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Tucci L, Fanelli F, Improta I, Bissi V, Lena C, Galante G, Mezzullo M, Magagnoli M, Lalumera AB, Colombin G, Coscia K, Rotolo L, Vicennati V, Pagotto U, Di Dalmazi G. Monitoring adrenal insufficiency through salivary steroids: a pilot study. Eur J Endocrinol 2024; 190:327-337. [PMID: 38571387 DOI: 10.1093/ejendo/lvae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/21/2024] [Accepted: 03/11/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Various glucocorticoid replacement therapies (GRTs) are available for adrenal insufficiency (AI). However, their effectiveness in restoring glucocorticoid rhythm and exposure lacks adequate biochemical markers. We described the diurnal salivary cortisol (SalF) and cortisone (SalE) rhythm among different GRTs and analysed the associations between saliva-derived parameters and life quality questionnaires. METHODS Control subjects (CSs, n = 28) and AI patients receiving hydrocortisone (HC, n = 9), cortisone acetate (CA, n = 23), and dual-release hydrocortisone once (DRHC-od, n = 10) and twice a day (DRHC-td, n = 6) collected 9 saliva samples from 07:00 to 23:00. Patients compiled Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Scale, and Addison disease-specific quality-of-life questionnaires. SalE and SalF were measured by liquid chromatography-mass spectrometry. Exposure was monitored using SalE for HC and DRHC and SalF for CA. Area under the curve (AUC) was computed. Different GRTs were compared by Z-scores calculated from saliva-derived parameters. Questionnaire results predictors were evaluated with multiple regression analysis. RESULTS Compared with controls, all GRTs resulted in glucocorticoid overexposure in the morning. Hydrocortisone, CA, and DRHC-td caused overexposure also in afternoon and evening. Compared with other treatments, CA determined increased Z-score-07:00 (P < .001), DRHC-td determined increased Z-score-AUC07:00→14:00 (P = .007), and DRHC-od induced lower Z-score-AUC14:00→23:00 (P = .015). Z-scores-AUC14:00→16:00 ≥ .619 best predicted questionnaire scores. CONCLUSIONS None of the GRTs mimics normal glucocorticoid rhythmicity and exposure. SalE, SalF, and Z-score may be useful markers for monitoring and comparing different GRTs. Excess glucocorticoid in early afternoon best associated with depressive symptoms and worse life and sleep quality.
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Affiliation(s)
- Lorenzo Tucci
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Flaminia Fanelli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Ilaria Improta
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Valentina Bissi
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Claudia Lena
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Greta Galante
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Marco Mezzullo
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Matteo Magagnoli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Anna Bianca Lalumera
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Giacomo Colombin
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Kimberly Coscia
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Laura Rotolo
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Valentina Vicennati
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Uberto Pagotto
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Guido Di Dalmazi
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
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Hee NKY, Lim QH, Paramasivam S, Lim LL, Vethakkan S, Ganapathy SS, Ratnasingam J. The use of prednisolone during Ramadan fasting in patients with adrenal insufficiency. Clin Endocrinol (Oxf) 2024; 100:221-229. [PMID: 38031259 DOI: 10.1111/cen.14999] [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: 08/04/2023] [Revised: 10/24/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE Once daily prednisolone taken at predawn has been proposed to be the glucocorticoid replacement of choice in patients with adrenal insufficiency (AI) who intend to fast for the month of Ramadan. However, the effects of prednisolone on metabolic parameters and quality of life during fasting for Ramadan are unknown. DESIGN, PATIENTS AND MEASUREMENTS Patients with AI on twice-daily hydrocortisone, who had low or moderate risk and intended to fast, were recruited. Patients were converted to prednisolone 5 mg once daily taken at sahur (predawn) and Ramadan education given. Weight, sleep duration, biochemical parameters and quality of life measures (SF-36 questionnaire) were analysed at the end of Ramadan and compared against baseline. RESULTS Twenty patients (13 men) were recruited, with a mean age of 59.9 ± 15.0 years. All patients were on hydrocortisone 15 mg daily (in divided doses) as pre-Ramadan glucocorticoid replacement. Half had type 2 diabetes with low IDF-DAR risk. Eighty-five percent of patients completed the full 29 days of fasting with no complications. There was a significant reduction in weight (-1.1 ± 1.6 kg, p = .005), with no significant change in blood pressure or sleep duration. There was a significant increase in urea (0.80 ± 1.1 mmol/L, p = .005) and haematocrit, (0.011 ± 0.019 L/L, p = .019) and decrease in serum sodium (-1.6 ± 3.0 mmol/L, p = .028), with no change in serum creatinine or liver function. Quality of life measures were preserved in all domains with significant improvement in role limitation due to physical health (15.3 ± 21.6, p = .005) and bodily pain (8.8 ± 16.3, p = .031). CONCLUSIONS This study has demonstrated that converting patients with AI who are fasting for Ramadan from twice-daily hydrocortisone to prednisolone 5 mg daily at sahur was safe, with no major short-term adverse effects. Despite the higher equivalent glucocorticoid doses, patients experienced weight loss and no clinically significant change in blood pressure, sleep, biochemical parameters or quality of life. This study paves the way to trial even lower doses of prednisolone once daily in patients fasting for Ramadan with AI.
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Affiliation(s)
- Nicholas Ken Yoong Hee
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Quan Hziung Lim
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Sharmila Paramasivam
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Lee Ling Lim
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shireene Vethakkan
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shubash Shander Ganapathy
- Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
| | - Jeyakantha Ratnasingam
- Endocrine Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
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Bulut Y, Brandt-Jacobsen N, Buhl L, Schou M, Frystyk J, Kistorp C, Rasmussen JJ. Persistently Decreased Quality of Life and its Determinants in Previous Illicit Androgen Users. J Clin Endocrinol Metab 2024; 109:e689-e697. [PMID: 37708363 DOI: 10.1210/clinem/dgad551] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/06/2023] [Accepted: 09/12/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Quality of life (QoL) has never been assessed in previous illicit users of androgens years following androgen cessation. Therefore, the objective of this study was to assess QoL in previous illicit androgen users compared with current illicit androgen users and controls who had never used androgens. METHODS Cross-sectional study including men involved in recreational strength training grouped according to their history of androgen use. We used the RAND Short-Form-36 questionnaire to assess physical and mental health-related QoL. RESULTS We included 77 previous and 118 current androgen users and 39 healthy nonusers. The mean (SD) age of all participants was 33 (8) years. The elapsed duration since androgen cessation, geometric mean (95% CI), was 2.0 (1.5-2.6) years in former users. Median (25th-75th percentiles) serum total testosterone was lower in former users than controls, 14 (11-17) vs 19 (16-21) nmol/L, P < .001. Previous users displayed lower mean (SD) across both mental and physical (PCS) component summary scores, 48 (10) vs 54 (4) (P = .004) and 48 (9) vs 53 (3) (P = .002) compared with controls.Using multivariate linear regressions, evaluating physical and mental component scores as dependent variables, lower serum total testosterone, longer duration since androgen cessation, study recruitment from an endocrine outpatient clinic, and established chronic diseases were all independently associated with reduced QoL in previous users, P < .05. CONCLUSIONS Previous illicit androgen users exhibited reduced QoL 2 years after androgen discontinuation, which may be a persistent condition.
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Affiliation(s)
- Yeliz Bulut
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, DK-2200, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Denmark, Copenhagen, DK-2200, Denmark
| | - Niels Brandt-Jacobsen
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, DK-2200, Denmark
| | - Laust Buhl
- Department of Endocrinology, Odense University Hospital, Odense, DK-5000, Denmark
- Faculty of Health Sciences, University of Southern Denmark, Odense, DK-5230, Denmark
| | - Morten Schou
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Denmark, Copenhagen, DK-2200, Denmark
- Department of Cardiology, Herlev/Gentofte University Hospital, Herlev, DK-2730, Denmark
| | - Jan Frystyk
- Department of Endocrinology, Odense University Hospital, Odense, DK-5000, Denmark
- Faculty of Health Sciences, University of Southern Denmark, Odense, DK-5230, Denmark
| | - Caroline Kistorp
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, DK-2200, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Denmark, Copenhagen, DK-2200, Denmark
| | - Jon Jarløv Rasmussen
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, DK-2200, Denmark
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Russell G, Kalafatakis K, Durant C, Marchant N, Thakrar J, Thirard R, King J, Bowles J, Upton T, Thai NJ, Brooks JCW, Wilson A, Phillips K, Ferguson S, Grabski M, Rogers CA, Lampros T, Wilson S, Harmer C, Munafo M, Lightman SL. Ultradian hydrocortisone replacement alters neuronal processing, emotional ambiguity, affect and fatigue in adrenal insufficiency: The PULSES trial. J Intern Med 2024; 295:51-67. [PMID: 37857352 PMCID: PMC10952319 DOI: 10.1111/joim.13721] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND Primary adrenal insufficiency (PAI) mortality and morbidity remain unacceptably high, possibly arising as glucocorticoid replacement does not replicate natural physiology. A pulsatile subcutaneous pump can closely replicate cortisol's circadian and ultradian rhythm. OBJECTIVES To assess the effect of pump therapy on quality of life, mood, functional neuroimaging, behavioural/cognitive responses, sleep and metabolism. METHODS A 6-week randomised, crossover, double-blinded and placebo-controlled feasibility study of usual dose hydrocortisone in PAI administered as either pulsed subcutaneous or standard care in Bristol, United Kingdom (ISRCTN67193733). Participants were stratified by adrenal insufficiency type. All participants who received study drugs are included in the analysis. The primary outcome, the facial expression recognition task (FERT), occurred at week 6. RESULTS Between December 2014 and 2017, 22 participants were recruited - 20 completed both arms, and 21 were analysed. The pump was well-tolerated. No change was seen in the FERT primary outcome; however, there were subjective improvements in fatigue and mood. Additionally, functional magnetic resonance imaging revealed differential neural processing to emotional cues and visual stimulation. Region of interest analysis identified the left amygdala and insula, key glucocorticoid-sensitive regions involved in emotional ambiguity. FERT post hoc analysis confirmed this response. There were four serious adverse events (AE): three intercurrent illnesses requiring hospitalisation (1/3, 33.3% pump) and a planned procedure (1/1, 100% pump). There was a small number of expected AEs: infusion site bruising/itching (3/5, 60% pump), intercurrent illness requiring extra (3/7, 42% pump) and no extra (4/6, 66% pump) steroid. CONCLUSIONS These findings support the administration of hormone therapy that mimics physiology.
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Affiliation(s)
- Georgina Russell
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
- North Bristol NHS TrustBristolUK
| | - Konstantinos Kalafatakis
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- Department of Informatics and Telecommunications, Human‐Computer Interaction LaboratoryUniversity of IoanninaArtaGreece
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
- Faculty of Medicine and Dentistry (Malta Campus)Queen Mary University of LondonVictoriaMalta
| | - Claire Durant
- Department of Brain SciencesFaculty of MedicineImperial College LondonLondonUK
| | - Nicola Marchant
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Jamini Thakrar
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
| | - Russell Thirard
- Bristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Jade King
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
- North Bristol NHS TrustBristolUK
| | - Jane Bowles
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Thomas Upton
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
| | - Ngoc Jade Thai
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
- Neurosciences and Mental HealthLiverpool Health PartnersLiverpoolUK
| | | | - Aileen Wilson
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
| | - Kirsty Phillips
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Stuart Ferguson
- School of MedicineUniversity of TasmaniaHobartTasmaniaAustralia
| | | | - Chris A. Rogers
- Bristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Theodoros Lampros
- Department of Informatics and Telecommunications, Human‐Computer Interaction LaboratoryUniversity of IoanninaArtaGreece
| | - Sue Wilson
- Department of Brain SciencesFaculty of MedicineImperial College LondonLondonUK
| | - Catherine Harmer
- Department of PsychiatryOxford University and Oxford Health NHS Foundation TrustOxfordUK
| | - Marcus Munafo
- MRC Integrative Epidemiology UnitSchool of Psychological ScienceUniversity of BristolBristolUK
| | - Stafford L. Lightman
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
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Yazidi M, Salem MB, Oueslati I, Khessairi N, Chaker F, Chihaoui M. Adherence to glucocorticoid replacement therapy in Addison's disease: Association with patients' disease knowledge and quality of life. ENDOCRINOL DIAB NUTR 2023; 70:532-539. [PMID: 38783727 DOI: 10.1016/j.endien.2023.10.004] [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: 04/19/2023] [Accepted: 06/11/2023] [Indexed: 05/25/2024]
Abstract
Little is known about the quality of adherence to glucocorticoid replacement therapy in patients with Addison disease (AD). The aim of this study was to evaluate the quality of glucocorticoid treatment adherence in patients with AD and to assess its association with patients' disease knowledge and quality of life. METHODS This is a cross-sectional study including 58 patients with AD. The Girerd questionnaire was used to assess the quality of adherence to glucocorticoid replacement therapy. A questionnaire was specially designed to assess patients' disease knowledge. The AddiQol questionnaire, specific to AD, was used to assess the patients' quality of life. Patients were considered non-adherent if they gave three or fewer than three negative answers to the Girerd questionnaire (score≤3/6). RESULTS The mean age of the patients was 48.4±13.3 years (39 women and 19 men). Twenty-seven patients (46%) were non-adherent to glucocorticoid replacement therapy. An age below 48 years, poor adherence to comorbidity treatments, baseline cortisolemia at diagnosis>5μg/dl, history of adrenal crisis, poor knowledge about the disease, BMI<26.7kg/m2, waist circumference<90cm, low systolic blood pressure, fasting blood glucose<0.9g/l, and triglyceride<1g/l were the factors independently associated with non-adherence (respectively ORa [CI 95%]=4.8 [2.8-10.7], 5.0 [3.0-12.2], 2.3 [1.2-6.2], 4.1 [2.0-8.3], 3.9 [1.2-7.2], 3.9 [1.1-6.9], 1.8 [1.1-2.9], 4.8 [2.6-8.2], 2.5 [1.1-5.3], and 2.2 [1.1-5.1]). There was a positive correlation between the disease knowledge questionnaire score and the Girerd score (p=0.02, r=0.31). There was a positive correlation between the AddiQoL score and the Girerd score (p=0.01, r=0.32). CONCLUSION Non-adherence to glucocorticoid replacement therapy was common in patients with AD and was associated with more frequent adrenal crisis and poorer quality of life. The quality of treatment adherence was correlated with patients' disease knowledge. Therapeutic education is essential to reduce the frequency of non-adherence, especially among young patients.
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Affiliation(s)
- Meriem Yazidi
- Department of Endocrinology, University of Tunis el Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunisia.
| | - Maram Ben Salem
- Department of Endocrinology, University of Tunis el Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University of Tunis el Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunisia
| | - Nadia Khessairi
- Department of Endocrinology, University of Tunis el Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University of Tunis el Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunisia
| | - Melika Chihaoui
- Department of Endocrinology, University of Tunis el Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunisia
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Gasco V, Giannelli J, Campioni L, Arvat E, Ghigo E, Grottoli S, Maccario M, Giordano R. Benefits of dual-release hydrocortisone treatment on central adiposity and health-related quality of life in secondary adrenal insufficiency. J Endocrinol Invest 2023; 46:587-597. [PMID: 36251244 PMCID: PMC9938071 DOI: 10.1007/s40618-022-01940-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/12/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Patients with secondary adrenal insufficiency (SAI) have an increased morbidity and an impaired health-related quality of life (HRQoL), which seems to primarily depend on the sub-optimal replacement of hypoadrenalism with standard glucocorticoid (GC) therapy, and on the inadequate correction of other associated pituitary deficiencies. A dual-release hydrocortisone (DR-HC) formulation has shown to exert positive effects on morbidity and HRQoL, mainly in patients with primary adrenal insufficiency. We assessed the variations of anthropometric and metabolic parameters and HRQoL in patients with SAI after switching from cortisone acetate (CA) or hydrocortisone (HC) to DR-HC. METHODS Twenty-one patients (17 M, 4 F) treated with CA (n = 16; 25 mg/day twice a day) or HC (n = 5; 20 mg/day three times a day), were evaluated for waist circumference, BMI, fasting glucose, HbA1c, insulin, HOMA-IR index, serum lipids, electrolytes, blood pressure and HRQoL at baseline, at 3, 6 and 12 months after switching from CA/HC to DR-HC. RESULTS The study showed a significant reduction of waist circumference and BMI (p = 0.04, for both), after 3 and 6months of DR-HC treatment, respectively. No significant changes were observed for fasting glucose, insulin, HOMA-IR index, HbA1c, total cholesterol, triglycerides, LDL cholesterol, electrolytes, and blood pressure. However, HDL cholesterol significantly decreased (p = 0.003). An improvement of AddiQoL total score was observed during DR-HC treatment (p = 0.01), mainly for the category "emotions". No predictors resulted for these changes. CONCLUSION DR-HC treatment provides some benefits in patients with SAI, reducing central adiposity and improving HRQoL; however, worsening of HDL cholesterol is observed during treatment with DR-HC.
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Affiliation(s)
- V Gasco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - J Giannelli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - L Campioni
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - E Arvat
- Division of Oncological Endocrinology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - E Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - S Grottoli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - M Maccario
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - R Giordano
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences and Department of Clinical and Biological Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
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Mortensen ML, Ornstrup MJ, Gravholt CH. Patients with Hypocortisolism Treated with Continuous Subcutaneous Hydrocortisone Infusion (CSHI): An Option for Poorly Controlled Patients. Int J Endocrinol 2023; 2023:5315059. [PMID: 36994228 PMCID: PMC10042637 DOI: 10.1155/2023/5315059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/04/2023] [Accepted: 03/06/2023] [Indexed: 03/31/2023] Open
Abstract
OBJECTIVE Despite appropriate oral glucocorticoid replacement therapy, patients with hypocortisolism often suffer from impaired health and frequent hospitalizations. Continuous subcutaneous hydrocortisone infusion (CSHI) has been developed as an attempt to improve the health status of these patients. The objective of this study was to compare the effects of CSHI to conventional oral treatment on hospitalizations, glucocorticoid doses, and subjective health status. Patients. Nine Danish patients (males: 4 and females: 5) with adrenal insufficiency (AI) were included, with a median age of 48 years, due to Addison (n = 4), congenital adrenal hyperplasia (n = 1), steroid induced secondary adrenal insufficiency (n = 2), morphine induced secondary adrenal insufficiency (n = 1), and Sheehan's syndrome (n = 1). Only patients with severe symptoms of cortisol deficit on oral treatment were selected for CSHI. Their usual oral hydrocortisone doses varied from 25-80 mg per day. The duration of follow-up depended on when the treatment was changed. The first patient started CSHI in 2009 and the last in 2021. DESIGN A retrospective case series comparing hospitalizations and glucocorticoid doses before and after treatment with CSHI. In addition, patients were retrospectively interviewed about their health-related quality of life (HRQoL) after the change of treatment modality. RESULTS Patients significantly reduced their daily dose of glucocorticoids by 16.1 mg (p = 0.02) after changing to CSHI. The number of hospital admission due to adrenal crisis decreased by 1.3 per year on CSHI, which was a 50% reduction (p = 0.04). All patients found it easier to handle an adrenal crisis with CSHI, and almost all patients found it easier to overcome everyday activities and had fewer symptoms of cortisol deficit such as abdominal pain and nausea (7-8 out of 9 patients). CONCLUSIONS The change of treatment from conventional oral hydrocortisone to CSHI resulted in a reduced daily dose of glucocorticoids and a reduced number of hospitalizations. Patients reported regain of energy, achievement of better disease control, and better handling of adrenal crisis.
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Affiliation(s)
- Malene Lyder Mortensen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Marie Juul Ornstrup
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Claus H. Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Li D. Quality of Life in Patients with Adrenal Insufficiency. Endocrinol Metab Clin North Am 2022; 51:741-753. [PMID: 36244690 DOI: 10.1016/j.ecl.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients with adrenal insufficiency, despite standard glucocorticoid replacement therapy, continue to experience and report impaired self-perceived health status and quality of life. In this review, we will describe quality of life in this patient population, and summarize the determinants of quality of life, based on previous survey-based studies and clinical trials. In addition, some new emerging data during the still ongoing coronavirus disease pandemic are also reviewed in the present article.
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Affiliation(s)
- Dingfeng Li
- Department of Endocrinology, Endocrine and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, F20, Cleveland, OH 44195, USA.
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9
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Li D, Brand S, Hamidi O, Westfall AA, Suresh M, Else T, Vaidya A, Bancos I. Quality of Life and its Determinants in Patients With Adrenal Insufficiency: A Survey Study at 3 Centers in the United States. J Clin Endocrinol Metab 2022; 107:e2851-e2861. [PMID: 35350067 PMCID: PMC9202727 DOI: 10.1210/clinem/dgac175] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Current evidence on determinants of quality of life (QoL) in patients with adrenal insufficiency (AI) is limited. OBJECTIVE This work aimed to identify the determinants of QoL in different subtypes of AI. METHODS This multicenter cross-sectional survey study was conducted using a patient-centered questionnaire, the Short Form-36. RESULTS Of 529 participants, 223 (42.2%) had primary AI, 190 (35.9%) had secondary AI, and 116 (21.9%) had glucocorticoid-induced AI. Median age was 58 years (interquartile range: 43-68 years) and 342 (64.8%) were women. In multivariable analyses, patients were more likely to report worse physical scores if they were women (odds ratio [OR]: 3.3; 95% CI, 1.8-6.0), had secondary AI or glucocorticoid-induced AI (OR: 2.5; 95% CI, 1.4-4.3), had shorter duration of AI (OR: 2.0; 95% CI, 1.1-3.6), were treated with more than 25 mg hydrocortisone equivalent daily (OR: 2.3; 95% CI, 1.2-4.6), had more comorbidities related to glucocorticoid excess (OR: 2.3; 95% CI, 1.3-4.0), reported a higher financial burden from AI (OR: 2.1; 95% CI, 1.3-3.6), and reported difficulties with AI management (OR: 2.5; 95% CI, 1.2-5.2). Women (OR: 2.1; 95% CI, 1.08-4.0), shorter duration of AI (OR: 2.4; 95% CI, 1.4-4.3), higher financial burden (OR: 2.3; 95% CI, 1.3-4.0), difficulties with AI management (OR: 2.6; 95% CI, 1.4-4.9), and lack of family support (OR: 9.1; 95% CI, 2.3-33.3) were associated with worse mental component scores. CONCLUSION In patients with AI, QoL could be improved by addressing certain determinants, such as avoiding GC overreplacement, providing in-depth education on self-management, offering more comprehensive insurance coverage, and ensuring better family support.
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Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | - Sarah Brand
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA
| | - Ashleigh A Westfall
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA
| | - Malavika Suresh
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Tobias Else
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts 02115, USA
| | - Irina Bancos
- Correspondence: Irina Bancos, MD, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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10
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Ekbom K, Strandqvist A, Lajic S, Hirschberg A, Falhammar H, Nordenström A. The impact of adherence and therapy regimens on quality of life in patients with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2022; 96:666-679. [PMID: 34994970 PMCID: PMC9303581 DOI: 10.1111/cen.14676] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/15/2021] [Accepted: 12/24/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Varying outcomes regarding the quality of life (QoL) have been reported in patients with congenital adrenal hyperplasia (CAH). To assess the impact of adherence rate to medical therapy regimens on QoL in patients with CAH. PATIENTS Adolescents and adults aged 15-72 years with CAH due to 21-hydroxylase deficiency at Karolinska University Hospital, Stockholm, Sweden. MEASUREMENTS QoL was assessed using the Addison QoL (n = 72) and RAND 36 questionnaires (n = 75). Adherence to therapy regimens was measured using the Adherence Starts with Knowledge questionnaire (ASK-12). Associations between QoL, type of glucocorticoid therapy prescribed and ASK-12 results were examined. Results were compared to reference RAND 36 data obtained from a representative sample from the general Swedish population. RESULTS A good adherence rate to therapy regimens and a younger age were key factors for a better QoL in study participants with CAH. Younger patients on hydrocortisone and with good adherence had higher RAND 36 scores than older patients on prednisolone independently adherence. Participants with classic CAH (both the salt-wasting and simple virilizing form) reported higher QoL than those with nonclassic CAH. Patients with CAH, especially nonclassic, more frequently reported an impaired QoL than the general population, especially regarding limitations related to body pain, vitality and mental health. CONCLUSION A poor adherence rate to therapy regimens, rather than type of glucocorticoid was associated with impaired QoL in adolescents and adults with CAH.
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Affiliation(s)
- Kerstin Ekbom
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Department of Paediatric Endocrinology, Astrid Lindgren Children's HospitalKarolinska University HospitalStockholmSweden
| | - Anna Strandqvist
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Division of Psychology, Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
| | - Svetlana Lajic
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Department of Paediatric Endocrinology, Astrid Lindgren Children's HospitalKarolinska University HospitalStockholmSweden
| | - Angelica Hirschberg
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Department of Gynecology and Reproductive MedicineKarolinska University HospitalStockholmSweden
| | - Henrik Falhammar
- Department of EndocrinologyKarolinska University HospitalStockholmSweden
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Anna Nordenström
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Department of Paediatric Endocrinology, Astrid Lindgren Children's HospitalKarolinska University HospitalStockholmSweden
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11
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Fiore M, Baia M, Conti L, Piccioni F, Mariani L, Pasquali S, Seregni E, Maltese G, Galizia M, Radaelli S, Villa AM, Valenza F, Gronchi A. Residual Adrenal Function After Multivisceral Resection With Adrenalectomy in Adult Patients. JAMA Surg 2022; 157:415-423. [PMID: 35195679 PMCID: PMC8867388 DOI: 10.1001/jamasurg.2021.7588] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance The risk of developing adrenal insufficiency (AI) following adrenalectomy has been insufficiently studied in the context of multivisceral resection (MVR). Objective To evaluate the incidence of AI in patients undergoing MVR with en bloc adrenalectomy. Design, Setting, and Participants Prospective observational longitudinal study in a single referral center including 56 consecutive adult patients undergoing retroperitoneal sarcoma surgery from June 2019 to August 2020. Those who were candidates for MVR with en bloc adrenalectomy and had no preexisting adrenal impairment were considered eligible. Of these, 4 individuals were excluded because they did not receive adrenalectomy at the time of surgery and 2 because they were not considered evaluable for the main end point. Follow-up was set at 4 months after surgery, and 49 patients completed follow-up. Data were analyzed from October 2020 to September 2021. Exposures Diagnosis of AI was determined by low-dose (1 μg) adrenocorticotropic hormone (ACTH) stimulation test with a threshold of 20 μg/dL in blood samples retrieved 30 and 60 minutes after stimulation. ACTH test was repeated on postoperative days 1 and 10 and at 4 months' follow-up. Main Outcome and Measures The primary end point was incidence and relevance of AI after MVR. Secondary end points were associations with patient- and tumor-related factors, impact on perioperative hemodynamic management, and association with postoperative morbidity and mortality. Results Fifty patients (26 female; median [IQR] age, 59 [46-67] years) were evaluable. Incidence of AI was 64% (32 of 50 patients) in the early postoperative period and 38.5% (15 of 39 patients) at follow-up. Patients with AI showed lower postoperative cortisol values. Factors associated with risk of AI at univariate analysis were high American Society of Anesthesiologists score (odds ratio [OR], 0.31; 95% CI, 0.14-0.48) and high malignancy grade (OR, 0.35; 95% CI, 0.24-0.46). Clinical outcomes not associated with AI included morbidity, mortality, reoperation rate, admission to intensive care unit, length of intensive care unit stay, total hospital stay, and long-term quality of life. Conclusions and Relevance In this study, AI after MVR with en bloc adrenalectomy was frequent, even in patients with adequate preoperative adrenal function. Despite this, adrenalectomy can be safely performed. Patients at risk should be monitored in the long term to exclude underrated impairment of adrenal function.
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Affiliation(s)
- Marco Fiore
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marco Baia
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy,Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, University Birmingham Hospital NHS Trust, Birmingham, United Kingdom
| | - Lorenzo Conti
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy,Department of Surgery, ASST dei Sette Laghi, Varese, Italy
| | - Federico Piccioni
- Anesthesia and Intensive Care Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luigi Mariani
- Unit of Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sandro Pasquali
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Ettore Seregni
- Nuclear Medicine, Department of Radiotherapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gabriele Maltese
- Anesthesia and Intensive Care Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Mauro Galizia
- Anesthesia and Intensive Care Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefano Radaelli
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alessandro Maria Villa
- Anesthesia and Intensive Care Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Franco Valenza
- Anesthesia and Intensive Care Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy,Università degli Studi di Milano, Milan, Italy
| | - Alessandro Gronchi
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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12
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Hegedüs L, Bianco AC, Jonklaas J, Pearce SH, Weetman AP, Perros P. Primary hypothyroidism and quality of life. Nat Rev Endocrinol 2022; 18:230-242. [PMID: 35042968 PMCID: PMC8930682 DOI: 10.1038/s41574-021-00625-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 12/15/2022]
Abstract
In the 1970s, treatment with thyroid extract was superseded by levothyroxine, a synthetic L form of tetraiodothyronine. Since then, no major innovation has emerged for the treatment of hypothyroidism. The biochemical definition of subclinical hypothyroidism is a matter of debate. Indiscriminate screening for hypothyroidism has led to overdiagnosis and treatment initiation at lower serum levels of thyroid-stimulating hormone (TSH) than previously. Adverse health effects have been documented in individuals with hypothyroidism or hyperthyroidism, and these adverse effects can affect health-related quality of life (QOL). Levothyroxine substitution improves, but does not always normalize, QOL, especially for individuals with mild hypothyroidism. However, neither studies combining levothyroxine and liothyronine (the synthetic form of tri-iodothyronine) nor the use of desiccated thyroid extract have shown robust improvements in patient satisfaction. Future studies should focus not only on a better understanding of an individual's TSH set point (the innate narrow physiological range of serum concentration of TSH in an individual, before the onset of hypothyroidism) and alternative thyroid hormone combinations and formulations, but also on autoimmunity and comorbidities unrelated to hypothyroidism as drivers of patient dissatisfaction. Attention to the long-term health consequences of hypothyroidism, beyond QOL, and the risks of overtreatment is imperative.
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Affiliation(s)
- Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark.
| | - Antonio C Bianco
- Section of Adult and Paediatric Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Simon H Pearce
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Anthony P Weetman
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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13
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Quinkler M, Kienitz T. The ISAQ Score Does Not Predict Adrenal Crisis in Patients with Primary Adrenal Insufficiency. Exp Clin Endocrinol Diabetes 2022; 130:554-560. [PMID: 35240692 DOI: 10.1055/a-1734-2466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aimed to investigate the ability of the immune system assessment questionnaire (ISAQ) to predict adrenal crisis (AC) and infectious events in patients with primary adrenal insufficiency (PAI). DESIGN This was a prospective single-centre study over three years. METHODS Patients answered the ISAQ at baseline and were seen every 4-6 months in the endocrine outpatient clinic. At each visit previous infectious periods which required an increase in daily glucocorticoid dosage and AC were reported and documented. Seventy-five patients with PAI (53 women; 43 patients with autoimmune PAI, 20 patients with salt-wasting congenital adrenal hyperplasia and 12 patients who underwent bilateral adrenalectomy) were analysed. Due to the COVID-19 pandemic and consecutive lockdown measures, the data were analysed separately for March 2018 to March 2020 (period 1), and March 2020 to March 2021 (period 2). RESULTS During period 1 the ISAQ score significantly correlated with the number of reported infectious events (r=0.351; p<0.01), but not during period 2 (r=0.059, p=0.613), in which the number of infectious events per patient-year significantly decreased (1.1±0.1 vs 0.4±0.1; p<0.001). The frequency of AC decreased from 8.8 to 2.4 per 100 patient-years between the two study periods. The ISAQ score was not different between patients with or without AC. CONCLUSIONS The ISAQ score does not identify patients prone to ACs. The COVID-19 pandemic and consecutive lockdown measures significantly diminished the frequency of infectious events and ACs.
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Affiliation(s)
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
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14
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Blacha AK, Kropp P, Rahvar AH, Flitsch J, van de Loo I, Harbeck B. Poor quality of life and sleep in patients with adrenal insufficiency-another cause of increased mortality? Ir J Med Sci 2021; 191:1653-1658. [PMID: 34389925 PMCID: PMC9308573 DOI: 10.1007/s11845-021-02731-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 07/28/2021] [Indexed: 11/26/2022]
Abstract
Background Patients with adrenal insufficiency (AI) are treated with glucocorticoid replacement therapy (GRT). Although current glucocorticoid regimens aim to mimic the physiological circadian rhythm of cortisol secretion, temporary phases of hypo- and hypercortisolism are common undesired effects which lead to a variety of consequences like increased cardiovascular risk and premature mortality. Additionally, poor quality of life (QoL) and impaired sleep have been reported. However, little is known about these topics regarding the effects of daily dosage, duration of therapy, and patients with different forms of AI (primary, PAI, and secondary, SAI). Methods In this study, 40 adults with AI substituted with hydrocortisone (HC) and 20 matched healthy controls completed questionnaires evaluating depressive symptoms, subjective health status, quality of sleep and daytime sleepiness. Furthermore, demographic data, dosage of HC, duration of therapy and co-medication were evaluated. Patients were compared in different groups. Results Patients assessed general health significantly worse than controls; likewise, daytime sleepiness was reported significantly more often. Depressive symptoms differed significantly in the two groups but did not reach clinically relevant scores. There was no difference between patients with PAI and SAI. High dosage of hydrocortisone had negative impact on mental health but not on sleep quality or daytime sleepiness. Conclusions The present data highlight that poor QoL and impaired sleep are still severe and underrated issues in current GRT and might be additional factors for premature mortality in patients with AI. Some AI patients reach normal or near-normal self-assessed QoL and sleep, even despite unphysiological replacement.
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Affiliation(s)
- Antje K Blacha
- I. Department of Medicine, University of Luebeck, Luebeck, Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, University of Rostock, Rostock, Germany
| | - Amir H Rahvar
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Birgit Harbeck
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Amedes Experts, Hamburg, Germany.
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15
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Pilli T, Cardinale S, Cantara S, Dalmazio G, Forleo R, Capezzone M, Bassi C, Negrini M, Ferracin M, Castagna MG. Preliminary results from whole-genome expression analysis in patients with secondary adrenal insufficiency treated with modified-release hydrocortisone. Endocrine 2021; 73:177-185. [PMID: 33417142 DOI: 10.1007/s12020-020-02578-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/26/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Conventional (CONV) treatment of adrenal insufficiency (AI) is associated with risk of overtreatment: glyco-metabolic impairment, bone loss, and reduced quality of life. Recent findings suggest that modified-release hydrocortisone (MOD) may restore a more physiological cortisol profile. Our aims were: (1) to compare the gene expression profile of peripheral blood mononuclear cells derived from patients, with secondary AI (SAI), under CONV (cortisone acetate or hydrocortisone) or MOD versus healthy controls; and (2) to evaluate MOD effects on serum cortisol profile, glucose, lipid, bone, and clinical parameters. METHODS Thirteen patients with SAI were switched from CONV to MOD at equivalent dose. Area under curve (AUC) of both formulations was calculated in six patients. Clinical, metabolic and bone parameters were measured at baseline and 3 months after MOD in all patients. In six patients and six age- and sex-matched healthy controls, a whole-genome expression analysis was performed at baseline, 1 month, and 3 months after MOD. RESULTS (1) The number of genes differentially expressed (n = 235; mainly involved in immune response and metabolism) in SAI patients compared to controls progressively and significantly decreased switching from CONV to MOD (n = 78 at 3 months). (2) Under MOD: AUC of cortisol exposure tended to be smaller and cortisol levels showed a more physiological profile; no significant changes of clinical, metabolic and bone parameters were observed, likely due to the short follow-up, but triglycerides tended slightly to increase. CONCLUSIONS MOD may restore a normal gene expression profile as soon as 1 month after switching from CONV.
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Affiliation(s)
- Tania Pilli
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - Sandro Cardinale
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - Silvia Cantara
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - Gilda Dalmazio
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - Raffaella Forleo
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - Marco Capezzone
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - Cristian Bassi
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Massimo Negrini
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Manuela Ferracin
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Maria Grazia Castagna
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy.
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16
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Zamponi V, Lardo P, Maggio R, Simonini C, Mazzilli R, Faggiano A, Pugliese G, Stigliano A. Female Sexual Dysfunction in Primary Adrenal Insufficiency. J Clin Med 2021; 10:jcm10132767. [PMID: 34202462 PMCID: PMC8268403 DOI: 10.3390/jcm10132767] [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: 05/21/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose. No data are currently available on female sexual dysfunction (FSD) in primary adrenal insufficiency (PAI) and the possible impact of replacement therapy. The aim of this study was to evaluate the prevalence of FSD and sexual distress (SD), and to evaluate the possible impact of replacement therapy on sexuality in women with PAI. Methods. Female Sexual Function Index-6 (FSFI-6) and Sexual Distress Scale (SDS) questionnaires were administered to 22 women with PAI and 23 healthy women matched for age as controls. Results. The prevalence of sexual symptoms measured by FSFI-6 (total score < 19) was significantly higher in women with PAI (15/22; 68.2%) compared to the controls (2/23; 8.7%; p = 0.001). Regarding the questionnaire items, significantly different scores were found for desire (p < 0.001), arousal (p = 0.0006), lubrication (p = 0.046) and overall sexual satisfaction (p < 0.0001) in women with PAI compared to the controls. The rate of FSD (FSFI < 19 with SDS >15) was 60% in patients with PAI. A significant inverse correlation was found between FSFI-6 total scores and SD (r = −0.65; p = 0.0011), while a significant direct correlation was found between FSFI-6 total scores and serum cortisol levels (r = 0.55; p = 0.035). Conclusions. A higher prevalence of FSD was found in women affected by PAI compared to healthy women. Desire seems to be the most impaired aspect of sexual function. Moreover, sexual dysfunction in this population seems to be related to sexual distress and cortisol levels.
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17
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Li D, Suresh M, Abbondanza T, Vaidya A, Bancos I. The Impact of the COVID-19 Pandemic on Self-Reported Outcomes in Patients With Adrenal Insufficiency. J Clin Endocrinol Metab 2021; 106:e2469-e2479. [PMID: 34042985 PMCID: PMC8194854 DOI: 10.1210/clinem/dgab334] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Indexed: 12/15/2022]
Abstract
CONTEXT The COVID-19 pandemic has impacted healthcare environment. OBJECTIVE To determine the impact of the pandemic on self-reported outcomes in patients with adrenal insufficiency (AI). DESIGN AND SETTING Prospective longitudinal survey study at 2 tertiary centers. PARTICIPANTS Patients with AI. INTERVENTION Patient-centered questionnaire. MAIN OUTCOME MEASURES Depression Anxiety Stress Scales-21, Short Form-36, and AI self-management. RESULTS Of 342 patients, 157 (46%) had primary AI, 109 (32%) had secondary AI, and 76 (22%) had glucocorticoid-induced AI. When compared to prepandemic, daily glucocorticoid dose and number of adrenal crises did not change. However, patients reported a higher financial impact from AI (34% vs 23%, P = 0.006) and difficulty accessing medical care (31% vs 7%, P < 0.0001) during the pandemic. A third of patients reported difficulty managing AI during the pandemic. After adjusting for duration and subtypes of AI, younger patients [odds ratio (OR) 2.3, CI 95% 1.3-4.1], women (OR 3.7, CI 95% 1.9-7.1), poor healthcare access(OR 4.2, CI 95% 2.3-7.7), lack of good insurance support (OR 2.8, CI 95% 1.3-5.9), and those with a higher financial impact (OR 2.3, CI 95% 1.3-4.3) reported greater difficulties managing AI. Patients were more likely to report a higher anxiety score (≥8) if they found managing AI challenging during the pandemic (OR 3.0, CI 95% 1.3-6.9), and had lower Physical Component Summary (OR 4.9, CI 95% 2.2-11.0) and Mental Component Summary (OR 4.1, CI 95% 1.8-9.5) scores prior to the pandemic. CONCLUSIONS A third of patients with AI reported difficulties with management of AI during the pandemic, particularly in younger patients, women, and those with poor healthcare access.
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Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Malavika Suresh
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Tiffany Abbondanza
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, MA, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
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18
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Spagnolo F, Trimarchi F. Impatto della pandemia da COVID-19 sullo stress psicofisico nei pazienti con insufficienza surrenalica. L'ENDOCRINOLOGO 2021. [PMCID: PMC8120749 DOI: 10.1007/s40619-021-00876-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Federica Spagnolo
- Distretto Sanitario di Cividale e Tarcento, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italia
| | - Francesco Trimarchi
- Dipartimento di Medicina clinica e sperimentale, Università degli Studi di Messina, Messina, Italia
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19
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Martino M, Aboud N, Cola MF, Giancola G, Ciarloni A, Salvio G, Arnaldi G. Impact of COVID-19 pandemic on psychophysical stress in patients with adrenal insufficiency: the CORTI-COVID study. J Endocrinol Invest 2021; 44:1075-1084. [PMID: 32946078 PMCID: PMC7499003 DOI: 10.1007/s40618-020-01422-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/08/2020] [Indexed: 12/27/2022]
Abstract
PURPOSE COVID-19 is a novel threat to patients with adrenal insufficiency (AI), whose life expectancy and quality (QoL) are impaired by an increased risk of infections and stress-triggered adrenal crises (AC). If infected, AI patients require prompt replacement tailoring. We assessed, in a cohort of AI patients: prevalence and clinical presentation of COVID-19; prevalence of AC and association with intercurrent COVID-19 or pandemic-related psychophysical stress; lockdown-induced emotional burden, and health-related QoL. METHODS In this monocentric (Ancona University Hospital, Italy), cross-sectional study covering February-April 2020, 121 (40 primary, 81 secondary) AI patients (59 males, 55 ± 17 years) completed telematically three questionnaires: the purpose-built "CORTI-COVID", assessing medical history and concern for COVID-19-related global health, AI-specific personal health, occupational, economic, and social consequences; the AddiQoL-30; the Short-Form-36 (SF-36) Health Survey. RESULTS COVID-19 occurred in one (0·8% prevalence) 48-year-old woman with primary AI, who promptly tailored her replacement. Dyspnea lasted three days, without requiring hospitalization. Secondary AI patients were not involved. No AC were experienced, but pandemic-related stress accounted for 6/14 glucocorticoid up-titrations. Mean CORTI-COVID was similar between groups, mainly depending on "personal health" in primary AI (ρ = 0.888, p < 0.0001) and "economy" in secondary AI (ρ = 0.854, p < 0.0001). Working restrictions increased occupational concern. CORTI-COVID correlated inversely with QoL. AddiQoL-30 and SF-36 correlated strongly. Comorbidities worsened patients' QoL. CONCLUSION If educational efforts are made in preventing acute events, AI patients seem not particularly susceptible to COVID-19. The novel "CORTI-COVID" questionnaire reliably assesses the pandemic-related emotional burden in AI. Even under unconventional stress, educated AI patients preserve a good QoL.
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Affiliation(s)
- M Martino
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - N Aboud
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - M F Cola
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - G Giancola
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - A Ciarloni
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - G Salvio
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - G Arnaldi
- Department of Endocrinology and Metabolic Diseases (DISCLIMO), Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy.
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20
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Hahner S, Ross RJ, Arlt W, Bancos I, Burger-Stritt S, Torpy DJ, Husebye ES, Quinkler M. Adrenal insufficiency. Nat Rev Dis Primers 2021; 7:19. [PMID: 33707469 DOI: 10.1038/s41572-021-00252-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/25/2022]
Abstract
Adrenal insufficiency (AI) is a condition characterized by an absolute or relative deficiency of adrenal cortisol production. Primary AI (PAI) is rare and is caused by direct adrenal failure. Secondary AI (SAI) is more frequent and is caused by diseases affecting the pituitary, whereas in tertiary AI (TAI), the hypothalamus is affected. The most prevalent form is TAI owing to exogenous glucocorticoid use. Symptoms of AI are non-specific, often overlooked or misdiagnosed, and are related to the lack of cortisol, adrenal androgen precursors and aldosterone (especially in PAI). Diagnosis is based on measurement of the adrenal corticosteroid hormones, their regulatory peptide hormones and stimulation tests. The goal of therapy is to establish a hormone replacement regimen that closely mimics the physiological diurnal cortisol secretion pattern, tailored to the patient's daily needs. This Primer provides insights into the epidemiology, mechanisms and management of AI during pregnancy as well as challenges of long-term management. In addition, the importance of identifying life-threatening adrenal emergencies (acute AI and adrenal crisis) is highlighted and strategies for prevention, which include patient education, glucocorticoid emergency cards and injection kits, are described.
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Affiliation(s)
- Stefanie Hahner
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Richard J Ross
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Wiebke Arlt
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephanie Burger-Stritt
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Diseases, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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21
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Li D, Genere N, Behnken E, Xhikola M, Abbondanza T, Vaidya A, Bancos I. Determinants of Self-reported Health Outcomes in Adrenal Insufficiency: A Multisite Survey Study. J Clin Endocrinol Metab 2021; 106:e1408-e1419. [PMID: 32995875 PMCID: PMC7947833 DOI: 10.1210/clinem/dgaa668] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/28/2020] [Indexed: 12/22/2022]
Abstract
CONTEXT Current evidence on determinants of adverse health outcomes in patients with adrenal insufficiency (AI) is scarce, especially in regards to AI subtypes. OBJECTIVE To determine predictors of adverse outcomes in different subtypes of AI. DESIGN AND SETTING Cross-sectional survey study at 2 tertiary centers. PARTICIPANTS A total of 696 patients with AI: primary AI (PAI, 42%), secondary AI (SAI, 32%), and glucocorticoid-induced AI (GIAI, 26%). INTERVENTION Patient-centered questionnaire. MAIN OUTCOME MEASURES Patients' knowledge, self-management of AI, self-perceived health, and adverse outcomes. RESULTS The incidence rate of adrenal crisis was 24/100 patient-years with 44% experiencing at least 1 adrenal crisis since diagnosis (59% in PAI vs 31% in SAI vs 37% in GIAI, P < .0001). All patients described high degrees of discomfort with self-management and receiving prompt treatment. Patients with PAI were most likely to develop adrenal crises (adjusted OR 2.8, 95% CI 1.9-4.0) despite reporting better self-perceived health (adjusted OR 3.3, 95% CI 2.1-5.3), understanding of their diagnosis (89% vs 74-81% in other subtypes, P = .002), higher comfort with self-management (62% vs 52-61% in other sub types, P = .005), and higher likelihood to receive prompt treatment for adrenal crises in the emergency department (42% vs 19-30% in other subtypes, P < .0001). CONCLUSIONS Patients with AI reported high degrees of discomfort with self-management and treatment delays when presenting with adrenal crises. Despite better self-perceived health and understanding of diagnosis, patients with PAI experienced the highest frequency of adrenal crises. A multidimensional educational effort is needed for patients and providers to improve the outcomes of all subtypes of AI.
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Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Natalia Genere
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Emma Behnken
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota
| | - Majlinda Xhikola
- Division of Endocrinology, University of Florida and Malcom Randall VA Medical Center, Gainesville, Florida
| | - Tiffany Abbondanza
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts
- Correspondence and Reprint requests: Irina Bancos M.D., Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. E-mail: ; or Anand Vaidya, MD MMSc, Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, RFB 287, Boston, MA 02115 USA. E-mail:
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
- Correspondence and Reprint requests: Irina Bancos M.D., Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. E-mail: ; or Anand Vaidya, MD MMSc, Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, RFB 287, Boston, MA 02115 USA. E-mail:
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22
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Husebye ES, Pearce SH, Krone NP, Kämpe O. Adrenal insufficiency. Lancet 2021; 397:613-629. [PMID: 33484633 DOI: 10.1016/s0140-6736(21)00136-7] [Citation(s) in RCA: 140] [Impact Index Per Article: 46.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/12/2020] [Accepted: 09/21/2020] [Indexed: 12/11/2022]
Abstract
Adrenal insufficiency can arise from a primary adrenal disorder, secondary to adrenocorticotropic hormone deficiency, or by suppression of adrenocorticotropic hormone by exogenous glucocorticoid or opioid medications. Hallmark clinical features are unintentional weight loss, anorexia, postural hypotension, profound fatigue, muscle and abdominal pain, and hyponatraemia. Additionally, patients with primary adrenal insufficiency usually develop skin hyperpigmentation and crave salt. Diagnosis of adrenal insufficiency is usually delayed because the initial presentation is often non-specific; physician awareness must be improved to avoid adrenal crisis. Despite state-of-the-art steroid replacement therapy, reduced quality of life and work capacity, and increased mortality is reported in patients with primary or secondary adrenal insufficiency. Active and repeated patient education on managing adrenal insufficiency, including advice on how to increase medication during intercurrent illness, medical or dental procedures, and profound stress, is required to prevent adrenal crisis, which occurs in about 50% of patients with adrenal insufficiency after diagnosis. It is good practice for physicians to provide patients with a steroid card, parenteral hydrocortisone, and training for parenteral hydrocortisone administration, in case of vomiting or severe illness. New modes of glucocorticoid delivery could improve the quality of life in some patients with adrenal insufficiency, and further advances in oral and parenteral therapy will probably emerge in the next few years.
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Affiliation(s)
- Eystein S Husebye
- Department of Clinical Science and KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Simon H Pearce
- Department of Endocrinology, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nils P Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK; Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Olle Kämpe
- Department of Clinical Science and KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway; Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Center of Molecular Medicine, and Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
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23
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Boesen VB, Borresen SW, Christoffersen T, Klose M, Watt T, Feldt-Rasmussen U. The effect of dual-release versus conventional hydrocortisone on fatigue, measured by ecological momentary assessments. Endocrine 2021; 71:467-475. [PMID: 33063273 DOI: 10.1007/s12020-020-02507-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/23/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Replicating the physiological cortisol secretion is key in the treatment of glucocorticoid insufficient individuals and optimization may enhance quality of life. The study investigates fatigue measured by ecological momentary assessments in patients treated with conventional hydrocortisone compared with once-daily dual-release hydrocortisone (Plenadren). METHODS A 21-week open-label switch pilot trial included 30 patients with adrenal insufficiency due to hypopituitarism. Fatigue was assessed four times daily for 20 days using a momentary item version of the Multidimensional Fatigue Inventory on patients' usual hydrocortisone regimen. Participants switched treatment to an identical daily dose of Plenadren for 16 weeks where fatigue assessments were repeated. Change in fatigue and diurnal variation of fatigue was analyzed using mixed models for repeated measurements. RESULTS In four out of five fatigue subscales fatigue was significantly reduced 0.7-1.1 points (scales ranging from 4 to 20), when treated with Plenadren compared with conventional hydrocortisone, corresponding to small effect sizes below the scale-specific minimal important changes. However, 33% of the participants completing the study (9/27) experienced reductions in fatigue above the minimal important change. On Plenadren, we found larger between-person variances and smaller within-person variances. Finally, we identified diurnal fatigue curves for both treatments. CONCLUSIONS The Plenadren-related reduction in fatigue was significant but not necessarily of clinical importance when looking at a group level. However, there was a large interindividual variation in treatment effect, why patients with a large benefit in quality of life should be identified. Future RCTs should be powered to detect the effect magnitudes identified here.
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Affiliation(s)
- Victor Brun Boesen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Stina Willemoes Borresen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Thea Christoffersen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Marianne Klose
- Department of Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Torquil Watt
- Department of Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Internal Medicine, Copenhagen University Hospital Herlev Gentofte, Gentofte, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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24
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Sævik ÅB, Wolff AB, Björnsdottir S, Simunkova K, Hynne MS, Dolan DWP, Bratland E, Knappskog PM, Methlie P, Carlsen S, Isaksson M, Bensing S, Kämpe O, Husebye ES, Løvås K, Øksnes M. Potential Transcriptional Biomarkers to Guide Glucocorticoid Replacement in Autoimmune Addison's Disease. J Endocr Soc 2021; 5:bvaa202. [PMID: 33553982 PMCID: PMC7853175 DOI: 10.1210/jendso/bvaa202] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Indexed: 12/11/2022] Open
Abstract
Background No reliable biomarkers exist to guide glucocorticoid (GC) replacement treatment in autoimmune Addison's disease (AAD), leading to overtreatment with alarming and persistent side effects or undertreatment, which could be fatal. Objective To explore changes in gene expression following different GC replacement doses as a means of identifying candidate transcriptional biomarkers to guide GC replacement in AAD. Methods Step 1: Global microarray expression analysis on RNA from whole blood before and after intravenous infusion of 100 mg hydrocortisone (HC) in 10 patients with AAD. In 3 of the most highly upregulated genes, we performed real-time PCR (rt-PCR) to compare gene expression levels before and 3, 4, and 6 hours after the HC infusion. Step 2: Rt-PCR to compare expression levels of 93 GC-regulated genes in normal versus very low morning cortisol levels in 27 patients with AAD. Results Step 1: Two hours after infusion of 100 mg HC, there was a marked increase in FKBP5, MMP9, and DSIPI expression levels. MMP9 and DSIPI expression levels correlated with serum cortisol. Step 2: Expression levels of CEBPB, DDIT4, FKBP5, DSIPI, and VDR were increased and levels of ADARB1, ARIDB5, and POU2F1 decreased in normal versus very low morning cortisol. Normal serum cortisol levels positively correlated with DSIPI, DDIT4, and FKBP5 expression. Conclusions We introduce gene expression as a novel approach to guide GC replacement in AAD. We suggest that gene expression of DSIPI, DDIT4, and FKBP5 are particularly promising candidate biomarkers of GC replacement, followed by MMP9, CEBPB, VDR, ADARB1, ARID5B, and POU2F1.
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Affiliation(s)
- Åse Bjorvatn Sævik
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Anette B Wolff
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Sigridur Björnsdottir
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Eirik Bratland
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Per M Knappskog
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Paal Methlie
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Siri Carlsen
- Department of Endocrinology, Stavanger University Hospital, Stavanger, Norway
| | - Magnus Isaksson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Olle Kämpe
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Kristian Løvås
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Marianne Øksnes
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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25
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Didriksen NM, Sævik ÅB, Sortland LS, Øksnes M, Husebye ES. Sex-Specific Limitations in Physical Health in Primary Adrenal Insufficiency. Front Endocrinol (Lausanne) 2021; 12:718660. [PMID: 34733237 PMCID: PMC8558514 DOI: 10.3389/fendo.2021.718660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/29/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients with primary adrenal insufficiency (PAI) suffer reduced quality of life (QoL), but comparisons with large-scale normative data are scarce. The clinical characteristics associated with reduced QoL are largely unknown. METHODS Cross-sectional data on clinical characteristics and QoL scores from 494 patients were included. QoL was measured using RAND-36 (generic) and AddiQoL (-30 and -8, disease-specific). RAND-36 is reported as subdomain scores as well as physical (PCS) and metal (MCS) summary scores and compared with normative data. RESULTS Perception of physical role was consistently decreased across age groups in patients with PAI compared with normative data [75 (0-100) vs. 100 (50-100), p<0.001]. Men with PAI reported significantly lower scores for social functioning [88 (75-100) vs. 100 (75-100), p<0.001], as well as for vitality and physical role. In women, the greatest impairment was seen in physical role [50 (0-100) vs. 100 (50-100), p<0.001], followed by social functioning, vitality, physical function, general health, mental health, and emotional role. Overall, better QoL was associated with male sex (AddiQoL-30: 89 ± 13 vs. 82 ± 13, p<0.002), younger age (e.g. 20-29 vs. 80-89 years: PCS 59 [50-62] vs. 46 [37-53], p<0.001), autoimmune etiology [PCS: 53 (45-59) vs.. 45 (38-54), p<0.001], and absence of autoimmune comorbidity [PCS: 54 (45-59) vs. 50 (43-58), p<0.001]. There were no significant differences in QoL scores between different doses or dosing regimens of glucocorticoid or mineralocorticoid replacement. CONCLUSION QoL is reduced in patients with PAI, especially perception of physical role in women and social functioning in men. Among patients with PAI, female sex, higher age, non-autoimmune etiology, and autoimmune comorbidity was associated with lower QoL-scores.
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Affiliation(s)
| | - Åse Bjorvatn Sævik
- Department of Clinical Science, University of Bergen, Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Linn Solveig Sortland
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Marianne Øksnes
- Department of Clinical Science, University of Bergen, Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Eystein Sverre Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- *Correspondence: Eystein Sverre Husebye,
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26
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Oftedal BE, Wolff ASB. New era of therapy for endocrine autoimmune disorders. Scand J Immunol 2020; 92:e12961. [PMID: 32853446 DOI: 10.1111/sji.12961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/10/2020] [Accepted: 08/19/2020] [Indexed: 12/24/2022]
Abstract
The new era of immune and reconstitution therapy of autoimmune disorders is ongoing. However, endocrine autoimmune diseases comprise a group of elaborating pathologies where the development of new treatment strategies remains slow. Substitution of the missing hormones is still standard practice, taking care of the devastating symptoms but not the cause of disease. As our knowledge of the genetic contribution to the aetiology of endocrine disorders increases and early diagnostic tools are available, it is now possible to identify persons at risk before they acquire full-blown disease. This review summarizes current knowledge and treatment of endocrine autoimmune disorders, focusing on type 1 diabetes, Addison's disease, autoimmune thyroid diseases and primary ovarian insufficiency. We explore which new therapies might be used in the different stages of the disease, focus on legalized therapy and elaborate on the ongoing clinical studies for these diseases and the research front, before hypothesizing on the way ahead.
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Affiliation(s)
- Bergithe E Oftedal
- Department of Clinical Science, University of Bergen, Bergen, Norway.,KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Anette S B Wolff
- Department of Clinical Science, University of Bergen, Bergen, Norway.,KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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27
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Sævik ÅB, Åkerman AK, Methlie P, Quinkler M, Jørgensen AP, Höybye C, Debowska AJ, Nedrebø BG, Dahle AL, Carlsen S, Tomkowicz A, Sollid ST, Nermoen I, Grønning K, Dahlqvist P, Grimnes G, Skov J, Finnes T, Valland SF, Wahlberg J, Holte SE, Simunkova K, Kämpe O, Husebye ES, Bensing S, øksnes M. Residual Corticosteroid Production in Autoimmune Addison Disease. J Clin Endocrinol Metab 2020; 105:5835888. [PMID: 32392298 PMCID: PMC7274491 DOI: 10.1210/clinem/dgaa256] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/07/2020] [Indexed: 01/26/2023]
Abstract
CONTEXT Contrary to current dogma, growing evidence suggests that some patients with autoimmune Addison disease (AAD) produce corticosteroids even years after diagnosis. OBJECTIVE To determine frequencies and clinical features of residual corticosteroid production in patients with AAD. DESIGN Two-staged, cross-sectional clinical study in 17 centers (Norway, Sweden, and Germany). Residual glucocorticoid (GC) production was defined as quantifiable serum cortisol and 11-deoxycortisol and residual mineralocorticoid (MC) production as quantifiable serum aldosterone and corticosterone after > 18 hours of medication fasting. Corticosteroids were analyzed by liquid chromatography-tandem mass spectrometry. Clinical variables included frequency of adrenal crises and quality of life. Peak cortisol response was evaluated by a standard 250 µg cosyntropin test. RESULTS Fifty-eight (30.2%) of 192 patients had residual GC production, more common in men (n = 33; P < 0.002) and in shorter disease duration (median 6 [0-44] vs 13 [0-53] years; P < 0.001). Residual MC production was found in 26 (13.5%) patients and associated with shorter disease duration (median 5.5 [0.5-26.0] vs 13 [0-53] years; P < 0.004), lower fludrocortisone replacement dosage (median 0.075 [0.050-0.120] vs 0.100 [0.028-0.300] mg; P < 0.005), and higher plasma renin concentration (median 179 [22-915] vs 47.5 [0.6-658.0] mU/L; P < 0.001). There was no significant association between residual production and frequency of adrenal crises or quality of life. None had a normal cosyntropin response, but peak cortisol strongly correlated with unstimulated cortisol (r = 0.989; P < 0.001) and plasma adrenocorticotropic hormone (ACTH; r = -0.487; P < 0.001). CONCLUSION In established AAD, one-third of the patients still produce GCs even decades after diagnosis. Residual production is more common in men and in patients with shorter disease duration but is not associated with adrenal crises or quality of life.
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Affiliation(s)
- Åse Bjorvatn Sævik
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Anna-Karin Åkerman
- Department of Medicine, Örebro University Hospital, Örebro, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Paal Methlie
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | | | | | - Charlotte Höybye
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | | | - Bjørn Gunnar Nedrebø
- Department of Clinical Science, University of Bergen, Norway
- Department of Internal Medicine, Haugesund Hospital, Haugesund, Norway
| | - Anne Lise Dahle
- Department of Internal Medicine, Haugesund Hospital, Haugesund, Norway
| | - Siri Carlsen
- Department of Endocrinology, Stavanger University Hospital, Stavanger, Norway
| | - Aneta Tomkowicz
- Department of Medicine, Sørlandet Hospital, Kristiansand, Norway
| | - Stina Therese Sollid
- Department of Medicine, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Ingrid Nermoen
- Department of Endocrinology, Akershus University Hospital, Lørenskog, Norway
| | - Kaja Grønning
- Department of Endocrinology, Akershus University Hospital, Lørenskog, Norway
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Guri Grimnes
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
- Tromsø Endocrine Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Jakob Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Trine Finnes
- Section of Endocrinology, Innlandet Hospital Trust, Hamar, Norway
| | | | - Jeanette Wahlberg
- Department of Endocrinology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | | | | | - Olle Kämpe
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Eystein Sverre Husebye
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne øksnes
- Department of Clinical Science, University of Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
- Correspondence and Reprint Requests: Marianne Øksnes, University of Bergen, Klinisk Institutt 2, Laboratoriebygget, 8. et., Jonas Lies vei 91B, 5021 Bergen, Norway, E-mail:
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Isidori AM, Arnaldi G, Boscaro M, Falorni A, Giordano C, Giordano R, Pivonello R, Pozza C, Sbardella E, Simeoli C, Scaroni C, Lenzi A. Towards the tailoring of glucocorticoid replacement in adrenal insufficiency: the Italian Society of Endocrinology Expert Opinion. J Endocrinol Invest 2020; 43:683-696. [PMID: 31773582 DOI: 10.1007/s40618-019-01146-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/11/2019] [Indexed: 11/28/2022]
Abstract
CONTEXT Glucocorticoid (GC) replacement therapy in patients with adrenal insufficiency (AI) is life saving. After over 50 years of conventional GC treatment, novel formulations are now entering routine clinical practice. METHODS Given the spectrum of medications currently available and new insights into the understanding of AI, the authors reviewed relevant medical literature with emphasis on original studies, prospective observational data and randomized controlled trials performed in the past 35 years. The Expert Opinion of a panel of selected endocrinologists was sought to answer specific clinical questions. The objective was to provide an evidence-supported guide, for the use of GC in various settings from university hospitals to outpatient clinics, that offers specific advice tailored to the individual patient. RESULTS The Panel reviewed available GC replacement therapies, comprising short-acting, intermediate and long-acting oral formulations, subcutaneous formulations and the novel modified-release hydrocortisone. Advantages and disadvantages of these formulations were reviewed. CONCLUSIONS In the Panel's opinion, achieving the optimal GC timing and dosing is needed to improve the outcome of AI. No-single formulation offers the best option for every patients. Recent data suggest that more emphasis should be given to the timing of intake. Tailoring of GS should be attempted in all patients-by experts-on a case-by-case basis. The Panel identified specific subgroups of AI patients that could be help by this process. Long-term studies are needed to confirm the short-term benefits associated with the modified-release GCs. The impact of GC tailoring has yet to be proven in terms of hospitalization rate, morbidity and mortality.
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Affiliation(s)
- A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - G Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Azienda Ospedaliero-Universitaria, Università Politecnica delle Marche, Ancona, Italy
| | - M Boscaro
- UOC Endocrinologia, Dipartimento di Medicina DIMED, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - A Falorni
- Dipartimento di Medicina, Università di Perugia, Perugia, Italy
| | - C Giordano
- Section of Diabetology, Endocrinology and Metabolism, PROMISE, University of Palermo, Palermo, Italy
| | - R Giordano
- Department of Clinical and Biological Sciences, Division of Endocrinology, Diabetes and Metabolism-Department of Medical Sciences, University of Turin, Turin, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - C Pozza
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - C Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - C Scaroni
- UOC Endocrinologia, Dipartimento di Medicina DIMED, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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Delle Cese F, Corsello A, Cintoni M, Locantore P, Pontecorvi A, Corsello SM, Paragliola RM. Switching From Immediate-Release to Fractionated Dual-Release Hydrocortisone May Improve Metabolic Control and QoL in Selected Primary Adrenal Insufficiency Patients. Front Endocrinol (Lausanne) 2020; 11:610904. [PMID: 33597926 PMCID: PMC7883639 DOI: 10.3389/fendo.2020.610904] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/17/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The use of once-daily dual-release HC (DR-HC) in primary adrenal insufficiency (PAI) is often associated with benefits in metabolic parameters when compared to immediate-release HC (IR-HC). In this study, we evaluated the effects on clinical, biochemical and metabolic parameters of switching from IR-HC to lower-dose DR-HC given both in once and fractionated daily doses. METHODS Twenty autoimmune-PAI subjects were included. Patients on 30 mg/day divided in three doses IR-HC regimen (group A) were switched to DR-HC 25 mg/day given in two daily doses (20 mg in the morning and 5 mg at 2.00 p.m.); patients on 25 mg/day divided in two doses IR-HC regimen (group B) were switched to DR-HC 20 mg once daily. Biochemical and metabolic parameters, BMI and quality of life (QoL) were evaluated at the baseline and six months after the switch. RESULTS Our small non-randomized study with short follow up showed significant benefits in both group A and group B without any apparent side-effects. After the switch to DR-HC, a significant decrease in adrenocorticotropic hormone (ACTH), HbA1c, total cholesterol, triglycerides, LDL, cholesterol, BMI as well as a significant improvement in QoL, were observed in both groups. At 6 months, ACTH levels were lower in group A while HbA1C and total cholesterol were lower in group B. CONCLUSION The DR-HC is a valid and effective therapeutic strategy to improve the metabolic control and the QoL in PAI. The reduction of ACTH levels with DR-HC regimens reflects a better biochemical control of PAI, obtained by using a lower dose and more physiological HC formulation. Both once-daily and fractionated daily doses of DR-HC showed advantages compared with IR-HC formulation.
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Affiliation(s)
- Francesca Delle Cese
- Endocrinology, Università Cattolica del Sacro Cuore-Fondazione Policlinico “Gemelli” IRCCS, Rome, Italy
| | - Andrea Corsello
- Endocrinology, Università Cattolica del Sacro Cuore-Fondazione Policlinico “Gemelli” IRCCS, Rome, Italy
| | - Marco Cintoni
- Scuola di Specializzazione in Scienza dell’Alimentazione, Università di Roma Tor Vergata, Rome, Italy
| | - Pietro Locantore
- Endocrinology, Università Cattolica del Sacro Cuore-Fondazione Policlinico “Gemelli” IRCCS, Rome, Italy
| | - Alfredo Pontecorvi
- Endocrinology, Università Cattolica del Sacro Cuore-Fondazione Policlinico “Gemelli” IRCCS, Rome, Italy
| | - Salvatore Maria Corsello
- Endocrinology, Università Cattolica del Sacro Cuore-Fondazione Policlinico “Gemelli” IRCCS, Rome, Italy
- *Correspondence: Salvatore Maria Corsello,
| | - Rosa Maria Paragliola
- Endocrinology, Università Cattolica del Sacro Cuore-Fondazione Policlinico “Gemelli” IRCCS, Rome, Italy
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Abstract
Primary adrenal insufficiency (PAI) occurs in 1/5000-1/7000 individuals in the general population. Autoimmune Addison's disease (AAD) is the major cause of PAI and is a major component of autoimmune polyendocrine syndrome type 1 (APS1) and type 2 (APS2). Presence of 21-hydroxylase autoantibodies (21OHAb) identifies subjects with ongoing clinical or pre-clinical adrenal autoimmunity. AAD requires life-long substitutive therapy with two-three daily doses of hydrocortisone (HC) (15-25 mg/day) or one daily dose of dual-release HC and with fludrocortisone (0.5-2.0 mg/day). The lowest possible HC dose must be identified according to clinical and biochemical parameters to minimize long-term complications that include osteoporosis and cardiovascular and metabolic alterations. Women with AAD have lower fertility and parity as compared to age-matched healthy controls. Patients must be educated to double-triple HC dose in the case of fever or infections and to switch to parenteral HC in the case of vomiting, diarrhoea or acute hypotension.
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Affiliation(s)
- Serena Saverino
- Section of Internal Medicine and Endocrine and Metabolic Sciences, Department of Medicine, University of Perugia, Perugia, Italy
| | - Alberto Falorni
- Section of Internal Medicine and Endocrine and Metabolic Sciences, Department of Medicine, University of Perugia, Perugia, Italy.
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Chihaoui M, Mimita W, Oueslati I, Rejeb O, Ben Amor Z, Grira W, Yazidi M, Chaker F. Prednisolone or hydrocortisone replacement in patients with corticotrope deficiency fasting during Ramadan result in similar risks of complications and quality of life: a randomized double-blind controlled trial. Endocrine 2020; 67:155-160. [PMID: 31552584 DOI: 10.1007/s12020-019-02082-w] [Citation(s) in RCA: 6] [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] [Received: 04/25/2019] [Accepted: 09/03/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The aims of the study were to compare the risk of complications and the quality of life in patients with corticotrope deficiency, who fasted during Ramadan. Both hydrocortisone and prednisolone were compared as treatments. METHODS A randomized double-blind crossover clinical trial conducted in the department of Endocrinology of the University Hospital la Rabta in Tunis, during Ramadan 2018, on 53 patients with known corticotrope deficiency treated with hydrocortisone 20 mg per day and who were willing to fast during Ramadan. Patients were randomized into two groups; AB that received hydrocortisone twice daily for 14 days then prednisolone once daily with a placebo for 14 days and group BA that received the two treatments in the reverse order. Patients had to complete a daily follow-up sheet about their eating and sleeping habits, the occurrence of complications and blood glucose monitoring and also to respond to the AddiQoL questionnaire at the end of each treatment period. RESULTS Fifty patients' data were analyzed; 29 men, mean age: 42.4 ± 13.3 years, mean duration of the disease: 8.1 ± 7.6 years. The frequency of complications, mean blood glucose levels and the quality of life did not differ on hydrocortisone compared to prednisolone after adjustment for the sequence of the treatment. CONCLUSIONS the risks of Ramadan fasting in patients with corticotrope deficiency were the same on hydrocortisone or prednisolone.
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Affiliation(s)
- Melika Chihaoui
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Wafa Mimita
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ons Rejeb
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Zohra Ben Amor
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Wafa Grira
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Ebrahimi F, Widmer A, Wagner U, Mueller B, Schuetz P, Christ-Crain M, Kutz A. Association of adrenal insufficiency with patient-oriented health-care outcomes in adult medical inpatients. Eur J Endocrinol 2019; 181:701-709. [PMID: 31581127 PMCID: PMC6977938 DOI: 10.1530/eje-19-0469] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 10/03/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Adrenal insufficiency in the outpatient setting is associated with excess morbidity, mortality, and impaired quality of life. Evidence on its health-care burden in medical inpatients is scarce. The aim of this study was to assess the health-care burden of primary adrenal insufficiency (PAI) and secondary adrenal insufficiency (SAI) among hospitalized inpatients. DESIGN AND METHODS In this nationwide cohort study, adult medical patients with either PAI or SAI hospitalized between 2011 and 2015 were compared with propensity-matched (1:1) medical controls, respectively. The primary outcome was 30-day all-cause in-hospital mortality. Main secondary outcomes included ICU admission rate, length-of-hospital stay, 30-day and 1-year all-cause readmission rates. RESULTS In total, 594 hospitalized cases with PAI and 4880 cases with SAI were included. Compared with matched controls, in-hospital mortality was not increased among PAI or SAI patients, respectively. Patients with adrenal insufficiency were more likely to be admitted to ICU (PAI: OR 1.9 (95% CI, 1.27 to 2.72) and SAI: OR 1.5 (95% CI, 1.35 to 1.75)). Length of hospital stay was prolonged by 1.0 days in PAI patients (8.9 vs 7.9 days (95% CI, 0.06 to 1.93)), and by 3.3 days in SAI patients (12.1 vs 8.8 days (95% CI, 2.82 to 3.71)), when compared with matched controls. Patients with SAI were found to have higher 30-day and 1-year readmission rates (14.1 vs 12.1% and 50.0 vs 40.7%; P < 0.001) than matched controls. CONCLUSIONS While no difference in in-hospital mortality was found, adrenal insufficiency was associated with prolonged length of hospital stay, and substantially higher rates of ICU admission and hospital readmission.
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Affiliation(s)
- Fahim Ebrahimi
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Andrea Widmer
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Ulrich Wagner
- Division of Health and Social Affairs, Section Health, Swiss Federal Office for Statistics, Neuchâtel, Switzerland
- Foundation National Institute for Cancer Epidemiology and Registration (NICER), University of Zurich, Zurich, Switzerland
| | - Beat Mueller
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Division of Endocrinology, Diabetes, and Metabolism, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Division of Endocrinology, Diabetes, and Metabolism, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Mirjam Christ-Crain
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Alexander Kutz
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Correspondence should be addressed to A Kutz;
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Betterle C, Presotto F, Furmaniak J. Epidemiology, pathogenesis, and diagnosis of Addison's disease in adults. J Endocrinol Invest 2019; 42:1407-1433. [PMID: 31321757 DOI: 10.1007/s40618-019-01079-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/25/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Addison's disease (AD) is a rare disorder and among adult population in developed countries is most commonly caused by autoimmunity. In contrast, in children genetic causes are responsible for AD in the majority of patients. PURPOSE This review describes epidemiology, pathogenesis, genetics, natural history, clinical manifestations, immunological markers and diagnostic strategies in patients with AD. Standard care treatments including the management of patients during pregnancy and adrenal crises consistent with the recent consensus statement of the European Consortium and the Endocrine Society Clinical Practice Guideline are described. In addition, emerging therapies designed to improve the quality of life and new strategies to modify the natural history of autoimmune AD are discussed. CONCLUSIONS Progress in optimizing replacement therapy for patients with AD has allowed the patients to lead a normal life. However, continuous education of patients and health care professionals of ever-present danger of adrenal crisis is essential to save lives of patients with AD.
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Affiliation(s)
- C Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padova, Via Ospedale Civile 105, 35128, Padua, Italy
| | - F Presotto
- Endocrine Unit, Department of Medicine (DIMED), University of Padova, Via Ospedale Civile 105, 35128, Padua, Italy.
- Unit of Internal Medicine, Ospedale dell'Angelo, via Paccagnella 11, 30174, Mestre-Venice, Italy.
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Cardini F, Torlone E, Bini V, Falorni A. Continuous subcutaneous hydrocortisone infusion in a woman with secondary adrenal insufficiency. Endocrine 2019; 63:398-400. [PMID: 30353412 DOI: 10.1007/s12020-018-1780-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/01/2018] [Indexed: 11/30/2022]
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Dineen R, Thompson CJ, Sherlock M. Adrenal crisis: prevention and management in adult patients. Ther Adv Endocrinol Metab 2019; 10:2042018819848218. [PMID: 31223468 PMCID: PMC6566489 DOI: 10.1177/2042018819848218] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/04/2019] [Indexed: 12/24/2022] Open
Abstract
Adrenal crisis is an acute life-threatening emergency contributing to the excess mortality that is reported in patients with adrenal insufficiency. The incidence of adrenal crisis is estimated to be 8 per 100 patient years in patients with adrenal insufficiency. Patients with adrenal crisis present systemically unwell with nonspecific signs and symptoms often leading to misdiagnosis and delayed treatment. An adrenal crisis may be the first presentation of adrenal insufficiency or can occur in patients who have been established on glucocorticoid replacement therapy. Infections are the major precipitating factor, but other causes include physical stress such as a surgical procedure or trauma, forgetting or discontinuing glucocorticoid therapy, pronounced physical activity, and psychological stress. The emergency treatment involves prompt recognition and administration of parenteral hydrocortisone, rehydration and management of electrolyte abnormalities. Prevention is centred around patient education. All patients should be educated on stress dosing and parenteral glucocorticoid administration. They should carry a steroid dependency alert card and wear a medical alert bracelet or similar identification. Despite many improvements in the management of patients with adrenal insufficiency, adrenal crisis continues to occur and represents a major source of morbidity, mortality and distress for patients. Improved patient and clinician education and measures to facilitate parenteral hydrocortisone self-administration in impending crisis are central to the management of this life-threatening event.
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Affiliation(s)
- Rosemary Dineen
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
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Mallappa A, Nella AA, Sinaii N, Rao H, Gounden V, Perritt AF, Kumar P, Ling A, Liu CY, Soldin SJ, Merke DP. Long-term use of continuous subcutaneous hydrocortisone infusion therapy in patients with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2018; 89:399-407. [PMID: 30003563 PMCID: PMC6166869 DOI: 10.1111/cen.13813] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/18/2018] [Accepted: 07/08/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND In a phase 2 short-term (6 months) study of patients with congenital adrenal hyperplasia (CAH), continuous subcutaneous hydrocortisone infusion (CSHI) was found to be a safe, effective and well-tolerated method of replacing cortisol with improved disease and patient-related outcomes. OBJECTIVE To evaluate the safety and efficacy of long-term CSHI. DESIGN Single-centre, open-label, phase 2 extension study. PATIENTS Five adults with classic CAH. MEASUREMENTS Biomarkers of disease control, metabolic indices and health-related quality-of-life (HRQoL) estimates. RESULTS Six of eight patients chose to continue on long-term CSHI therapy. Compared to baseline, eighteen months of CSHI resulted in decreased (P = 0.043) 0700-hour ACTH, 17-hydroxyprogesterone, androstenedione and progesterone; increased whole-body lean mass (P = 0.024); and improved HRQoL, especially symptoms of adrenal insufficiency (P = 0.003). Findings at six and eighteen months did not differ, and improvements achieved in androgen control, lean body mass and HRQoL after 6 months of CSHI were maintained at eighteen months. The hydrocortisone dose appeared to decrease with time [6 vs 18 months: 38.3 ± 8.8 vs 33.6 ± 12.2 mg/day (P = 0.062)], especially in women receiving oral contraceptives. Reduction of testicular adrenal rest and adrenal size observed at 6 months remained stable. In one patient, an adrenal adenoma continually decreased over time. Subjective improvement in hirsutism was reported. CONCLUSIONS Long-term use of CSHI is a safe and well-tolerated treatment option in a select set of adults with classic CAH. Improvements observed short term in disease control and subjective health status continued long term.
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Affiliation(s)
- Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Aikaterini A. Nella
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA 20892
| | - Ninet Sinaii
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Hamsini Rao
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Verena Gounden
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Ashley F. Perritt
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Parag Kumar
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Alexander Ling
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Chia-Ying. Liu
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Steven J. Soldin
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Deborah P. Merke
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA 20892
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Sorgdrager FJH, Werumeus Buning J, Bos EH, Van Beek AP, Kema IP. Hydrocortisone Affects Fatigue and Physical Functioning Through Metabolism of Tryptophan: A Randomized Controlled Trial. J Clin Endocrinol Metab 2018; 103:3411-3419. [PMID: 29982583 DOI: 10.1210/jc.2018-00582] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/27/2018] [Indexed: 12/19/2022]
Abstract
CONTEXT Hydrocortisone (HC) treatment influences health-related quality of life (HRQOL) in secondary adrenal insufficiency (AI). Glucocorticoids regulate tryptophan metabolism through the kynurenine pathway, which modulates mood and energy homeostasis. OBJECTIVE This study investigated whether tryptophan metabolism mediated the effect of HC dose on HRQOL in patients with secondary AI. DESIGN, SETTING, AND PATIENTS Forty-seven patients with secondary AI participated in this double-blind randomized controlled cross-over trial in the University Medical Center Groningen. INTERVENTION Patients were treated for two 10-week periods with a daily HC dose of 0.2 to 0.3 mg/kg and 0.4 to 0.6 mg/kg body weight, respectively. MAIN OUTCOME MEASURES Diary data and questionnaires were used to assess HRQOL. Tryptophan, kynurenine and 3-hydroxykynurenine were measured in serum and dialyzed plasma and the kynurenine-to-tryptophan ratio (Kyn/Trp ratio) ratio was calculated. RESULTS A higher dose HC was associated with increased levels of tryptophan (95% CI for mean difference 0.37 to 12.5, P = 0.038), reduced levels of kynurenine (95% CI, -0.49 to -0.10, P = 0.004) and 3-hydroxykynurenine (95% CI, -10.6 to -2.35, P = 0.003), and a reduced Kyn/Trp ratio (95% CI, -0.84 to -0.50, P < 0.001). The Kyn/Trp ratio mediated the effect of a higher dose HC on fatigue (P = 0.041) and physical functioning (P = 0.005). CONCLUSION Metabolism of tryptophan through the kynurenine pathway is reduced after a 10-week treatment with a higher dose HC and plays a role in the effect of HC on fatigue and physical functioning in patients with secondary AI.
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Affiliation(s)
- Freek J H Sorgdrager
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, RB Groningen, Netherlands
| | - Jorien Werumeus Buning
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, RB Groningen, Netherlands
| | - Elske H Bos
- Interdisciplinary Center Psychopathology and Emotion Regulation, University of Groningen, University Medical Center Groningen, RB Groningen, Netherlands
- Department of Developmental Psychology, University of Groningen, TS Groningen, Netherlands
| | - André P Van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, RB Groningen, Netherlands
| | - Ido P Kema
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, RB Groningen, Netherlands
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Ho W, Druce M. Quality of life in patients with adrenal disease: A systematic review. Clin Endocrinol (Oxf) 2018; 89:119-128. [PMID: 29672878 DOI: 10.1111/cen.13719] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/12/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evaluating the patient with adrenal disease is challenging due to the lack of precise clinical and biochemical parameters for disease control. Quality of life (QOL) evaluation aims to measure the patient's subjective experience. OBJECTIVE To describe how QOL is defined and measured in adrenal disease, critically appraise the use of QOL tools in published literature, discuss the implications of these findings and provide direction for further research in this field. MATERIALS AND METHODS We searched the Cochrane library, EMBASE, Google Scholar, PsycINFO, PubMed, Web of Science databases to identify only primary studies where self-reported QOL was measured as a parameter in adults with confirmed adrenal disease, and results presented in English. Key data were independently extracted from each study and adherence to reporting guidelines evaluated. RESULTS A total of 117 studies involving 13 717 subjects were included. The vast majority of studies did not define QOL. The most common approach was to combine generic and domain-specific tools, although disease-specific tools are increasingly being used. Adherence to reporting guidelines was variable. A narrative synthesis of the findings was performed. CONCLUSION We present the first systematic review of QOL in adrenal disease. Quality of life is reduced in patients with adrenal disease, irrespective of adrenal hyperfunction or hypofunction. Quality of life improved with therapy but was not completely reversed despite biochemical remission. Authors should adhere to consistent reporting practices which are interpretable by clinicians. Further research is required to explain the mechanisms driving impaired QOL and value of QOL evaluations in the clinical context.
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Affiliation(s)
- Winnie Ho
- Centre for Endocrinology, Barts and the London School of Medicine & Dentistry, William Harvey Research Institute, Queen Mary University of London, London, UK
- Department of Endocrinology, Western Health, Melbourne, Vic., Australia
| | - Maralyn Druce
- Centre for Endocrinology, Barts and the London School of Medicine & Dentistry, William Harvey Research Institute, Queen Mary University of London, London, UK
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Meyer G, Koch M, Herrmann E, Bojunga J, Badenhoop K. Longitudinal AddiQoL scores may identify higher risk for adrenal crises in Addison's disease. Endocrine 2018; 60:355-361. [PMID: 29388043 DOI: 10.1007/s12020-017-1513-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 12/23/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE Several studies have shown a reduced quality of life (QoL) in patients with Addison's disease (AD), but investigations of QoL over a long-term course are lacking. Adrenal crises (AC) are life-threatening complications in AD. The purpose of this prospective study was to test whether the repeated use of QoL-questionnaires can detect prodromal periods of an AC. METHODS 110 patients with AD were asked to complete the disease specific-QoL questionnaire AddiQoL and a short questionnaire about adverse events once monthly over a period of ten months. AC was defined if at least two of the following symptoms were reported: (a) hypotension, (b) nausea or vomiting, (c) severe fatigue, (d) documented hyponatremia, hyperkalemia, or hypoglycemia, and subsequent parenteral glucocorticoid administration was carried out. RESULTS Prevalence of AC was 10.9/100 patient years. AddiQoL scores in patients with AC showed a trend (p = 0,08) to a wider fluctuation over time. Subjective precrises not meeting the criteria for AC were reported by 31 patients who had significantly lower AddiQoL scores (p = 0,018). CONCLUSIONS These are the first data showing the course of QoL during a period of ten months in patients with AD. Incidence of AC exceeds previous data. Our data show, that subjective precrises in AD associate with lower QoL. AC, as well as precrises affect intraindividual AddiQol-scores over time with a trend to a stronger fluctuation. Longitudinal AddiQol scores and self-reporting of precrises via patient diaries are additional clinical tools to identify higher risk for critical events.
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Affiliation(s)
- Gesine Meyer
- Division of Endocrinology, Department of Internal Medicine 1, Goethe-University Hospital, Frankfurt, Germany.
| | - Maike Koch
- Division of Endocrinology, Department of Internal Medicine 1, Goethe-University Hospital, Frankfurt, Germany
| | - Eva Herrmann
- Institut for Biostatistics and Mathematic Modelling, Goethe-University, Frankfurt, Germany
| | - Jörg Bojunga
- Division of Endocrinology, Department of Internal Medicine 1, Goethe-University Hospital, Frankfurt, Germany
| | - Klaus Badenhoop
- Division of Endocrinology, Department of Internal Medicine 1, Goethe-University Hospital, Frankfurt, Germany
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Isidori AM, Venneri MA, Graziadio C, Simeoli C, Fiore D, Hasenmajer V, Sbardella E, Gianfrilli D, Pozza C, Pasqualetti P, Morrone S, Santoni A, Naro F, Colao A, Pivonello R, Lenzi A. Effect of once-daily, modified-release hydrocortisone versus standard glucocorticoid therapy on metabolism and innate immunity in patients with adrenal insufficiency (DREAM): a single-blind, randomised controlled trial. Lancet Diabetes Endocrinol 2018; 6:173-185. [PMID: 29229498 DOI: 10.1016/s2213-8587(17)30398-4] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/09/2017] [Accepted: 10/12/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Conventional treatment of patients with adrenal insufficiency involves administration of glucocorticoids multiple times a day and has been associated with weight gain and metabolic impairment. The optimal glucocorticoid replacement therapy for these patients is highly debated because of the scarcity of evidence from randomised trials. We aimed to establish whether the timing and pharmacokinetics of glucocorticoid replacement therapy affect the metabolism and immune system of patients with adrenal insufficiency. METHODS We did a single-blind randomised controlled trial at two reference university hospitals in Italy. Eligible patients (aged 18-80 years) with adrenal insufficiency were on conventional glucocorticoid therapy and had been stable for at least 3 months before enrolment. Patients were randomly assigned (1:1) with a computer-generated random sequence stratified by type of adrenal insufficiency and BMI to continue conventional glucocorticoid therapy (standard treatment group) or to switch to an equivalent dose of once-daily, modified-release oral hydrocortisone (switch treatment group). Outcome assessors were masked to treatment allocation. The primary outcome was bodyweight change from baseline to 24 weeks. Secondary outcomes included immune cell profiles, susceptibility to infections, and quality of life. Efficacy analyses included all patients who received at least one dose of the study drug. This trial is registered with ClinicalTrials.gov, NCT02277587. FINDINGS Between March 1, 2014, and June 30, 2016, 89 patients with adrenal insufficiency were randomly assigned to continue standard glucocorticoid therapy (n=43) or to switch to once-daily, modified-release hydrocortisone (n=46). At 24 weeks, bodyweight reduction was superior in patients in the once-daily hydrocortisone group compared with those in the standard treatment group (-2·1 kg [95% CI -4·0 to -0·3] vs 1·9 kg [-0·1 to 3·9]; treatment difference -4·0 kg, 95% CI -6·9 to -1·1; p=0·008). Additionally, patients in the once-daily hydrocortisone group had more normal immune cell profiles, reduced susceptibility to infections, and improved quality of life compared with the standard glucocorticoid therapy group. We observed no difference in frequency or severity of adverse events between the two intervention groups, although a lower cumulative number of recurrent upper respiratory tract infections was observed with once-daily hydrocortisone than with standard treatment (17 vs 38; p=0·016). Most adverse events were mild; three serious adverse events occurred in each group, of which one adverse advent (arthritis) in the switch treatment group could be considered drug related. INTERPRETATION Patients with adrenal insufficiency on conventional glucocorticoid replacement therapy multiple times a day exhibit a pro-inflammatory state and weakened immune defence. Restoration of a more physiological circadian glucocorticoid rhythm by switching to a once-daily, modified-release regimen reduces bodyweight, normalises the immune cell profile, reduces recurrent infections, and improves the quality of life of patients with adrenal insufficiency. FUNDING Italian Ministry of University and Research.
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Affiliation(s)
- Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - Mary Anna Venneri
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Graziadio
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Daniela Fiore
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Carlotta Pozza
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Patrizio Pasqualetti
- Service of Medical Statistics and Information Technology, Fatebenefratelli Foundation for Health Research and Education, Rome, Italy
| | - Stefania Morrone
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Angela Santoni
- Department of Molecular Medicine, Pasteur Institute-Cenci Bolognetti Foundation, Sapienza University of Rome, Rome, Italy
| | - Fabio Naro
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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Boesen VB, Christoffersen T, Watt T, Borresen SW, Klose M, Feldt-Rasmussen U. PlenadrEMA: effect of dual-release versus conventional hydrocortisone on fatigue, measured by ecological momentary assessments: a study protocol for an open-label switch pilot study. BMJ Open 2018; 8:e019487. [PMID: 29362269 PMCID: PMC5786125 DOI: 10.1136/bmjopen-2017-019487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Patients with adrenal insufficiency have impaired health-related quality of life (QoL). The dual-release hydrocortisone preparation, Plenadren, has been developed to mimic the physiological cortisol release more closely than conventional hydrocortisone treatment. Plenadren has been shown to improve QoL, in particular fatigue, in patients with primary adrenal insufficiency. However, the effect has not been investigated in patients with secondary adrenal insufficiency; furthermore, no study has taken the diurnal variation of fatigue into account. To assess diurnal variations, it is necessary to use repeated daily measurements, such as ecological momentary assessments (EMAs). This study aims to evaluate EMAs of fatigue as outcome in future large-scale randomised clinical trials. METHODS AND ANALYSIS The PlenadrEMA trial is an investigator-initiated open-label switch pilot trial of the effect of Plenadren versus conventional hydrocortisone on fatigue in patients with secondary adrenal insufficiency. The trial will include 30 participants. After 5 weeks on their usual hydrocortisone treatment, patients will be shifted to Plenadren for 16 weeks. Fatigue will be assessed using momentary versions of the Multidimensional Fatigue Inventory (MFI-20). Items will be administered to participants via a smartphone application four times daily during 20 days. Assessments will be performed before treatment shift and repeated after 12.5 weeks on Plenadren. The study will identify the best suited outcome for future randomised clinical trials, and in addition, estimate the variability and difference in fatigue between the two treatments to perform power calculations. ETHICS AND DISSEMINATION The trial will be conducted in accordance with the Declaration of Helsinki and has been approved by the Regional Scientific Ethical Committee in Copenhagen (ID: H-1-2014-073). All patients will receive written and verbal information about the trial and will give informed consent before enrolment. Findings will be published in peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBER EudraCT201400203932.
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Affiliation(s)
- Victor Brun Boesen
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Thea Christoffersen
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Torquil Watt
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Internal Medicine, Copenhagen University Hospital Herlev Gentofte, Denmark
| | | | - Marianne Klose
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Endocrinology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Mongioì LM, Condorelli RA, La Vignera S, Calogero AE. Dual-release hydrocortisone treatment: glycometabolic profile and health-related quality of life. Endocr Connect 2018; 7:211-219. [PMID: 29233815 PMCID: PMC5793805 DOI: 10.1530/ec-17-0368] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 12/12/2017] [Indexed: 12/02/2022]
Abstract
OBJECTIVE Adrenal insufficiency (AI) is a chronic condition associated with increased mortality and morbidity. The treatment of AI in the last years has been object of important changes due to the development of a dual-release preparation of hydrocortisone. It differs from previous therapeutic strategy as it contemplates a once-daily tablet that allows more closely mimicking the physiological circadian cortisol rhythm. The aim of the study was to evaluate the effects of dual-release hydrocortisone treatment on the glycometabolic profile and health-related quality of life of patients with AI. DESIGN AND METHODS In this clinical open trial, we enrolled ten patients with primary AI (41 ± 2.67 years) and nine patients with AI secondary to hypopituitarism (53.2 ± 17.7 years). We evaluated the glycometabolic profile before and 3, 6, 9 and 12 months after dual-release hydrocortisone administration. We also evaluated health-related quality of life, estimated by the AddiQol questionnaire. The mean dose administered of dual-release hydrocortisone was 28.33 ± 6.68 mg/day. RESULTS One female hypopituitary patient dropped out from the study. After 12 months of treatment, the mean dosage administered of dual-release hydrocortisone was significantly lower (P < 0.05) and all patients reported improved quality of life and well-being. The glycometabolic profile improved and the glycosylated hemoglobin decreased significantly in patients with primary AI (6.25 ± 0.2 vs 5.35 ± 0.17, P < 0.05). In contrast, hypopituitary patients had worse glycometabolic profile and a trend toward hypertriglyceridemia. CONCLUSIONS Dual-release hydrocortisone treatment improved the quality of life of patients with AI, and it allowed a decrease of cortisol dosage administered in the absence of side effects. The glycometabolic profile worsened in hypopituitary patients.
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Affiliation(s)
- L M Mongioì
- Department of Clinical and Experimental MedicineUniversity of Catania, Catania, Italy
| | - R A Condorelli
- Department of Clinical and Experimental MedicineUniversity of Catania, Catania, Italy
| | - S La Vignera
- Department of Clinical and Experimental MedicineUniversity of Catania, Catania, Italy
| | - A E Calogero
- Department of Clinical and Experimental MedicineUniversity of Catania, Catania, Italy
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Mazziotti G, Formenti AM, Frara S, Roca E, Mortini P, Berruti A, Giustina A. MANAGEMENT OF ENDOCRINE DISEASE: Risk of overtreatment in patients with adrenal insufficiency: current and emerging aspects. Eur J Endocrinol 2017; 177:R231-R248. [PMID: 28583942 DOI: 10.1530/eje-17-0154] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/31/2017] [Accepted: 06/05/2017] [Indexed: 01/17/2023]
Abstract
The effects of long-term replacement therapy of adrenal insufficiency (AI) are still a matter of controversy. In fact, the established glucocorticoid replacement regimens do not completely reproduce the endogenous hormonal production and the monitoring of AI treatment may be a challenge for the lack of reliable clinical and biochemical markers. Consequently, several AI patients are frequently exposed to relative glucocorticoid excess potentially leading to develop chronic complications, such as diabetes mellitus, dyslipidemia, hypertension and fragility fractures with consequent impaired QoL and increased mortality risk. This review deals with the pathophysiological and clinical aspects concerning the over-replacement therapy of primary and secondary AI.
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Affiliation(s)
- G Mazziotti
- Endocrinology Unit, ASST, Carlo Poma, Mantua, Italy
| | - A M Formenti
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - S Frara
- Chair of Endocrinology, San Raffaele Vita-Salute University, Milan, Italy
| | - E Roca
- Chair of Medical Oncology, University of Brescia, Brescia, Italy
| | - P Mortini
- Chair of Neurosurgery, San Raffaele Vita-Salute University, Milan, Italy
| | - A Berruti
- Chair of Medical Oncology, University of Brescia, Brescia, Italy
| | - A Giustina
- Chair of Endocrinology, San Raffaele Vita-Salute University, Milan, Italy
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De Bucy C, Guignat L, Niati T, Bertherat J, Coste J. Health-related quality of life of patients with hypothalamic-pituitary-adrenal axis dysregulations: a cohort study. Eur J Endocrinol 2017; 177:1-8. [PMID: 28404594 DOI: 10.1530/eje-17-0048] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/06/2017] [Accepted: 04/12/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Health-related quality of life (HrQoL) is increasingly considered to be an important outcome of care for hypothalamic-pituitary-adrenal (HPA) axis dysregulation. The objective of this study was to assess the influence of type of HPA axis dysregulation and cortisol status on HrQOL and its evolution with time and treatment. DESIGN Prospective cohort study. METHODS Between September 2007 and April 2014, HrQoL questionnaires were administered during routine management to all patients with HPA axis dysregulation hospitalized in a single department, and this was repeated after 6- 12-, 24- and 36-month during standard follow-up. The Medical Outcomes Study 36-item short-form health survey (SF-36) and the General Health Questionnaire 12 (GHQ-12) were used simultaneously, with a common time schedule to measure the impact of HPA axis dysregulation on HrQoL. Multivariate mixed linear regression models were constructed to adjust for potential confounders. RESULTS 343 patients (206 with Cushing's syndrome of pituitary origin, 91 with Cushing's syndrome of adrenal origin and 46 with Addison's disease) responded to the questionnaires. Overall, HrQoL scores were well below population values. Cushing syndrome of pituitary origin was associated with worse HrQoL, especially in physical dimensions. More than half of the patients, of all diagnoses and cortisol status, had psychological distress requiring attention according to the GHQ-12. Hypercortisolism had the greatest negative influence on HrQoL. CONCLUSIONS HRQoL appears significantly altered by all forms of HPA axis dysregulation, and most substantially and broadly by Cushing's syndrome, notably during periods of hypercortisolism. These effects on HRQoL deserve further consideration both in clinical practice and research.
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Affiliation(s)
- Charlotte De Bucy
- Center for Rare Adrenal DiseasesEndocrinology Department, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Laurence Guignat
- Center for Rare Adrenal DiseasesEndocrinology Department, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Tanya Niati
- Center for Rare Adrenal DiseasesEndocrinology Department, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jérôme Bertherat
- Center for Rare Adrenal DiseasesEndocrinology Department, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
- INSERM U1016Institut Cochin, Paris, France
- Université Paris DescartesSorbonne Paris Cité, Paris, France
| | - Joel Coste
- Université Paris DescartesSorbonne Paris Cité, Paris, France
- Biostatistics and Epidemiology UnitHôtel Dieu, AP-HP, Paris, France
- EA 4360 (APEMAC)Paris, France
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Nilsson AG, Bergthorsdottir R, Burman P, Dahlqvist P, Ekman B, Engström BE, Ragnarsson O, Skrtic S, Wahlberg J, Achenbach H, Uddin S, Marelli C, Johannsson G. Long-term safety of once-daily, dual-release hydrocortisone in patients with adrenal insufficiency: a phase 3b, open-label, extension study. Eur J Endocrinol 2017; 176:715-725. [PMID: 28292927 PMCID: PMC5425941 DOI: 10.1530/eje-17-0067] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/10/2017] [Accepted: 03/14/2017] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To investigate the long-term safety and tolerability of a once-daily, dual-release hydrocortisone (DR-HC) tablet as oral glucocorticoid replacement therapy in patients with primary adrenal insufficiency (AI). DESIGN Prospective, open-label, multicenter, 5-year extension study of DR-HC conducted at five university clinics in Sweden. METHODS Seventy-one adult patients diagnosed with primary AI who were receiving stable glucocorticoid replacement therapy were recruited. Safety and tolerability outcomes included adverse events (AEs), intercurrent illness episodes, laboratory parameters and vital signs. Quality of life (QoL) was evaluated using generic questionnaires. RESULTS Total DR-HC exposure was 328 patient-treatment years. Seventy patients reported 1060 AEs (323 per 100 patient-years); 85% were considered unrelated to DR-HC by the investigator. The most common AEs were nasopharyngitis (70%), fatigue (52%) and gastroenteritis (48%). Of 65 serious AEs reported by 32 patients (20 per 100 patient-years), four were considered to be possibly related to DR-HC: acute AI (n = 2), gastritis (n = 1) and syncope (n = 1). Two deaths were reported (fall from height and subarachnoid hemorrhage), both considered to be unrelated to DR-HC. From baseline to 5 years, intercurrent illness episodes remained relatively stable (mean 2.6-5.4 episodes per patient per year), fasting plasma glucose (0.7 mmol/L; P < 0.0001) and HDL cholesterol (0.2 mmol/L; P < 0.0001) increased and patient-/investigator-assessed tolerability improved. QoL total scores were unchanged but worsening physical functioning was recorded (P = 0.008). CONCLUSIONS In the first prospective study evaluating the long-term safety of glucocorticoid replacement therapy in patients with primary AI, DR-HC was well tolerated with no safety concerns observed during 5-year treatment.
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Affiliation(s)
- Anna G Nilsson
- Department of EndocrinologySahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ragnhildur Bergthorsdottir
- Department of EndocrinologySahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pia Burman
- Department of EndocrinologySkåne University Hospital Malmö, University of Lund, Lund, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical MedicineUmeå University, Umeå, Sweden
| | - Bertil Ekman
- Departments of Endocrinology and Medical and Health SciencesLinköping University, Linköping, Sweden
| | - Britt Edén Engström
- Department of Medical SciencesEndocrinology and Metabolism, University Hospital, Uppsala, Sweden
| | - Oskar Ragnarsson
- Department of EndocrinologySahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stanko Skrtic
- Department of EndocrinologySahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- AstraZeneca R&DMölndal, Sweden
| | - Jeanette Wahlberg
- Departments of Endocrinology and Medical and Health SciencesLinköping University, Linköping, Sweden
| | | | | | | | - Gudmundur Johannsson
- Department of EndocrinologySahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Correspondence should be addressed to G Johannsson;
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Gan EH, Pearce SH. MANAGEMENT OF ENDOCRINE DISEASE: Regenerative therapies in autoimmune Addison's disease. Eur J Endocrinol 2017; 176:R123-R135. [PMID: 27810905 DOI: 10.1530/eje-16-0581] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 09/19/2016] [Accepted: 11/03/2016] [Indexed: 12/15/2022]
Abstract
The treatment for autoimmune Addison's disease (AAD) has remained virtually unchanged in the last 60 years. Most patients have symptoms that are relatively well controlled with exogenous steroid replacement, but there may be persistent symptoms, recurrent adrenal crisis and poor quality of life, despite good compliance with optimal current treatments. Treatment with conventional exogenous steroid therapy is also associated with premature mortality, increased cardiovascular risk and complications related to excessive steroid replacement. Hence, novel therapeutic approaches have emerged in the last decade attempting to improve the long-term outcome and quality of life of patients with AAD. This review discusses the recent developments in treatment innovations for AAD, including the novel exogenous steroid formulations with the intention of mimicking the physiological biorhythm of cortisol secretion. Our group has also carried out a few studies attempting to restore endogenous glucocorticoid production via immunomodulatory and regenerative medicine approaches. The recent advances in the understanding of adrenocortical stem cell biology, and adrenal plasticity will also be discussed to help comprehend the science behind the therapeutic approaches adopted.
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Affiliation(s)
- Earn H Gan
- Institute of Genetic MedicineInternational Centre for Life, Centre Parkway, Newcastle upon Tyne, UK
| | - Simon H Pearce
- Institute of Genetic MedicineInternational Centre for Life, Centre Parkway, Newcastle upon Tyne, UK
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47
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Nella AA, Mallappa A, Perritt AF, Gounden V, Kumar P, Sinaii N, Daley LA, Ling A, Liu CY, Soldin SJ, Merke DP. A Phase 2 Study of Continuous Subcutaneous Hydrocortisone Infusion in Adults With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2016; 101:4690-4698. [PMID: 27680873 PMCID: PMC5155681 DOI: 10.1210/jc.2016-1916] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Classic congenital adrenal hyperplasia (CAH) management remains challenging, given that supraphysiologic glucocorticoid doses are often needed to optimally suppress the ACTH-driven adrenal androgen overproduction. OBJECTIVE This study sought to approximate physiologic cortisol secretion via continuous subcutaneous hydrocortisone infusion (CSHI) and evaluate the safety and efficacy of CSHI in patients with difficult-to-treat CAH. DESIGN Eight adult patients with classic CAH participated in a single-center open-label phase I-II study comparing CSHI to conventional oral glucocorticoid treatment. All patients had elevated adrenal steroids and one or more comorbidities at study entry. Assessment while receiving conventional therapy at baseline and 6 months following CSHI included: 24-hour hormonal sampling, metabolic and radiologic evaluation, health-related quality-of-life (HRQoL), and fatigue questionnaires. MAIN OUTCOME MEASURES The ability of CSHI to approximate physiologic cortisol secretion and the percent of patients with 0700-hour 17-hydroxyprogesterone (17-OHP) ≤1200 ng/dL was measured. RESULTS CSHI approximated physiologic cortisol secretion. Compared with baseline, 6 months of CSHI resulted in decreased 0700-hour and 24-hour area under the curve 17-OHP, androstenedione, ACTH, and progesterone, increased osteocalcin, c-telopeptide and lean mass, and improved HRQoL (and SF-36 Vitality Score), and fatigue. One of three amenorrheic women resumed menses. One man had reduction of testicular adrenal rest tissue. CONCLUSIONS CSHI is a safe and well-tolerated modality of cortisol replacement that effectively approximates physiologic cortisol secretion in patients with classic CAH poorly controlled on conventional therapy. Improved adrenal steroid control and positive effects on HRQoL suggest that CSHI should be considered a treatment option for classic CAH. The long-term effect on established comorbidities requires further study.
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Affiliation(s)
- Aikaterini A Nella
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Ashwini Mallappa
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Ashley F Perritt
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Verena Gounden
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Parag Kumar
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Ninet Sinaii
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Lori-Ann Daley
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Alexander Ling
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Chia-Ying Liu
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Steven J Soldin
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
| | - Deborah P Merke
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (A.A.N. D.P.M.), National Institutes of Health, Bethesda, Maryland 20892; and National Institutes of Health Clinical Center (A.A.N., A.M., A.F.P., V.G., P.K., N.S., L.-A.D., A.L., C.-Y.L., S.J.S., D.P.M.), Bethesda, Maryland 20892
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Andela CD, Staufenbiel SM, Joustra SD, Pereira AM, van Rossum EFC, Biermasz NR. Quality of life in patients with adrenal insufficiency correlates stronger with hydrocortisone dosage, than with long-term systemic cortisol levels. Psychoneuroendocrinology 2016; 72:80-6. [PMID: 27388687 DOI: 10.1016/j.psyneuen.2016.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 06/07/2016] [Accepted: 06/20/2016] [Indexed: 01/03/2023]
Abstract
In patients with adrenal insufficiency (AI) a higher hydrocortisone intake has been associated with more impairment in quality of life (QoL). Irrespective of age, sex and severity of AI the dosage of hydrocortisone is titrated around 20mg/D in all patients with AI based on physical and mental signs and symptoms. However, until now it is unknown whether these QoL impairments are related to increased systemic cortisol exposure. Measurement of hair cortisol levels (CORThair) can be used to assess chronic systemic cortisol exposure. This study aimed to explore whether QoL in patients with AI is associated with CORThair and daily hydrocortisone intake. We performed a cross-sectional study in 120 patients with AI on stable hydrocortisone replacement, in whom hair samples and QoL data were collected. CORThair were measured with ELISA, and QoL was assessed with validated questionnaires (SF-36, EQ-5D, HADS, MFI-20). Patients reported impairments in 14 of 15 QoL subscales (p<0.001). More impairments in physical aspects of QoL correlated with higher CORThair and higher daily hydrocortisone intake (p<0.05), an effect that was more pronounced in female patients. Regression analyses including both CORThair and hydrocortisone intake revealed a significant negative contribution of higher hydrocortisone intake on physical aspects of QoL (p≤0.046), whereas no significant contribution was found for CORThair. The present study showed that patients with AI report several impairments in QoL which are associated with hydrocortisone intake, and to a lesser extent reflected by chronic systemic cortisol exposure as measured by hair cortisol. This suggests that QoL impairments in patients with AI are not per se the effect of prolonged exposure to elevated systemic cortisol levels.
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Affiliation(s)
- Cornelie D Andela
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands.
| | - Sabine M Staufenbiel
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sjoerd D Joustra
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Alberto M Pereira
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Elisabeth F C van Rossum
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nienke R Biermasz
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
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49
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Bensing S, Hulting AL, Husebye ES, Kämpe O, Løvås K. MANAGEMENT OF ENDOCRINE DISEASE: Epidemiology, quality of life and complications of primary adrenal insufficiency: a review. Eur J Endocrinol 2016; 175:R107-16. [PMID: 27068688 DOI: 10.1530/eje-15-1242] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/06/2016] [Indexed: 12/13/2022]
Abstract
In this article, we review published studies covering epidemiology, natural course and mortality in primary adrenal insufficiency (PAI) or Addison's disease. Autoimmune PAI is a rare disease with a prevalence of 100-220 per million inhabitants. It occurs as part of an autoimmune polyendocrine syndrome in more than half of the cases. The patients experience impaired quality of life, reduced parity and increased risk of preterm delivery. Following a conventional glucocorticoid replacement regimen leads to a reduction in bone mineral density and an increase in the prevalence of fractures. Registry studies indicate increased mortality, especially evident in patients diagnosed with PAI at a young age and in patients with the rare disease autoimmune polyendocrine syndrome type-1. Most notably, unnecessary deaths still occur because of adrenal crises. All these data imply the need to improve the therapy and care of patients with PAI.
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Affiliation(s)
- Sophie Bensing
- Department of Molecular Medicine and SurgeryKarolinska Institutet, and Department of Endocrinology, Diabetes and Metabolism, Karolinska University Hospital, Stockholm, Sweden
| | - Anna-Lena Hulting
- Department of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - Eystein S Husebye
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway Department of MedicineHaukeland University Hospital, Bergen, Norway
| | - Olle Kämpe
- Department of Medicine (Solna)Centre for Molecular Medicine, Karolinska Institutet, and Department of Endocrinology, Diabetes and Metabolism, Karolinska University Hospital, Stockholm, Sweden
| | - Kristian Løvås
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway Department of MedicineHaukeland University Hospital, Bergen, Norway
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50
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Schulz J, Frey KR, Cooper MS, Zopf K, Ventz M, Diederich S, Quinkler M. Reduction in daily hydrocortisone dose improves bone health in primary adrenal insufficiency. Eur J Endocrinol 2016; 174:531-8. [PMID: 26811406 DOI: 10.1530/eje-15-1096] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 01/25/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Individuals with primary adrenal insufficiency (PAI) or congenital adrenal hyperplasia (CAH) receive life-long glucocorticoid (GC) replacement therapy. Current daily GC doses are still higher than the reported adrenal cortisol production rate. This GC excess could result in long-term morbidities such as osteoporosis. No prospective trials have investigated the long-term effect of GC dose changes in PAI and CAH patients. METHODS This is a prospective and longitudinal study including 57 subjects with PAI (42 women) and 33 with CAH (21 women). Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry at baseline and after 2 years. Subjects were divided into three groups (similar baseline characteristics) depending on changes in daily hydrocortisone equivalent dose (group 1: unchanged 25.2±8.2 mg (mean±S.D., n=50); group 2: increased 18.7±10.3 to 25.9±12.0 mg (n=13); group 3: decreased 30.8±8.5 to 21.4±7.2 mg (n=27)). RESULTS Subjects in group 1 showed normal lumbar and femoral Z-scores which were unchanged over time. Group 2 subjects showed a significant decrease in femoral neck Z-scores over time (-0.15±1.1 to -0.37±1.0 (P<0.05)), whereas group 3 subjects showed a significant increase in lumbar spine and hip Z-scores (L1-L4: -0.93±1.2 to -0.65±1.5 (P<0.05); total hip: -0.40±1.0 to -0.28±1.0 (P<0.05)). No changes in BMI over time were seen within any group. Reduction in GC dose did not increase the risk of adrenal crisis. CONCLUSION This study demonstrates for the first time that cautious reduction in hydrocortisone equivalent doses leads to increases in BMD, whereas dose increments reduced BMD. These data emphasize the need for the lowest possible GC replacement dose in AI patients to maintain health and avoid long-term adverse effects.
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Affiliation(s)
- Julia Schulz
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Kathrin R Frey
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Mark S Cooper
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Kathrin Zopf
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Manfred Ventz
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Sven Diederich
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Marcus Quinkler
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
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