs in the evaluation of HPA axe in patients with pituitary disorders. We conducted a prospective study in which ITT and GST were performed within 7 days in 81 patients. Serum cortisol was measured. We divided our population in Group 1 (G1): Adrenal Insufficiency (Peak cortisol under ITT <200 ng/mL) and Group 2 (G2): normal response (Peak cortisol under ITT >200 ng/mL). Receiver-operating characteristic (ROC) analysis was performed to identify the thresholds for GST. The mean peak of cortisol under GST was not significantly different from that obtained after ITT in the whole cohort (182.67 ± 89.07 ng/mL vs. 179.75 ± 79.01 ng/mL), and it was significantly reduced in patients of G1 (p < 10-3). ROC curve analysis showed that the best diagnostic accuracy was obtained with a peak cortisol cut-off to GST of 167 ng/mL (sensitivity, 89%; specificity, 79%). Using this cut-off, 86.4% of the patients were correctly classified. In our prospective series, GST is a potential accurate and safe alternative test for the assessment HPA. Test-specific cut-offs should be applied to avoid misinterpretation.
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Affiliation(s)
- Taieb Ach
- Department of Endocrinology and Diabetology, University Hospital of Farhat Hached, Sousse, Tunisia
| | - Hasni Yosra
- Department of Endocrinology and Diabetology, University Hospital of Farhat Hached, Sousse, Tunisia
| | - Maatoug Jihen
- Department of Epidemiology, University Hospital of Farhat Hached, Sousse, Tunisia
| | - Ben Abdelkarim Asma
- Department of Endocrinology and Diabetology, University Hospital of Farhat Hached, Sousse, Tunisia
| | - Kacem Maha
- Department of Endocrinology and Diabetology, University Hospital of Farhat Hached, Sousse, Tunisia
| | - Chaieb Molka
- Department of Endocrinology and Diabetology, University Hospital of Farhat Hached, Sousse, Tunisia
| | - Sonia Rouatbi
- Department of Physiology, University Hospital of Farhat Hached, Sousse, Tunisia
| | - Zaouali Monia
- Department of Physiology, University Hospital of Farhat Hached, Sousse, Tunisia
| | - Koussay Ach
- Department of Endocrinology and Diabetology, University Hospital of Farhat Hached, Sousse, Tunisia
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11
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Acar S, Paketçi A, Tuhan H, Demir K, Böber E, Abaci A. Comparison of the effects of the L-dopa and insulin tolerance tests on cortisol secretion. J Endocrinol Invest 2018; 41:901-907. [PMID: 29353394 DOI: 10.1007/s40618-017-0815-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/09/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE The aims of the present study are to evaluate the effect of L-dopa on the secretion of cortisol and adrenocorticotropic hormone (ACTH) in short children and compare the performance of this test with the insulin tolerance test (ITT) in a large number of patients. METHODS A total of 29 short but otherwise healthy children [mean age 9.5 ± 3.1 years (range 3.7-14.9 years)] who had inadequate growth hormone (GH) responses to ITT, which was performed as the first test, were consecutively enrolled in this study. GH, cortisol, and ACTH levels were measured just before administration of L-dopa and then at 30-min intervals afterward over a total time of 120 min. Peak concentrations of cortisol and ACTH exceeding 18 µg/dL (496 mmol/L) and 46 pg/mL (10.2 pmol/L), respectively, were defined as an adequate response. RESULTS While the L-dopa test revealed that 26 of the 29 children (89.7%) had peak serum cortisol levels of > 18 µg/dL, the ITT revealed that only 23 children (79.3%) had adequate cortisol responses. The L-dopa test revealed normal ACTH responses (> 46 pg/mL) in 24 (82.8%) patients. Peak cortisol levels were higher in children with normal ACTH responses than in those with subnormal ACTH responses (25.6 ± 6.2 vs. 19.5 ± 6.4 µg/dL, p = 0.054), but the difference observed was statistically insignificant. CONCLUSION The results of the current study confirm that the L-dopa test is a reliable test of cortisol secretion. As such, this test may be applicable to assessments of the hypothalamic-pituitary-adrenal axis.
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Affiliation(s)
- S Acar
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University School of Medicine, Narlıdere, 35340, Izmir, Turkey
| | - A Paketçi
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University School of Medicine, Narlıdere, 35340, Izmir, Turkey
| | - H Tuhan
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University School of Medicine, Narlıdere, 35340, Izmir, Turkey
| | - K Demir
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University School of Medicine, Narlıdere, 35340, Izmir, Turkey
| | - E Böber
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University School of Medicine, Narlıdere, 35340, Izmir, Turkey
| | - A Abaci
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University School of Medicine, Narlıdere, 35340, Izmir, Turkey.
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12
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Patti G, Guzzeti C, Di Iorgi N, Maria Allegri AE, Napoli F, Loche S, Maghnie M. Central adrenal insufficiency in children and adolescents. Best Pract Res Clin Endocrinol Metab 2018; 32:425-444. [PMID: 30086867 DOI: 10.1016/j.beem.2018.03.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Central adrenal insufficiency (CAI) is a life-threatening condition caused by either pituitary disease (secondary adrenal insufficiency) or impaired hypothalamic function with inadequate CRH production (tertiary adrenal insufficiency). ACTH deficiency may be isolated or, more frequently, occur in conjunction with other pituitary hormone deficiencies and midline defects. Genetic mutations of the TBX19 causing isolated CAI are rare but a number of genes encoding transcription factors involved in hypothalamic-pituitary gland development, as well as other genes including POMC and PC1, are associated with ACTH deficiency. CAI is frequently identified in congenital, malformative, genetic, and epigenetic syndromes as well as in several acquired conditions of different etiologies. The signs and symptoms vary considerably and depend on the age of onset and the number and severity of associated pituitary defects. They may include hypoglycemia, lethargy, apnea, poor feeding, prolonged cholestatic jaundice, jitteriness, seizures, and sepsis in the neonate, or nonspecific signs such as fatigue, hypotension, vomiting and hyponatremia without hyperkalemia in children. The diagnosis of CAI relies on the measurement of morning cortisol concentrations along with dynamic test for cortisol release with different stimulating agents. Early recognition of CAI and its correct management are mandatory in order to avoid both morbidity and mortality in affected neonates, children and adolescents.
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Affiliation(s)
- Giuseppa Patti
- Departments of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Chiara Guzzeti
- SSD Endocrinologia Pediatrica, Ospedale Pediatrico Microcitemico "A. Cao", AO Brotzu, Cagliari, Italy
| | - Natascia Di Iorgi
- Departments of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | | | - Flavia Napoli
- Departments of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Sandro Loche
- SSD Endocrinologia Pediatrica, Ospedale Pediatrico Microcitemico "A. Cao", AO Brotzu, Cagliari, Italy
| | - Mohamad Maghnie
- Departments of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy.
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Weintrob N, Davidov AS, Becker AS, Israeli G, Oren A, Eyal O. SERUM FREE CORTISOL DURING GLUCAGON STIMULATION TEST IN HEALTHY SHORT-STATURED CHILDREN AND ADOLESCENTS. Endocr Pract 2018; 24:288-293. [PMID: 29547045 DOI: 10.4158/ep-2017-0132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The total cortisol (TC) response may be measured during the glucagon stimulation test (GST) for growth hormone (GH) reserve in order to assess the integrity of the hypothalamic-pituitary-adrenal (HPA) axis. Measurements of TC are unreliable in conditions of albumin and cortisol-binding globulin (CBG) alterations (e.g., hypoproteinemia or CBG deficiency). We aimed to measure the serum free cortisol (sFC) response to the GST in children and adolescents and determine whether it could predict the GH response to glucagon stimulation. METHODS Infants and children with either short stature or growth attenuation who were referred for evaluation of GH reserve underwent the GST. RESULTS The study population consisted of 103 subjects (62 females), median age 3.9 years (range, 0.5-14). The mean basal and peak TC levels were 13.3 ± 6.7 μg/dL and 29.6 ± 8.8 μg/dL, respectively. The mean basal and peak sFC levels were 0.7 ± 0.8 μg/dL and 1.7 ± 1.1 μg/dL, respectively. There was a negative correlation between peak TC and age ( r = -0.3, P = .007) but not between peak sFC and age ( r = -0.09, P = .36). Ninety-five percent of the patients had peak TC levels >15.8 μg/dL and peak sFC levels >0.6 μg/dL. CONCLUSION Our results on a cohort of healthy short-statured children can serve as reference values for the sFC response during GST. Based on these results, we propose peak TC levels >15.8 μg/dL and peak sFC levels >0.6 μg/dL for defining normalcy of the HPA axis during the GST in children and adolescents. ABBREVIATIONS ACTH = adrenocorticotrophic hormone BMI = body mass index CBG = cortisol-binding globulin GH = growth hormone GST = glucagon stimulation test HPA = hypothalamic-pituitary-adrenal SDS = standard deviation score sFC = serum free cortisol TC = total cortisol.
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14
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Ciresi A, Radellini S, Vigneri E, Guarnotta V, Bianco J, Mineo MG, Giordano C. Correlation between adrenal function, growth hormone secretion, and insulin sensitivity in children with idiopathic growth hormone deficiency. J Endocrinol Invest 2018; 41:333-342. [PMID: 28819906 DOI: 10.1007/s40618-017-0747-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/11/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Patients with growth hormone deficiency (GHD) demonstrate an increased cortisol/cortisone ratio which could potentially explain the metabolic features of GHD, while GH treatment (GHT) could increase the cortisol metabolism. METHODS In 35 children (27 M, mean age 10.1 years) with idiopathic GHD at baseline and after 12 months of GHT and in 25 controls, in addition to metabolic parameters, we assessed adrenal function by morning serum cortisol, its peak, and its area under the curve (AUCCOR) during insulin tolerance test (ITT). RESULTS A cortisol peak <18 µg/dl was shown in 22 and 31% of GHD children at baseline and after GHT, respectively. At baseline, GHD children had lower fasting glucose (p < 0.001) and ISI-Matsuda (p = 0.042), with concomitant higher Homa-IR (p = 0.006) and morning cortisol (p = 0.012) than controls. Morning cortisol was negatively correlated with GH (p < 0.001), fasting glucose (p < 0.001) and ISI-Matsuda (p < 0.001) and positively with Homa-IR (p = 0.010). Both cortisol peak and AUCCOR were negatively correlated with GH (all p < 0.001) and ISI-Matsuda (p = 0.016 and p = 0.001, respectively). After 12 months of GHT, a significant increase in fasting glucose (p < 0.001), and Homa-IR (p = 0.011) was documented, with a concomitant decrease in morning cortisol (p = 0.002), AUCCOR (p = 0.038), total (p = 0.003) and LDL-cholesterol (p = 0.016). No significant correlations were found among cortisol levels and all parameters were investigated. CONCLUSIONS Cortisol levels correlate with GH secretion and with many metabolic parameters in GHD children, while the metabolic effects during GHT are mainly due to GHT per se and less to cortisol reduction.
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Affiliation(s)
- A Ciresi
- Section of Endocrinology, Diabetology and Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - S Radellini
- Section of Endocrinology, Diabetology and Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - E Vigneri
- Section of Endocrinology, Diabetology and Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - V Guarnotta
- Section of Endocrinology, Diabetology and Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - J Bianco
- Section of Endocrinology, Diabetology and Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - M G Mineo
- Section of Endocrinology, Diabetology and Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - C Giordano
- Section of Endocrinology, Diabetology and Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy.
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Abstract
Secondary adrenal insufficiency can result from insufficient stimulation of the adrenal glands due to inadequate secretion or synthesis of adrenocorticotropic hormone (ACTH). This can be caused by hypopituitarism, central nervous system injury (tumors, radiation, and surgery) or long-term glucocorticoid therapy. Glucocorticoids were introduced in the 1950s, and have been used for their anti-inflammatory and other pharmacological effects, and also as replacement therapy for adrenal insufficiency. However, chronic glucocorticoid use may lead to suppression of the hypothalamic pituitary adrenal axis through negative feedback. This may lead to secondary adrenal insufficiency. Typically, the hypothalamic pituitary adrenal axis recovers after cessation of glucocorticoids, but the timing of recovery can be variable and can take anywhere from 6-12 months. Understanding the effect of exogenous glucocorticoids on the hypothalamic pituitary adrenal axis, recovery of the axis, and tests used to assess the recovery, are crucial to avoid prescribing unnecessary steroid replacement or missing a critical diagnosis with detrimental consequences.
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Affiliation(s)
- Areej K Younes
- Section of Endocrinology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Noor K Younes
- Division of Pediatrics, King Hussein Cancer Center, Amman, Jordan
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16
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Wong MTY, van Ravenswaaij-Arts CMA, Munns CF, Hsu P, Mehr S, Bocca G. Central Adrenal Insufficiency Is Not a Common Feature in CHARGE Syndrome: A Cross-Sectional Study in 2 Cohorts. J Pediatr 2016; 176:150-5. [PMID: 27321065 DOI: 10.1016/j.jpeds.2016.05.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 04/20/2016] [Accepted: 05/19/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate whether central adrenal insufficiency (CAI) is present in CHARGE (Coloboma of the eye, Heart defects, Atresia of the choanae, Retardation of growth and/or development, Genital hypoplasia, and Ear abnormalities, including deafness) syndrome, a complex malformation disorder that includes central endocrine dysfunction. STUDY DESIGN Two cross-sectional studies were performed in Dutch (September 2013-February 2015) and Australian (January 2012-January 2014) CHARGE syndrome clinics. Twenty-seven Dutch and 19 Australian patients (aged 16 months-18 years) with genetically confirmed CHARGE syndrome were included. The low-dose adrenocorticotropin (ACTH) test was used to assess CAI in the Dutch cohort. A peak cortisol response less than 18.1 μg/dL (500 nmol/L) was suspected for CAI, and a glucagon stimulation test was performed for confirmation. Australian patients were screened by single measurements of ACTH and cortisol levels. If adrenal dysfunction was suspected, a standard-dose ACTH test was performed. RESULTS The low-dose ACTH test was performed in 23 patients (median age 8.4 [1.9-16.9] years). Seven patients showed an insufficient maximum cortisol level (10.3-17.6 μg/dL, 285-485 nmol/L), but CAI was confirmed by glucagon stimulation test in only 1 patient (maximum cortisol level 15.0 μg/dL, 415 nmol/L). In the Australian cohort, 15 patients (median age 9.1 [1.3-17.8] years) were screened, and none had CAI. CONCLUSIONS CAI was not common in our cohorts, and routine testing of adrenal function in children with CHARGE syndrome is not indicated.
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Affiliation(s)
- Monica T Y Wong
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | | | - Craig F Munns
- Department of Endocrinology, The Children's Hospital at Westmead, Sydney, Australia
| | - Peter Hsu
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Sydney, Australia
| | - Sam Mehr
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Sydney, Australia
| | - Gianni Bocca
- Department of Pediatrics, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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17
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Hamrahian AH, Yuen KCJ, Gordon MB, Pulaski-Liebert KJ, Bena J, Biller BMK. Revised GH and cortisol cut-points for the glucagon stimulation test in the evaluation of GH and hypothalamic-pituitary-adrenal axes in adults: results from a prospective randomized multicenter study. Pituitary 2016; 19:332-41. [PMID: 26897383 DOI: 10.1007/s11102-016-0712-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
CONTEXT Recent studies suggest using lower GH cut-points for the glucagon stimulation test (GST) in diagnosing adult GH deficiency (GHD), especially in obese patients. There are limited data on evaluating GH and hypothalamic-pituitary-adrenal (HPA) axes using weight-based dosing for the GST. OBJECTIVE To define GH and cortisol cut-points to diagnose adult GHD and secondary adrenal insufficiency (SAI) using the GST, and to compare fixed-dose (FD: 1 or 1.5 mg in patients >90 kg) with weight-based dosing (WB: 0.03 mg/kg). Response to the insulin tolerance test (ITT) was considered the gold standard, using GH and cortisol cut-points of ≥3 ng/ml and ≥18 µg/dL, respectively. DESIGN 28 Patients with hypothalamic-pituitary disease and 1-2 (n = 14) or ≥3 (n = 14) pituitary hormone deficiencies, and 14 control subjects matched for age, sex, estrogen status and body mass index (BMI) underwent the ITT, FD- and WB-GST in random order. RESULTS Age, sex ratio and BMI were comparable between the three groups. The best GH cut-point for diagnosis of GHD was 1.0 (92 % sensitivity, 100 % specificity) and 2.0 ng/mL (96 % sensitivity and 100 % specificity) for FD- and WB-GST, respectively. Age negatively correlated with peak GH during FD-GST (r = -0.32, P = 0.04), but not WB-GST. The best cortisol cut-point for diagnosis of SAI was 8.8 µg/dL (92 % sensitivity, 100 % specificity) and 11.2 µg/dL (92 % sensitivity and 100 % specificity) for FD-GST and WB-GST, respectively. Nausea was the most common side effect, and one patient had a seizure during the FD-GST. CONCLUSION The GST correctly classified GHD using GH cut-points of 1 ng/ml for FD-GST and 2 ng/ml for WB-GST, hence using 3 ng/ml as the GH cut-point will misclassify some GH-sufficient adults. The GST may also be an acceptable alternative to the ITT for evaluating the HPA axis utilizing cortisol cut-points of 9 µg/dL for FD-GST and 11 µg/dL for WB-GST.
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Affiliation(s)
- Amir H Hamrahian
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, OH, 44022, USA.
- Department of Endocrinology, Medical Subspecialty Institute, Cleveland Clinic Abu Dhabi, 7th Floor, Swing Wing, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE.
| | - Kevin C J Yuen
- Swedish Pituitary Center, Swedish Neuroscience Institute, Seattle, WA, 98122, USA
| | - Murray B Gordon
- Department of Medicine and Neurosurgery, Allegheny Neuroendocrinology Center, Allegheny General Hospital, Pittsburgh, PA, 15212, USA
| | | | - James Bena
- Quantitatve Health Sciences, Lerner Research Institute, Cleveland, OH, 44195, USA
| | - Beverly M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, 02114, USA
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18
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Yuen KCJ, Frystyk J, Rhoads SA, Bidlingmaier M. Pegvisomant-primed glucagon stimulation test in assessing GH reserve and GH/IGF kinetics in adults suspected of GH deficiency. Pituitary 2016; 19:65-74. [PMID: 26496767 DOI: 10.1007/s11102-015-0688-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE The accuracy of the glucagon stimulation test(GST) in diagnosing adult GH deficiency (GHD) has recently been questioned. Because pegvisomant (PegV)increases endogenous GH secretion, we hypothesized that priming PegV to the GST (PegV-GST) 72 h beforehand would improve the diagnostic accuracy of this test. This pilot study aimed to prospectively compare PegV-GST to two other diagnostic tests for adult GHD. METHODS Adults suspected of GHD underwent PegVGST,GST and insulin tolerance test (ITT) in random order.Growth hormone levels (measured by a PegV insensitive assay) during PegV-GST, GST and ITT were compared,and acute effects of PegV on GH/IGF kinetics were assessed. RESULTS Ten subjects with hypothalamic-pituitary disease and 1–4 pituitary hormone deficiencies were studied. Basal and peak GH levels with the PegV-GST were comparable to those of the GST and ITT. The five subjects that failed the GST and ITT were the same subjects that failed the PegVGST,using the peak GH cut point of<3 ng/mL for this test. After PegV priming, basal GH and GH binding protein(GHBP) increased (both P<0.01) and total IGF-I and bioactive IGF decreased (both P<0.05), whereas IGF-II and IGFBPs -1, -2 and -3 were unchanged compared to pre-PegV priming. Serum PegV levels correlated positively with basal GH, peak GH, IGFBP-1 and IGFBP-2 levels, and negatively with D bioactive IGF and DGHBP (all P<0.05). CONCLUSION Single dose PegV administration in adults suspected of GHD increased basal GH and GHBP, with concomitant rapid fall in IGF-I levels and bioactive IGF. PegV priming did not appear to improve the diagnostic accuracy of the GST. Further studies involving larger subject numbers are needed to verify the clinical utility of PegV-GST in evaluating adult GHD.
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19
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Chen YC, Inui A, Chang ES, Chen SC, Lee WJ, Chen CY. Comparison of gut hormones and adipokines stimulated by glucagon test among patients with type II diabetes mellitus after metabolic surgery. Neuropeptides 2016; 55:39-45. [PMID: 26621498 DOI: 10.1016/j.npep.2015.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 11/09/2015] [Accepted: 11/09/2015] [Indexed: 02/06/2023]
Abstract
Laparoscopic Roux-en-Y gastric bypass (RYGB) achieves a higher remission of type 2 diabetes mellitus (T2DM) than laparoscopic sleeve gastrectomy (SG) in non-morbidly obese patients. However, the mechanisms of the higher remission are unknown. To compare glucagon-provoked acute insulin responses, as well as changes of gut and pancreatic hormones and adipokines between patients with T2DM after RYGB and SG at one year post-operatively, a total of 14 RYGB and 13 SG patients were followed-up and evaluated for glucose metabolism, gut and pancreatic hormones, and adipokines. One year after surgery, 1-mg intravenous glucagon tests were performed. The differences in each hormone at different time points and the area under the curve (AUC) were compared between the two groups. Glucagon-stimulated acute insulin responses were not different between the RYGB and SG groups, nor were they different between the remitters and non-remitters at one year after the metabolic surgery. Plasma des-acyl ghrelin and nesfatin-1 levels significantly decreased at 6 min after glucagon stimulation in the RYGB and SG groups, as well as in the remitters and non-remitters. The glucagon test did not affect intestinal hormones. Plasma resistin was suppressed after intravenous glucagon stimulation in both RYGB and SG groups. In conclusion, intravenous glucagon inhibited plasma levels of des-acyl ghrelin, nesfatin-1, and resistin in T2DM patients at one year after both RYGB and SG, whereas post-glucagon suppression of plasma obestatin and resistin was shown in the remitters but not in the non-remitters.
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Affiliation(s)
- Ying-Chieh Chen
- Division of Digestive Medicine, Taipei City Hospital Yangming Branch, Taipei, Taiwan
| | - Akio Inui
- Department of Psychosomatic Internal Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - En-Su Chang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Shu-Chun Chen
- Department of Nursing, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Wei-Jei Lee
- Department of Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Chih-Yen Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Nursing, Min-Sheng General Hospital, Taoyuan, Taiwan.
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20
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Beauloye V, Dhondt K, Buysse W, Nyakasane A, Zech F, De Schepper J, Van Aken S, De Waele K, Craen M, Gies I, Francois I, Beckers D, Desloovere A, Francois G, Cools M. Evaluation of the hypothalamic-pituitary-adrenal axis and its relationship with central respiratory dysfunction in children with Prader-Willi syndrome. Orphanet J Rare Dis 2015; 10:106. [PMID: 26329144 PMCID: PMC4557896 DOI: 10.1186/s13023-015-0312-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Children with Prader-Willi Syndrome (PWS) have been considered at risk for central adrenal insufficiency (CAI). Hypothalamic dysregulation has been proposed as a common mechanism underlying both stress-induced CAI and central respiratory dysfunction during sleep. OBJECTIVE To evaluate CAI and sleep-related breathing disorders in PWS children. PATIENTS AND METHODS Retrospective study of cortisol response following either insulin tolerance test (ITT) or glucagon test (GT) in 20 PWS children, and comparison with 33 non- Growth Hormone deficient (GHD) controls. Correlation between sleep related breathing disorders and cortisol response in 11 PWS children who received both investigations. RESULTS In PWS children, the cortisol peak value showed a significant, inverse correlation with age (Kendall's τ = -0.411; p = 0.012). A similar though non-significant correlation was present between cortisol increase and age (τ = -0.232; p = 0.16). Similar correlations were found in controls. In only 1 of 20 PWS children (5 %), ITT was suggestive of CAI. Four patients had an elevated central apnea index but they all exhibited a normal cortisol response. No relationship was found between peak cortisol or cortisol increase and central apnea index (respectively p = 0.94 and p = 0.14) or the other studied polysomnography (PSG) parameters. CONCLUSIONS CAI assessed by ITT/GT is rare in PWS children. Our data do not support a link between CAI and central respiratory dysregulation.
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Affiliation(s)
- Veronique Beauloye
- Unité d'Endocrinologie pédiatrique, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, avenue Hippocrate 10/1300, Brussels, B-1200, Belgium.
| | - K Dhondt
- Department of Pediatrics, Division of Child Neurology and Metabolism, Pediatric sleep center, Ghent University Hospital, Ghent, Belgium.
| | - W Buysse
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital and Ghent University, Ghent, Belgium.
| | - A Nyakasane
- Unité d'Endocrinologie pédiatrique, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, avenue Hippocrate 10/1300, Brussels, B-1200, Belgium.
| | - F Zech
- IREC, Université Catholique de Louvain, Brussels, Belgium.
| | - J De Schepper
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital and Ghent University, Ghent, Belgium. .,Department of Pediatrics, Division of Ped Endocrinology, UZ Brussel, Brussels, Belgium.
| | - S Van Aken
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital and Ghent University, Ghent, Belgium.
| | - K De Waele
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital and Ghent University, Ghent, Belgium.
| | - M Craen
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital and Ghent University, Ghent, Belgium.
| | - I Gies
- Department of Pediatrics, Division of Ped Endocrinology, UZ Brussel, Brussels, Belgium.
| | - I Francois
- Department of Pediatrics, Division of Ped Endocrinology, KULeuven, Leuven, Belgium.
| | - D Beckers
- Department of Pediatrics, Division of Ped Endocrinology, KULeuven, Leuven, Belgium. .,Department of Pediatrics, Division of Ped Endocrinology, CHU Mont-Godinne-Dinant, Université Catholique de Louvain, Yvoir, Belgium.
| | - A Desloovere
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital and Ghent University, Ghent, Belgium.
| | - G Francois
- Unité de sommeil, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.
| | - M Cools
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital and Ghent University, Ghent, Belgium.
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Guran T, Guran O, Paketci C, Kipoglu O, Firat I, Turan S, Atay Z, Haliloglu B, Bereket A. Effects of leukemia inhibitory receptor gene mutations on human hypothalamo-pituitary-adrenal function. Pituitary 2015; 18:456-60. [PMID: 25145448 DOI: 10.1007/s11102-014-0594-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Stuve-Wiedemann syndrome (STWS) (MIM #601559) is a rare autosomal recessive disorder caused by mutations in the leukemia inhibitory factor receptor (LIFR) gene. STWS has a diverse range of clinical features involving hematopoietic, skeletal, neuronal and immune systems. STWS manifests a high mortality due to increased risk of sudden death. Heterodimerization of the LIFR mediates leukemia inhibitory factor (LIF) signalling through the intracellular Janus kinase (JAK)/STAT3 signalling cascade. The LIF/LIFR system is highly expressed in and regulates the hypothalamo-pituitary-adrenal (HPA) axis. OBJECTIVES HPA function was investigated in three STWS patients to characterise consequences of impaired LIF/LIFR signalling on adrenal function. DESIGN Six genetically proven STWS patients from four unrelated Turkish families were included in the study. Sudden death occurred in three before 2 years of age. Basal adrenal function tests were performed by measurement of early morning serum cortisol and plasma ACTH concentrations on at least two different occasions. Low dose synacthen stimulation test and glucagon stimulation tests were performed to explore adrenal function in three patients who survived. RESULTS All patients carried the same LIFR (p.Arg692X) mutation. Our oldest patient had attenuated morning serum cortisol and plasma ACTH levels at repeated measurements. Two of three patients had attenuated cortisol response (<18 μg/dl) to glucagon, one of whom also had borderline cortisol response to low dose (1 μg) ACTH stimulation consistent with central adrenal insufficiency. CONCLUSIONS STWS patients may develop central adrenal insufficiency due to impaired LIF/LIFR signalling. LIF/LIFR system plays a role in human HPA axis regulation.
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Affiliation(s)
- Tulay Guran
- Department of Pediatric Endocrinology, Faculty of Medicine, Marmara University Hospital, Fevzi Cakmak Mh.Mimar Sinan Cd.No 41., Ustkaynarca/Pendik, 34899, Istanbul, Turkey,
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Tenenbaum A, Phillip M, de Vries L. The intramuscular glucagon stimulation test does not provide good discrimination between normal and inadequate ACTH reserve when used in the investigation of short healthy children. Horm Res Paediatr 2015; 82:194-200. [PMID: 25139316 DOI: 10.1159/000365190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 06/10/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Few studies have addressed the role of the glucagon stimulation test (GST) in evaluating the hypothalamic-pituitary-adrenal axis in children. We investigated the diagnostic value of the GST in evaluating the adrenocortical response in short healthy children. METHODS The GST was performed in 190 children investigated for short stature. A peak cortisol >500 nmol/l was considered a normal response. In the 45 (23.7%) with subnormal response, a 250-μg ACTH test was done. RESULTS The rate of subnormal adrenal response to GST was higher among boys (33.9 vs. 8.9%, p < 0.001) and among children ≥6 years than among younger children (32.7 vs. 18.4%, p < 0.02). Both mean basal and peak cortisol levels were higher in girls than in boys: 381 ± 165 vs. 319 ± 151 nmol/l (p = 0.003) and 741 ± 102 vs. 595 ± 208 nmol/l (p < 0.001), respectively. Peak cortisol on GST was associated with basal cortisol (r = 0.45, p < 0.001) but not with glucose nadir (r = -0.31, p = 0.67), peak GH (r = 0.069, p = 0.33) or BMI-SDS (r = -0.08, p = 0.28). Peak cortisol was >500 nmol/l in all the patients undergoing an ACTH stimulation test. CONCLUSIONS Since adrenal response to GST is age- and gender-related and the false-positive rate is high, its routine performance in healthy children warrants reconsideration.
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Affiliation(s)
- Ariel Tenenbaum
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
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A significant proportion of thalassemia major patients have adrenal insufficiency detectable on provocative testing. J Pediatr Hematol Oncol 2015; 37:54-9. [PMID: 24942024 PMCID: PMC4393555 DOI: 10.1097/mph.0000000000000199] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Advances in chelation therapy and noninvasive monitoring of iron overload have resulted in substantial improvements in the survival of transfusion-dependent patients with thalassemia major. Myocardial decompensation and sepsis remain the major causes of death. Although endocrine abnormalities are a well-recognized problem in these iron-overloaded patients, adrenal insufficiency and its consequences are underappreciated by the hematology community. The aims of this study were to determine the prevalence of adrenal insufficiency in thalassemia major subjects, to identify risk factors for adrenal insufficiency, and to localize the origin of the adrenal insufficiency within the hypothalamic-pituitary-adrenal axis. Eighteen subjects with thalassemia major (18.9±9.3 y old, 7 female) were tested for adrenal insufficiency using a glucagon stimulation test. Those found to have adrenal insufficiency (stimulated cortisol <18 µg/dL) subsequently underwent an ovine corticotropin-releasing hormone (oCRH) stimulation test to define the physiological basis for the adrenal insufficiency. The prevalence of adrenal insufficiency was 61%, with an increased prevalence in males over females (92% vs. 29%, P=0.049). Ten of 11 subjects who failed the glucagon stimulation test subsequently demonstrated normal ACTH and cortisol responses to oCRH, indicating a possible hypothalamic origin to their adrenal insufficiency.
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Giavoli C, Tagliabue C, Profka E, Senatore L, Bergamaschi S, Rodari G, Spada A, Beck-Peccoz P, Esposito S. Evaluation of pituitary function after infectious meningitis in childhood. BMC Endocr Disord 2014; 14:80. [PMID: 25287789 PMCID: PMC4196011 DOI: 10.1186/1472-6823-14-80] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 09/29/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A number of studies of adults have shown that pituitary deficiencies can develop in a considerable proportion of subjects during the acute phase of meningitis or years after the infection has disappeared. The results of the very few studies of the impact of pediatric meningitis on hypothalamic-pituitary function are conflicting. METHODS In order to determine the incidence of pituitary dysfunction in children with central nervous system infection, we evaluated pituitary function and anthropometric parameters in 19 children with meningitis of different etiologies (15 males; mean age ± standard deviation [SD] at pituitary evaluation, 5.9 ± 4.0 years; mean time from the acute event ± SD, 18 ± 10 months). RESULTS All of the subjects had a normal stature and growth velocity for their age and gender, and none of them was obese. On the basis of Tanner's reference charts, 17 subjects (13 boys and all four girls) were pre-pubertal; two boys were in Tanner stage 2. None of the subjects had central hypothyroidism. All of the patients had normal serum of insulin growth factor (IGF)-I and prolactin. Their sex steroid and gonadotropin levels were concordant with their age and pubertal status. Early morning urine osmolality and serum electrolyte levels showed no signs of diabetes insipidus. All of the patients had normal plasma adrenocorticotropic hormone (ACTH) levels. Peak cortisol responses to the standard dose Synacthen test (SDST) were normal in all cases. CONCLUSIONS The results showed that hypopituitarism following infectious meningitis appears to be infrequent in childhood and children's pituitary glands seem to be less vulnerable to damage than those of adults.
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Affiliation(s)
- Claudia Giavoli
- />Endocrinology and Diabetology Unit, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudia Tagliabue
- />Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via Commenda 9, 20122 Milan, Italy
| | - Eriselda Profka
- />Endocrinology and Diabetology Unit, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Senatore
- />Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via Commenda 9, 20122 Milan, Italy
| | - Silvia Bergamaschi
- />Endocrinology and Diabetology Unit, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Rodari
- />Endocrinology and Diabetology Unit, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Spada
- />Endocrinology and Diabetology Unit, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Beck-Peccoz
- />Endocrinology and Diabetology Unit, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Susanna Esposito
- />Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via Commenda 9, 20122 Milan, Italy
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Kuhn JM, Prévost G. [How to manage the interruption of a treatment with anti-inflammatory corticosteroids?]. Presse Med 2014; 43:453-9. [PMID: 24613064 DOI: 10.1016/j.lpm.2014.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 12/21/2013] [Accepted: 01/28/2014] [Indexed: 11/24/2022] Open
Abstract
A prolonged treatment with anti-inflammatory corticosteroids induces an inhibition of ACTH secretion from pituitary corticotroph cells. An abrupt interruption of such a treatment potentially leads to the risk of an acute adrenal failure, in particular in stressing situations. The inertia in reactivation of the secretion of the stimulating hypothalamic factors (CRH and AVP) and consecutively of ACTH can be responsible for an inability to adapt the secretion of glucocorticoids in response to stress. A short-time treatment (<3 weeks) with anti-inflammatory corticoids does not expose to this risk. On the contrary, a more prolonged treatment, especially with high daily doses, needs to perform an evaluation of the level of corticotroph secretion. This evaluation should be done before to consider that either stopping the treatment is out of risk or if the initiation of a substitutive treatment with hydrocortisone is required. The measurement of morning plasma cortisol level already provides a significant information. As to whether that is needed, a dynamic evaluation can be performed. Among the available tests, the Synacthen(®)test, easy to perform and using at best 1μg of β1-24 ACTH, appears the most finely informative to answer this question and to choose the most adapted follow-up.
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Affiliation(s)
- Jean-Marc Kuhn
- CHU de Rouen, service d'endocrinologie, diabète et maladies métaboliques, 76230 Bois-Guillaume, France.
| | - Gaëtan Prévost
- CHU de Rouen, service d'endocrinologie, diabète et maladies métaboliques, 76230 Bois-Guillaume, France
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Yuen KCJ, Biller BMK, Katznelson L, Rhoads SA, Gurel MH, Chu O, Corazzini V, Spiller K, Gordon MB, Salvatori R, Cook DM. Clinical characteristics, timing of peak responses and safety aspects of two dosing regimens of the glucagon stimulation test in evaluating growth hormone and cortisol secretion in adults. Pituitary 2013; 16:220-30. [PMID: 22806554 DOI: 10.1007/s11102-012-0407-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Weight-based (WB: 0.03 mg/kg) and fixed dose (FD: 1-1.5 mg) regimens of the glucagon stimulation test (GST) have been used to evaluate GH and cortisol secretion in children and adults, respectively. However, experience of the WB regimen in assessing GH and cortisol secretion in adults are limited. We describe a multicenter experience using WB and FD regimens in evaluating GH and cortisol secretion in adults suspected of GH deficiency and central adrenal insufficiency. Retrospective case series of GSTs (n = 515) performed at five tertiary centers. Peak and nadir glucose, and peak GH and peak cortisol responses occurred later with WB (mean dose: 2.77 mg) compared to FD (mean dose: 1.20 mg) regimens. Main side-effects were nausea and vomiting, particularly in younger females. Nausea was comparable but vomiting was more frequent in the WB regimen (WB: 10.0 % vs FD: 2.4 %; P < 0.05). Peak and nadir glucose, ΔGH, and peak and Δcortisol were higher in the WB regimen. In both regimens, age correlated negatively with peak cortisol levels, and body mass index (BMI), fasting, peak and nadir glucose correlated negatively with peak GH levels. WB and FD regimens can induce adult GH and cortisol secretion, but peak responses occur later in the WB regimen. Both regimens are relatively safe, and vomiting was more prevalent in the WB regimen. As age, BMI, and glucose tolerance negatively correlated with peak GH and cortisol levels, the WB regimen may be more effective than the FD regimen in older overweight glucose intolerant patients.
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Affiliation(s)
- Kevin C J Yuen
- Division of Endocrinology, Diabetes and Clinical Nutrition, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mailcode: L607, Portland, OR 97239, USA.
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Yuen KCJ. Glucagon stimulation testing in assessing for adult growth hormone deficiency: current status and future perspectives. ISRN ENDOCRINOLOGY 2011; 2011:608056. [PMID: 22363884 PMCID: PMC3262627 DOI: 10.5402/2011/608056] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 06/25/2011] [Indexed: 12/02/2022]
Abstract
Growth hormone deficiency (GHD) is a well-recognized clinical syndrome in adults. However, due to the high frequency of normal serum IGF-I levels in hypopituitary adults with GHD, it is now widely accepted that despite normal levels of total IGF-I, adults clinically suspected with GHD within the appropriate clinical setting must undergo GH provocative testing to confirm its diagnosis. Although the insulin tolerance test (ITT) is labor intensive, contraindicated in the elderly and in adults with seizure disorders and ischemic heart disease, can be unpleasant for the patient, and is potentially hazardous, this test remains the gold standard test for the biochemical demonstration of GHD in adults. In contrast, with the unavailability of the GHRH and arginine test as the alternative test to the ITT in the United States since 2008, the glucagon stimulation test (GST) has since been increasingly used in the United States because of its availability, reproducibility, safety, lack of influence by gender and hypothalamic cause of GHD, and relatively few contraindications. In this paper, we discuss our recommendations in performing this test, the potential drawbacks in conducting and caveats in interpreting this test, and its future perspectives.
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Affiliation(s)
- Kevin C J Yuen
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health and Science University, Portland, OR 97239-3098, USA
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Claahsen-van der Grinten HL, Otten BJ. Adrenal function: A gold standard test for adrenal insufficiency in children? Nat Rev Endocrinol 2010; 6:605-6. [PMID: 20962867 DOI: 10.1038/nrendo.2010.152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hedi L Claahsen-van der Grinten
- Radboud University Nijmegen Medical Centre, Department of Paediatric Endocrinology, PO Box P9101, 6500 HB Nijmegen, The Netherlands.
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Abstract
CONTEXT Adrenal failure secondary to hypothalamo-pituitary disease is a common clinical problem which has serious repercussions. It is essential to perform validated diagnostic procedures and manage such patients with clear objectives and based on well-established replacement programs. EVIDENCE ACQUISITION PubMed was searched for all data reflecting pituitary hypoadrenalism dating back to 1960 in order to establish a published database. EVIDENCE SYNTHESIS The results from published studies were assessed in the light of the author's extensive personal experience dating back some 30 yr in clinical endocrinology, in an attempt to provide clear diagnostic and management advice. CONCLUSIONS While much of the physiology of the hypothalamo-pituitary-adrenal axis is well understood, its clinical assessment and diagnostic procedures to establish the need for replacement are still far from perfect, and to a certain extent clinical judgement is still vital. In terms of replacement therapies, these are still far from optimal in terms of quality of life and mortality, although they are increasingly being based on objective evidence rather than established practice. However, it is anticipated that newer replacement protocols will improve a situation that has previously changed little for many years.
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