1
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Akirov A, Rudman Y, Fleseriu M. Hypopituitarism and bone disease: pathophysiology, diagnosis and treatment outcomes. Pituitary 2024:10.1007/s11102-024-01391-2. [PMID: 38709467 DOI: 10.1007/s11102-024-01391-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2024] [Indexed: 05/07/2024]
Abstract
Hypopituitarism is a rare but significant endocrine disorder characterized by the inadequate secretion of one or more pituitary hormones. The intricate relationship between hypopituitarism and bone health is a topic of growing interest in the medical community. In this review the authors explore associations between hypopituitarism and bone health, with specific examination of the impact of growth hormone deficiency, central hypogonadism, central hypocortisolism, and central hypothyroidism. Pathogenesis, diagnosis, and treatment options as well as challenges posed by osteopenia, osteoporosis, and fractures in hypopituitarism are discussed.
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Affiliation(s)
- Amit Akirov
- Institute of Endocrinology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yaron Rudman
- Institute of Endocrinology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Maria Fleseriu
- Pituitary Center, Departments of Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
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2
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Furman K, Gut P, Sowińska A, Ruchała M, Fichna M. Predictors of bone mineral density in patients receiving glucocorticoid replacement for Addison's disease. Endocrine 2024; 84:711-719. [PMID: 38334892 DOI: 10.1007/s12020-024-03709-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/18/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE Patients receiving long-term glucocorticoid (GC) treatment are at risk of osteoporosis, while bone effects of substitution doses in Addison's disease (AD) remain equivocal. The project was aimed to evaluate serum bone turnover markers (BTMs): osteocalcin, type I procollagen N-terminal propeptide (PINP), collagen C-terminal telopeptide (CTX), sclerostin, DKK-1 protein, and alkaline phosphatase (ALP) in relation to bone mineral density (BMD) during GC replacement. METHODS Serum BTMs and hormones were assessed in 80 patients with AD (22 males, 25 pre- and 33 postmenopausal females) on hydrocortisone (HC) substitution for ≥3 years. Densitometry with dual-energy X-ray absorptiometry covered the lumbar spine (LS) and femoral neck (FN). RESULTS Among BTMs, only PINP levels were altered in AD. BMD Z-scores remained negative except for FN in males. Considering T-scores, osteopenia was found in LS in 45.5% males, 24% young and 42.4% postmenopausal females, while osteoporosis in 9.0%, 4.0% and 21.1%, respectively. Lumbar BMD correlated positively with body mass (p = 0.0001) and serum DHEA-S (p = 9.899 × 10-6). Negative correlation was detected with HC dose/day/kg (p = 0.0320), cumulative HC dose (p = 0.0030), patient's age (p = 1.038 × 10-5), disease duration (p = 0.0004), ALP activity (p = 0.0041) and CTX level (p = 0.0105). However, only age, body mass, ALP, serum CTX, and sclerostin remained independent predictors of LS BMD. CONCLUSION Standard HC substitution does not considerably accelerate BMD loss in AD patients and their serum BTMs: CTX, osteocalcin, sclerostin, DKK-1, and ALP activity remain within the reference ranges. Independent predictors of low lumbar spine BMD, especially ALP activity, serum CTX and sclerostin, might be monitored during GC substitution.
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Affiliation(s)
- Katarzyna Furman
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
- Ludwik Perzyna Regional Hospital, Kalisz, Poland
| | - Paweł Gut
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Anna Sowińska
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznan, Poland
| | - Marek Ruchała
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Marta Fichna
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland.
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3
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Akkurt Kocaeli A, Erturk E. Bone Mineral Density and Vitamin D Status in Patients with Autoimmune Polyglandular Syndromes: A Single Tertiary Care Center Experience. Horm Metab Res 2024; 56:128-133. [PMID: 37931915 DOI: 10.1055/a-2205-2100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Immunological abnormalities, the resulting endocrinopathies, and their treatments may impact bone health and 25-hydroxyvitamin D (25-OHD) in patients with autoimmune polyglandular syndromes (APS). Several etiologies contribute to increased risk for low bone mineral density (BMD), including vitamin D deficiency. This study evaluated the vitamin D level and BMD of patients with APS. We performed a cross-sectional study on 44 patients with APS and 55 age and gender-matched control subjects. Among patients with APS, 14 were classified as APS-2 [Addison's disease (AD)+autoimmune thyroid disease (ATD) and/or type 1 diabetes(T1D)]. In contrast, the other 30 were APS-3 (ATD+T1D+other autoimmune diseases). Serum samples were analyzed for vitamin D levels. The lumbar spine and femoral neck BMD were measured by dual X-ray absorptiometry. Z-scores were obtained by comparison with age- and gender-matched average values (both patients and controls). The accepted normal levels were Z-score>-1 and 25-OHD>30 ng/ml. Patients with APS showed 25-OHD levels and BMD significantly lower than healthy controls (p<0.001 and p<0.05, respectively). The highest prevalence of abnormal BMD was observed in the APS-2 subgroup (13 out of 14 patients, 92.6%). Identifying and treating vitamin D deficiency and low BMD is critical in APS patients. The fact that the significant endocrine component of APS-2 is AD, and these patients receive chronic long-term glucocorticoid therapy can be shown as the reason for this result. However, more extensive prospective controlled studies are needed to confirm these findings.
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Affiliation(s)
| | - Erdınc Erturk
- Endocrinology, Uludag University Faculty of Medicine, Bursa, Turkey
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4
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Hasenmajer V, Ferrari D, De Alcubierre D, Sada V, Puliani G, Bonaventura I, Minnetti M, Tomaselli A, Pofi R, Sbardella E, Cozzolino A, Gianfrilli D, Isidori AM. Effects of Dual-Release Hydrocortisone on Bone Metabolism in Primary and Secondary Adrenal Insufficiency: A 6-Year Study. J Endocr Soc 2023; 8:bvad151. [PMID: 38090230 PMCID: PMC10714896 DOI: 10.1210/jendso/bvad151] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Indexed: 01/06/2024] Open
Abstract
Context Patients with primary (PAI) and secondary adrenal insufficiency (SAI) experience bone metabolism alterations, possibly due to excessive replacement. Dual-release hydrocortisone (DR-HC) has shown promising effects on several parameters, but bone metabolism has seldom been investigated. Objective We evaluated the long-term effects of once-daily DR-HC on bone in PAI and SAI. Methods Patients on immediate-release glucocorticoid therapy were evaluated before and up to 6 years (range, 4-6) after switching to equivalent doses of DR-HC, yielding data on bone turnover markers, femoral and lumbar spine bone mineral density (BMD), and trabecular bone score (TBS). Results Thirty-two patients (19 PAI, 18 female), median age 52 years (39.4-60.7), were included. At baseline, osteopenia was observed in 38% of patients and osteoporosis in 9%, while TBS was at least partially degraded in 41.4%. Higher body surface area-adjusted glucocorticoid doses predicted worse neck (P < .001) and total hip BMD (P < .001). Longitudinal analysis showed no significant change in BMD. TBS showed a trend toward decrease (P = .090). Bone markers were stable, albeit osteocalcin levels significantly varied. PAI and SAI subgroups behaved similarly, as did patients switching from hydrocortisone or cortisone acetate. Compared with men, women exhibited worse decline in TBS (P = .017) and a similar trend for neck BMD (P = .053). Conclusion After 6 years of chronic DR-HC replacement, BMD and bone markers remained stable. TBS decline is more likely due to an age-related derangement of bone microarchitecture rather than a glucocorticoid effect. Our data confirm the safety of DR-HC replacement on bone health in both PAI and SAI patients.
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Affiliation(s)
- Valeria Hasenmajer
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome 00161, Italy
| | - Davide Ferrari
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome 00161, Italy
| | - Dario De Alcubierre
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome 00161, Italy
- Inserm U1052, CNRS UMR5286, Claude Bernard Lyon 1 University, Cancer Research Center of Lyon, Lyon 69373 CEDEX 08, France
| | - Valentina Sada
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome 00161, Italy
| | - Giulia Puliani
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome 00128, Italy
| | - Ilaria Bonaventura
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome 00161, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome 00161, Italy
| | - Alessandra Tomaselli
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome 00161, Italy
| | - Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Emilia Sbardella
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome 00161, Italy
| | - Alessia Cozzolino
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome 00161, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome 00161, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, “Sapienza” University of Rome, Rome 00161, Italy
- Centre for Rare Diseases (Endo-ERN accredited), Policlinico Umberto I, Rome 00161, Italy
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Pofi R, Caratti G, Ray DW, Tomlinson JW. Treating the Side Effects of Exogenous Glucocorticoids; Can We Separate the Good From the Bad? Endocr Rev 2023; 44:975-1011. [PMID: 37253115 PMCID: PMC10638606 DOI: 10.1210/endrev/bnad016] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/25/2023] [Accepted: 05/26/2023] [Indexed: 06/01/2023]
Abstract
It is estimated that 2% to 3% of the population are currently prescribed systemic or topical glucocorticoid treatment. The potent anti-inflammatory action of glucocorticoids to deliver therapeutic benefit is not in doubt. However, the side effects associated with their use, including central weight gain, hypertension, insulin resistance, type 2 diabetes (T2D), and osteoporosis, often collectively termed iatrogenic Cushing's syndrome, are associated with a significant health and economic burden. The precise cellular mechanisms underpinning the differential action of glucocorticoids to drive the desirable and undesirable effects are still not completely understood. Faced with the unmet clinical need to limit glucocorticoid-induced adverse effects alongside ensuring the preservation of anti-inflammatory actions, several strategies have been pursued. The coprescription of existing licensed drugs to treat incident adverse effects can be effective, but data examining the prevention of adverse effects are limited. Novel selective glucocorticoid receptor agonists and selective glucocorticoid receptor modulators have been designed that aim to specifically and selectively activate anti-inflammatory responses based upon their interaction with the glucocorticoid receptor. Several of these compounds are currently in clinical trials to evaluate their efficacy. More recently, strategies exploiting tissue-specific glucocorticoid metabolism through the isoforms of 11β-hydroxysteroid dehydrogenase has shown early potential, although data from clinical trials are limited. The aim of any treatment is to maximize benefit while minimizing risk, and within this review we define the adverse effect profile associated with glucocorticoid use and evaluate current and developing strategies that aim to limit side effects but preserve desirable therapeutic efficacy.
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Affiliation(s)
- Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Giorgio Caratti
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - David W Ray
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Oxford Kavli Centre for Nanoscience Discovery, University of Oxford, Oxford OX37LE, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
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Wiromrat P, Namphaisan P, Wongsurawat N, Panamonta O, Nasomyont N. Elevated bone turnover markers predict bone mineral density accrual in adolescents with 21-hydroxylase deficiency. Clin Endocrinol (Oxf) 2023; 99:462-469. [PMID: 35941818 DOI: 10.1111/cen.14809] [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: 05/29/2022] [Revised: 07/25/2022] [Accepted: 08/02/2022] [Indexed: 11/29/2022]
Abstract
CONTEXT Prognostic biomarkers for monitoring bone health in adolescents with 21-hydroxylase deficiency (21OHD) are needed. OBJECTIVES To assess associations between concentrations of baseline bone turnover markers (BTMs) including osteocalcin (OC) and type-I collagen C-terminal telopeptide (CTX) and changes in lumbar spine bone mineral density (LSBMD) in adolescents with classic 21OHD. DESIGNS AND PATIENTS A retrospective-prospective study of 33 adolescents with classic 21OHD who had baseline data for LSBMD, bone age (BA), and BTM concentrations. METHODS BTM concentrations were converted into z-scores according to BA. We measured LSBMD at the follow-up study visit and calculated the annual percentage change in LSBMD (%∆LSBMD). RESULTS At baseline, participants (55% female, 79% Tanner 5) had mean (±SD) age of 14.6 ± 3.6 years, BA 16.7 ± 2.9 years, and average glucocorticoid (GC) dose 17.3 ± 5.6 mg/m2 /day of hydrocortisone equivalent. The mean follow-up duration was 14.4 ± 5.6 months. Median (Q1-Q3) %∆LSBMD was 3.6% (0-8.5)/year. %∆LSBMD was similar among genders or 21OHD subtypes. Prednisolone versus hydrocortisone replacement resulted in lower %∆LSBMD (p = .004). %∆LSBMD was increased across tertiles of CTX z-score (p = .014). %∆LSBMD correlated negatively with GC dose (p = .01) and positively with CTX and OC z-scores (p < .01). In regression analyses, only CTX z-score positively associated with %∆LSBMD (p = .003), adjusting for sex, BA, body mass index, testosterone, 25-hydroxyvitamin D, and GC type and dose. CONCLUSIONS Higher GC dose and the use of prednisolone were associated with decreased LSBMD accrual in adolescents with 21OHD. CTX z-score independently associated with LSBMD accrual, suggesting its potential for prognostic bone biomarker.
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Affiliation(s)
- Pattara Wiromrat
- Section of Endocrinology, Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Phanpaphorn Namphaisan
- Section of Endocrinology, Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Nantaporn Wongsurawat
- Section of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Ouyporn Panamonta
- Section of Endocrinology, Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Nat Nasomyont
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Laakso S, Xiaoyu T, Blouin S, Keplinger P, Välimäki VV, Kröger H, Mäkitie O, Hartmann MA. Bone Tissue Evaluation Indicates Abnormal Mineralization in Patients with Autoimmune Polyendocrine Syndrome Type I: Report on Three Cases. Calcif Tissue Int 2023; 112:675-682. [PMID: 36944707 DOI: 10.1007/s00223-023-01077-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/02/2023] [Indexed: 03/23/2023]
Abstract
Autoimmune polyendocrine syndrome type-1 (APS1) is characterized by autoimmune manifestations affecting different organs from early childhood on. Immunological abnormalities, the resulting endocrinopathies, and their treatments may compromise bone health. For the first time in APS1, we analyzed transiliac bone biopsy samples by bone histomorphometry and quantitative backscattered electron imaging in three adult patients (female P1, 38 years; male P2, 47 years; male P3, 25 years). All had biallelic mutations in the autoimmune regulator gene and in addition to endocrinopathies, also significant bone fragility. Histomorphometry showed bone volume in the lower normal range for P1 (BV/TV, - 0.98 SD) and P3 (- 1.34 SD), mainly due to reduced trabecular thickness (TbTh, - 3.63 and - 2.87 SD). In P1, osteoid surface was low (OS/BS, - 0.96 SD); active osteoblasts and double labeling were seen only on cortical bone. P3 showed a largely increased bone turnover rate (BFR/BV, + 4.53 SD) and increased mineralization lag time (Mlt, + 3.40 SD). Increased osteoid surface (OS/BS, + 2.03 and + 4.71 SD for P2 and P3) together with a large proportion of lowly mineralized bone area (Trab CaLow, + 2.22 and + 9.81 SD for P2 and P3) and focal mineralization defects were consistent with abnormal mineralization. In all patients, the density and area of osteocyte lacunae in cortical and trabecular bone were similar to healthy adults. The bone tissue characteristics were variable and included decreased trabecular thickness, increased amount of osteoid, and abnormal mineralization which are likely to contribute to bone fragility in patients with APS1.
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Affiliation(s)
- Saila Laakso
- Children's Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, Helsinki, Finland.
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
- Folkhälsan Research Center, Helsinki, Finland.
| | - Tong Xiaoyu
- Department of Orthopedics, Kuopio Musculoskeletal Research Unit, University of Eastern Finland, and, Kuopio University Hospital, Kuopio, Finland
| | - Stéphane Blouin
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department Hanusch Hospital, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Petra Keplinger
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department Hanusch Hospital, Vienna, Austria
| | - Ville-Valtteri Välimäki
- Department of Orthopedics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Heikki Kröger
- Department of Orthopedics, Kuopio Musculoskeletal Research Unit, University of Eastern Finland, and, Kuopio University Hospital, Kuopio, Finland
| | - Outi Mäkitie
- Children's Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Markus A Hartmann
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department Hanusch Hospital, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
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8
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Auer MK, Nordenström A, Lajic S, Reisch N. Congenital adrenal hyperplasia. Lancet 2023; 401:227-244. [PMID: 36502822 DOI: 10.1016/s0140-6736(22)01330-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 05/17/2022] [Accepted: 06/13/2022] [Indexed: 12/13/2022]
Abstract
Congenital adrenal hyperplasia is a group of autosomal recessive disorders leading to multiple complex hormonal imbalances caused by various enzyme deficiencies in the adrenal steroidogenic pathway. The most common type of congenital adrenal hyperplasia is due to steroid 21-hydroxylase (21-OHase, henceforth 21OH) deficiency. The rare, classic (severe) form caused by 21OH deficiency is characterised by life-threatening adrenal crises and is the most common cause of atypical genitalia in neonates with 46,XX karyotype. After the introduction of life-saving hormone replacement therapy in the 1950s and neonatal screening programmes in many countries, nowadays neonatal survival rates in patients with congenital adrenal hyperplasia are high. However, disease-related mortality is increased and therapeutic management remains challenging, with multiple long-term complications related to treatment and disease affecting growth and development, metabolic and cardiovascular health, and fertility. Non-classic (mild) forms of congenital adrenal hyperplasia caused by 21OH deficiency are more common than the classic ones; they are detected clinically and primarily identified in female patients with hirsutism or impaired fertility. Novel treatment approaches are emerging with the aim of mimicking physiological circadian cortisol rhythm or to reduce adrenal hyperandrogenism independent of the suppressive effect of glucocorticoids.
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Affiliation(s)
- Matthias K Auer
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany.
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Guarnotta V, Di Stefano C, Giordano C. Long-term outcomes of conventional and novel steroid replacement therapy on bone health in primary adrenal insufficiency. Sci Rep 2022; 12:13280. [PMID: 35918399 PMCID: PMC9345970 DOI: 10.1038/s41598-022-13506-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/25/2022] [Indexed: 11/21/2022] Open
Abstract
Steroids affect bone health causing osteoporosis and fractures. The study aims to compare dual-release hydrocortisone (DR-HC) and conventional steroids on bone metabolism in patients with primary adrenal insufficiency (PAI). Thirty-five patients with PAI on conventional steroids (group A) and 35 patients switched to DR-HC (group B), consecutively referred at our hospital, were evaluated at baseline and after 18, 36 and 60 months of treatment. After 60 months of follow-up, patients in group A had a significant increase in body mass index (p = 0.004) and waist circumference (WC) (p = 0.026) and a significant decrease in osteocalcin (p = 0.002), bone alkaline phosphatase (p = 0.029), lumbar spine bone mass density (BMD) T and Z scores (p < 0.001 and p = 0.001, respectively) and vertebral fractures rate (p = 0.021) than baseline. By contrast, patients in group B had a significant decrease in WC (p = 0.047) and increase in bone alkaline phosphatase (p = 0.019), lumbar spine BMD T score (p = 0.032), femoral neck BMD T and Z scores (p = 0.023 and p = 0.036, respectively) than baseline. Long-term conventional steroid replacement therapy is associated with a decrease in BMD, notably at lumbar spine, and increase in vertebral fractures rate. By contrast, DR-HC treatment is associated with improvement of BMD.
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Affiliation(s)
- Valentina Guarnotta
- Dipartimento di Promozione della Salute, Materno - infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, piazza delle cliniche 2, 90127, Palermo, Italy
| | - Claudia Di Stefano
- Dipartimento di Promozione della Salute, Materno - infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, piazza delle cliniche 2, 90127, Palermo, Italy
| | - Carla Giordano
- Dipartimento di Promozione della Salute, Materno - infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, piazza delle cliniche 2, 90127, Palermo, Italy.
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10
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Impact of hydrocortisone replacement on bone mineral density and bone turnover markers in patients with primary adrenal insufficiency. Endocr Regul 2022; 56:209-215. [DOI: 10.2478/enr-2022-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objective. The study was aimed to assess the effect of hydrocortisone (HC) replacement therapy on bone mineral density (BMD) and bone turnover markers in patients with primary adrenal insufficiency (PAI).
Methods. A cross-sectional study was conducted in 37 PAI patients treated with HC. BMD and selected bone turnover markers (β-crosslaps and osteocalcin) were measured. A stepwise binary logistic regression model was applied to determine the independent variables associated with low BMD.
Results. Osteoporosis was noted in 14.3% and osteopenia in 34.3% of cases. These patients were older (p=0.01) and received higher daily HC dose compared to patients with normal BMD (p=0.01). BMD values in the lumbar spine and the femoral neck were negatively correlated with daily HC dose (r=–0.36, p=0.03 and r=–0.34, p=0.05, respectively). Plasma osteocalcin was negatively correlated with disease duration (r=–0.38, p=0.02) and cumulative HC dose (r=–0.43, p<0.01). In multivariate analysis, a daily HC dose ≥12 mg/m2/day was independently associated with a higher risk of osteopenia/osteoporosis [OR (95% CI), 9.0 (1.1–74.6); p=0.04].
Conclusions. Impaired bone mineralization in patients with PAI is correlated with HC dose. A daily HC dose ≥12 mg/m2/day was associated with an increased risk of osteopenia and osteoporosis in these patients.
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Bennett G, Cussen L, O'Reilly MW. The role for long-term use of dehydroepiandrosterone in adrenal insufficiency. Curr Opin Endocrinol Diabetes Obes 2022; 29:284-293. [PMID: 35621180 DOI: 10.1097/med.0000000000000728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Dehydroepiandrosterone (DHEA) is an androgen produced by the zona reticularis of the adrenal gland. Patients with adrenal insufficiency will have a deficiency of DHEA. Unlike glucocorticoid and mineralocorticoid replacement, DHEA supplementation is not considered essential for life and is therefore not routinely replaced in adrenal failure. DHEA deficiency is associated with morbidity, including adverse impacts on metabolic function, quality of life and sexuality in multiple studies. The role for replacement, however, remains unclear. RECENT FINDINGS The benefits of DHEA supplementation have been definitively demonstrated in a number of historical studies of patients with primary and secondary adrenal insufficiency. Beneficial impacts on quality of life, body composition, bone health and metabolic markers have been demonstrated. However, published data are inconsistent; controversies persist around the exact role of DHEA replacement and around which patient cohorts are most likely to benefit. There is also a paucity of recent randomized controlled trials in the medical literature to inform on optimal dose and duration of DHEA replacement in adrenal failure. SUMMARY Here, we review the evidence for DHEA supplementation in patients with adrenal insufficiency. We highlight knowledge gaps in the medical literature and areas that should be prioritized for future research endeavours.
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Affiliation(s)
| | - Leanne Cussen
- Department of Endocrinology, Beaumont Hospital
- Department of Medicine, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Republic of Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Beaumont Hospital
- Department of Medicine, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Republic of Ireland
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12
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Herath M, Langdahl B, Ebeling PR, Milat F. Challenges in the diagnosis and management of glucocorticoid-induced osteoporosis in younger and older adults. Clin Endocrinol (Oxf) 2022; 96:460-474. [PMID: 34811782 DOI: 10.1111/cen.14637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/16/2021] [Accepted: 10/26/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Glucocorticoids constitute a considerable risk for developing osteoporosis in both younger and older adults. However, currently available bone imaging modalities and fracture-risk assessment tools do not adequately capture the dramatic changes in bone microarchitecture, heterogeneity of glucocorticoid exposure, the impact of chronic disease and other osteoporosis risk factors on the assessment of osteoporosis in these individuals. DESIGN A narrative review is presented, following a systematic search of the literature from 2000 to 2021. RESULTS Our current appreciation of glucocorticoid-induced osteoporosis (GIO) is focused on older populations, with limited evidence to guide the investigation, risk assessment and treatment in premenopausal women and men less than 50 years. The impact of the underlying chronic disease on secondary osteoporosis in these younger adults is also poorly understood. CONCLUSION Through this narrative review, we provide a comprehensive overview of and recommendations for optimising the management of this common cause of secondary osteoporosis younger and older adults.
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Affiliation(s)
- Madhuni Herath
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Bente Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter R Ebeling
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Frances Milat
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
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13
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Lee DH, Kong SH, Jang HN, Ahn CH, Lim SG, Lee YA, Kim SW, Kim JH. Association of androgen excess and bone mineral density in women with classical congenital adrenal hyperplasia with 21-hydroxylase deficiency. Arch Osteoporos 2022; 17:45. [PMID: 35258698 DOI: 10.1007/s11657-022-01090-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/26/2022] [Indexed: 02/03/2023]
Abstract
The relationship between androgen excess and bone health in patients with congenital adrenal hyperplasia (CAH) with 21-hydroxylase (21-OH) deficiency is not fully understood. This study demonstrated positive correlations between androgen hormones and bone mineral density (BMD) in CAH women with 21-OH deficiency. PURPOSE This study aims to assess BMD and its association with androgen excess in women with CAH. METHODS We enrolled 92 women with CAH with 21-OH deficiency and retrospectively reviewed their clinical features, hormone concentrations, body composition, glucocorticoid (GC) dose, and BMD. RESULTS BMD was not different according to the subtypes of CAH. BMD at the lumbar spine was lower in women with CAH with regular menstruation than those with irregular menstruation (1.081 vs. 1.165 g/cm2, P < 0.05). BMD was lower in women with CAH with 17-hydroxyprogesterone (17-OHP) < 10 ng/mL than in those with ≥ 10 ng/mL (lumbar spine, 1.019 vs. 1.150 g/cm2; femur neck, 0.806 vs. 0.899 g/cm2; total hip, 0.795 vs. 0.943 g/cm2; all P < 0.05). After adjusting for age and BMI in correlation analyses, testosterone concentrations were positively correlated with lumbar spine, femur neck, and total hip BMD (r = 0.46, r = 0.38, and r = 0.35, respectively; all P < 0.05), while 17-OHP was positively correlated with lumbar spine BMD (r = 0.38, P < 0.01). In subgroup analysis, 17-OHP was positively correlated with BMD (lumbar spine, r = 0.22; femur neck, r = 0.22; total hip, r = 0.24; all P < 0.05) only in the group with a total cumulative dose of GC ≥ 156.0 g/m2. CONCLUSION Androgen excess may have a protective effect on BMD in women with classic CAH and high cumulative doses of GC.
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Affiliation(s)
- Dong Ho Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea
| | - Sung Hye Kong
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Han Na Jang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea
| | - Chang Ho Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Seung Gyun Lim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea.,Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea. .,Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea.
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14
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Mazziotti G, Vena W, Pedersini R, Piccini S, Morenghi E, Cosentini D, Zucali P, Torrisi R, Sporeni S, Simoncini EL, Maroldi R, Balzarini L, Lania AG, Berruti A. Prediction of vertebral fractures in cancer patients undergoing hormone deprivation therapies: reliability of who fracture risk assessment tool (frax) and bone mineral density in real-life clinical practice. J Bone Oncol 2022; 33:100421. [PMID: 35310388 PMCID: PMC8928084 DOI: 10.1016/j.jbo.2022.100421] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 03/04/2022] [Accepted: 03/05/2022] [Indexed: 12/12/2022] Open
Abstract
In females under estrogen-deprivation therapies, risk of vertebral fractures was associated with FRAX score for major fractures, with the best therapeutic threshold of 6.5%. In males under androgen-deprivation therapy, risk of vertebral fractures was high when BMD T-score was lower than −1.0 SD or when subjects were treated with abiraterone. High body mass index was an independent risk factor for vertebral fractures in males exposed to androgen-deprivation therapy. In the setting of hormonal deprivation therapies, FRAX and BMD thresholds were lower than those used in post-menopausal osteoporosis and primary male osteoporosis.
Background and Objective Prediction of fractures in cancer survivors exposed to hormone-deprivation therapies (HDTs) is a challenge since bone loss is rapid and severe, and determinants of fractures in this setting are still largely unknown. In this study we investigated reliability of the WHO Fracture Risk Assessment Tool (FRAX) and bone mineral density (BMD) to identify subjects developing vertebral fractures during HDTs. Design Five-hundred-twenty-seven consecutive subjects (429 females with breast cancer, 98 males with prostate cancer; median age 61 years), under HDTs for at least 6 months, were evaluated for vertebral fractures by a radiological and morphometric approach, in relationship with FRAX score, body mass index (BMI), BMD, age and duration of HDTs. Results Vertebral fractures were found in 140 subjects (26.6%) and spine deformity index was significantly associated with duration of HDTs (rho 0.38; p < 0.001). Only in females, vertebral fractures were significantly associated with FRAX score for major fractures [OR 1.08; P < 0.001]. The best cut-off of FRAX score for major fractures, as calculated by receiving operating characteristic (ROC) analysis was 6.35%. In males, however, vertebral fractures were significantly and independently associated with BMI ≥ 25 Kg/m2 (OR 17.63; P < 0.001), BMD T-score below −1.0 SD at any skeletal site (OR 7.79; P < 0.001) and gonadotropin-releasing hormone agonists (GnRHa) plus abiraterone treatment (OR 11.51; P = 0.001). Conclusions FRAX and BMD may be useful for predicting vertebral fractures in subjects undergoing HDTs, but the thresholds seem to be lower than those used in the general population. High BMI is a determinant of vertebral fractures in males under HDT.
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15
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Falhammar H, Frisén L, Hirschberg AL, Nordenskjöld A, Almqvist C, Nordenström A. Increased Prevalence of Fractures in Congenital Adrenal Hyperplasia: A Swedish Population-based National Cohort Study. J Clin Endocrinol Metab 2022; 107:e475-e486. [PMID: 34601607 PMCID: PMC8764334 DOI: 10.1210/clinem/dgab712] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Low bone mineral density has been reported in individuals with congenital adrenal hyperplasia (CAH), but the prevalence of fractures is unclear. OBJECTIVE To study the prevalence of fractures in CAH. DESIGN, SETTING, AND PARTICIPANTS Patients with CAH (n = 714, all 21-hydroxylase deficiency) were compared with controls matched for sex and year and place of birth (n = 71 400). Data were derived by linking National Population-Based Registers. MAIN OUTCOME MEASURES Number and type of fractures. RESULTS Mean age was 29.8 ± 18.4 years. Individuals with CAH had more fractures compared to controls [23.5% vs 16.1%, odds ratio (OR) 1.61, 95% CI 1.35-1.91], and this was found in both sexes (females: 19.6% vs 13.3%, OR 1.57, 95% CI 1.23-2.02; males: 28.7% vs 19.6%, OR 1.65, 95% CI 1.29-2.12). Fractures were significantly increased in patients born before the introduction of neonatal screening but not in those born afterwards. Any major fracture associated with osteoporosis (spine, forearm, hip, or shoulder) was increased in all individuals with CAH (9.8% vs 7.5%, OR 1.34, 95% CI 1.05-1.72). The highest prevalence of fractures was seen in SV phenotype and I172N genotype while nonclassic phenotype and I2 splice genotype did not show increased prevalence. A transport accident as a car occupant and fall on the same level were more common in patients with CAH, both sexes, than in controls. CONCLUSIONS Patients with CAH had an increased prevalence of both any fracture and fractures associated with osteoporosis (both sexes) but not for patients neonatally screened. We conclude that fracture risk assessment and glucocorticoid optimization should be performed regularly.
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MESH Headings
- Adolescent
- Adrenal Hyperplasia, Congenital/complications
- Adrenal Hyperplasia, Congenital/diagnosis
- Adrenal Hyperplasia, Congenital/genetics
- Adrenal Hyperplasia, Congenital/metabolism
- Adult
- Bone Density/genetics
- Case-Control Studies
- Child
- Child, Preschool
- Female
- Fractures, Bone/epidemiology
- Fractures, Bone/genetics
- Fractures, Bone/metabolism
- Fractures, Bone/prevention & control
- Humans
- Infant
- Infant, Newborn
- Male
- Middle Aged
- Neonatal Screening/organization & administration
- Neonatal Screening/standards
- Prevalence
- Registries/statistics & numerical data
- Steroid 21-Hydroxylase/genetics
- Steroid 21-Hydroxylase/metabolism
- Sweden/epidemiology
- Young Adult
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Correspondence: Henrik Falhammar, MD, PhD, FRACP, Department of Molecular Medicine and Surgery, QB8:05, Karolinska Institutet, SE-171 76 Stockholm, Sweden. E-mail:
| | - Louise Frisén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Child and Adolescent Psychiatry Research Center, Stockholm, Sweden
| | - Angelica Lindén Hirschberg
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Nordenskjöld
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Lung and Allergy Unit, Astrid Lindgren Children’s Hospital, Karolinska University Hospital
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Endocrinology, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
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16
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 154] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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17
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Borges JH, de Oliveira DM, de Lemos-Marini SHV, Geloneze B, Guerra-Júnior G, Gonçalves EM. Normal bone health in young adults with 21-hydroxylase enzyme deficiency undergoing glucocorticoid replacement therapy. Osteoporos Int 2022; 33:283-291. [PMID: 34406442 DOI: 10.1007/s00198-021-06097-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
UNLABELLED It is of great importance to investigate any potential detrimental effect on bone health in young adults with 21-hydroxylase enzyme deficiency undergoing glucocorticoid replacement therapy. This study demonstrated normal bone health in well-controlled patients. Additionally, glucocorticoid dose may play an important role in the mineral density of femoral neck region. PURPOSE To compare regional bone mineral densities (BMDs) and bone statuses of young adults with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase enzyme (21OHase) deficiency with a control group. The duration and dose of glucocorticoid therapy and relative skeletal muscle index (an indicator of sarcopenia) were also analyzed as parameters to predict bone health. METHODS This case-control study included 23 patients (7 male and 16 female) and 20 controls (8 male and 12 female) matched by age range (18 to 31 years). Dual energy X-ray absorptiometry and phalangeal quantitative ultrasound (QUS) were used to estimate BMD and bone status, respectively. RESULTS No difference was observed between patients and controls (of both sexes) in absolute values of BMD and Z-scores for the total body, lumbar spine, and femoral neck; or the bone status (estimated by phalangeal QUS). Multiple linear regression analysis demonstrated that relative skeletal muscle index independently correlated with BMD of the entire body (β: 0.67, P = 0.007), the lumbar spine (β: 0.73, P = 0.005), and the femoral neck (β: 0.67, P = 0.007). However, the dose of glucocorticoids (β: - 0.38, P = 0.028) independently correlated with BMD in the femoral neck region alone. CONCLUSION No signs of change in bone health were observed in patients with CAH when compared to the reference group. Additionally, a marker of sarcopenia was demonstrated to have a role in mineral density mechanisms in all analyzed bone sites. Only the femoral neck BMD seemed to be significantly dependent on glucocorticoid dose.
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Affiliation(s)
- Juliano Henrique Borges
- Laboratory of Growth and Development (LabCreD), Center for Investigation in Pediatrics (CIPED), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), 126 Tessália Vieira de Camargo Street, Cidade Universitária Zeferino Vaz, Campinas, SP, 13083-887, Brazil.
| | | | - Sofia Helena Valente de Lemos-Marini
- Laboratory of Growth and Development (LabCreD), Center for Investigation in Pediatrics (CIPED), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), 126 Tessália Vieira de Camargo Street, Cidade Universitária Zeferino Vaz, Campinas, SP, 13083-887, Brazil
| | - Bruno Geloneze
- Laboratory of Investigation in Metabolism and Diabetes (LIMED), FCM, UNICAMP, Campinas, SP, Brazil
| | - Gil Guerra-Júnior
- Laboratory of Growth and Development (LabCreD), Center for Investigation in Pediatrics (CIPED), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), 126 Tessália Vieira de Camargo Street, Cidade Universitária Zeferino Vaz, Campinas, SP, 13083-887, Brazil
| | - Ezequiel Moreira Gonçalves
- Laboratory of Growth and Development (LabCreD), Center for Investigation in Pediatrics (CIPED), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), 126 Tessália Vieira de Camargo Street, Cidade Universitária Zeferino Vaz, Campinas, SP, 13083-887, Brazil
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18
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Li L, Bensing S, Falhammar H. Rate of fracture in patients with glucocorticoid replacement therapy: a systematic review and meta-analysis. Endocrine 2021; 74:29-37. [PMID: 33846948 DOI: 10.1007/s12020-021-02723-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The association between glucocorticoid replacement therapy for adrenal insufficiency (AI) and osteoporosis is unclear. Fracture is a major cause of morbidity in patients with osteoporosis. This study aims to determine if patients on glucocorticoid replacement therapy for AI have an increased rate of fractures compared to the general population. METHODS We included all studies with adult patients receiving glucocorticoid replacement therapy for either congenital adrenal hyperplasia (CAH), primary adrenal insufficiency (PAI), or secondary adrenal insufficiency (SAI). Studies without fracture data were excluded, as well as meeting abstracts. Studies with fractures but without a control group were eligible to be included in the systematic review but not in the meta-analysis. The primary outcome was the number of fractures, which was further differentiated into osteoporotic fractures. In addition, the glucocorticoid dose equivalents used were noted whenever possible. RESULTS Seventeen studies were included in the systematic review. Seven were used in the meta-analysis of any fracture and six were used for osteoporotic fracture. The reported fracture rate ranged between no fracture to 60.8% in the patient group and no fracture to 43.8% in the control group. The odds ratio (OR) for any fracture was 2.71 (95%CI: 1.36-5.43, P = 0.005) and for osteoporotic fracture 2.76 (95%CI: 2.39-3.19 P < 0.00001), favoring the control group. CONCLUSIONS Patients with AI on glucocorticoid replacement therapy have a higher rate of fractures compared to the control population.
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Affiliation(s)
- Ling Li
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia.
- Department of Endocrinology, Gold Coast University Hospital, Southport, QLD, Australia.
- Department of Endocrinology, Metabolism and Diabetes, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.
| | - Sophie Bensing
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, NT, Australia
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19
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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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Hachemi Y, Rapp AE, Lee S, Dorn AK, Krüger BT, Kaiser K, Ignatius A, Tuckermann J. Intact Glucocorticoid Receptor Dimerization Is Deleterious in Trauma-Induced Impaired Fracture Healing. Front Immunol 2021; 11:628287. [PMID: 33679723 PMCID: PMC7927427 DOI: 10.3389/fimmu.2020.628287] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 12/29/2020] [Indexed: 11/13/2022] Open
Abstract
Following severe trauma, fracture healing is impaired because of overwhelming systemic and local inflammation. Glucocorticoids (GCs), acting via the glucocorticoid receptor (GR), influence fracture healing by modulating the trauma-induced immune response. GR dimerization-dependent gene regulation is essential for the anti-inflammatory effects of GCs. Therefore, we investigated in a murine trauma model of combined femur fracture and thoracic trauma, whether effective GR dimerization influences the pathomechanisms of trauma-induced compromised fracture healing. To this end, we used mice with decreased GR dimerization ability (GRdim). The healing process was analyzed by cytokine/chemokine multiplex analysis, flow cytometry, gene-expression analysis, histomorphometry, micro-computed tomography, and biomechanical testing. GRdim mice did not display a systemic or local hyper-inflammation upon combined fracture and thorax trauma. Strikingly, we discovered that GRdim mice were protected from fracture healing impairment induced by the additional thorax trauma. Collectively and in contrast to previous studies describing the beneficial effects of intact GR dimerization in inflammatory models, we report here an adverse role of intact GR dimerization in trauma-induced compromised fracture healing.
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Affiliation(s)
- Yasmine Hachemi
- Institute of Comparative Molecular Endocrinology, Ulm University, Ulm, Germany
| | - Anna E Rapp
- Institute of Orthopedic Research and Biomechanics, Ulm University Medical Center, Ulm, Germany
| | - Sooyeon Lee
- Institute of Comparative Molecular Endocrinology, Ulm University, Ulm, Germany
| | - Ann-Kristin Dorn
- Institute of Comparative Molecular Endocrinology, Ulm University, Ulm, Germany
| | - Benjamin T Krüger
- Institute of Orthopedic Research and Biomechanics, Ulm University Medical Center, Ulm, Germany
| | - Kathrin Kaiser
- Institute of Orthopedic Research and Biomechanics, Ulm University Medical Center, Ulm, Germany
| | - Anita Ignatius
- Institute of Orthopedic Research and Biomechanics, Ulm University Medical Center, Ulm, Germany
| | - Jan Tuckermann
- Institute of Comparative Molecular Endocrinology, Ulm University, Ulm, Germany
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21
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Lakatos P, Szili B, Bakos B, Takacs I, Putz Z, Istenes I. Thyroid Hormones, Glucocorticoids, Insulin, and Bone. Handb Exp Pharmacol 2020; 262:93-120. [PMID: 32036458 DOI: 10.1007/164_2019_314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Several endocrine systems have important effects on bone tissue. Thyroid hormones are essential for normal growth and development. Excess of these hormones will result in clinically significant changes that may require intervention. Glucocorticoids also have a marked effect on bone metabolism by several pathways. Their endogenous or exogenous excess will induce pathological processes that might elevate the risk of fractures. Insulin and the carbohydrate metabolism elicit a physiological effect on bone; however, the lack of insulin (type 1 diabetes) or insulin resistance (type 2 diabetes) have deleterious influence on bone tissue.
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Affiliation(s)
- Peter Lakatos
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary.
| | - Balazs Szili
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Bence Bakos
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Istvan Takacs
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Putz
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Ildiko Istenes
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
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22
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Auer MK, Paizoni L, Hofbauer LC, Rauner M, Chen Y, Schmidt H, Huebner A, Bidlingmaier M, Reisch N. Effects of androgen excess and glucocorticoid exposure on bone health in adult patients with 21-hydroxylase deficiency. J Steroid Biochem Mol Biol 2020; 204:105734. [PMID: 32784048 DOI: 10.1016/j.jsbmb.2020.105734] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/05/2020] [Accepted: 07/27/2020] [Indexed: 01/08/2023]
Abstract
CONTEXT This study aimed to determine the role of modifiable predictors on bone health in congenital adrenal hyperplasia (CAH). DESIGN Cross-sectional, single center study, including 97 patients (N = 42 men) with classic CAH due to 21-hydroxylase deficiency (N = 65 salt wasting, N = 32 simple virilizing). MAIN OUTCOME MEASURES Treatment-related predictors of bone health. RESULTS Average T scores (-0.9 ± 1.4 vs. -0.4 ± 1.4; p = 0.036) as well as Z scores (-1.0 ± 1.3 vs. -0.1 ± 1.4; p = 0.012) at the spine in patients with CAH were significantly lower in men than women. While osteoporosis was rare in women, it was documented in 9.1% of men with CAH. There was a significant positive correlation of Z scores at the spine with advancing age in women with CAH (R² = 0.178; p = 0.003). In multivariate analysis, the intake of conventional hydrocortisone (HC) instead of synthetic glucocorticoids was independently associated with a higher bone mineral density (BMD) at the hip region in both sexes. In women, there was a positive association with vitamin D concentrations. Interestingly, higher sodium levels were associated with a lower BMD independent of renin levels and fludrocortisone dosage. Neither in men nor in women, markers of androgen control were predictive for BMD at any site. Markers of bone turnover indicated low bone turnover. No pathological fractures were documented. CONCLUSIONS Men with CAH are particularly prone to low bone density, while women seem to be relatively protected by androgen excess compared to the general female population. The use of HC instead of synthetic GCs for hormone replacement may translate into better bone health.
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Affiliation(s)
- Matthias K Auer
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Luisa Paizoni
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Lorenz C Hofbauer
- Division of Endocrinology and Diabetes, Department of Medicine III & Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
| | - Martina Rauner
- Division of Endocrinology and Diabetes, Department of Medicine III & Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
| | - Yiqing Chen
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Heinrich Schmidt
- Department of Pediatric Endocrinology, Dr. von Haunersches Children's Hospital, Klinikum der Universität München, LMU München, Munich, Germany
| | - Angela Huebner
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Martin Bidlingmaier
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany.
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23
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Dineen R, Behan LA, Kelleher G, Hannon MJ, Brady JJ, Rogers B, Keevil BG, Tormey W, Smith D, Thompson CJ, McKenna MJ, Arlt W, Stewart PM, Agha A, Sherlock M. The contribution of serum cortisone and glucocorticoid metabolites to detrimental bone health in patients receiving hydrocortisone therapy. BMC Endocr Disord 2020; 20:154. [PMID: 33036588 PMCID: PMC7547490 DOI: 10.1186/s12902-020-00633-1] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 10/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Glucocorticoid therapy is the most common cause of iatrogenic osteoporosis. Less is known regarding the effect of glucocorticoids when used as replacement therapy on bone remodelling in patients with adrenal insufficiency. Enhanced intracellular conversion of inactive cortisone to active cortisol, by 11 beta-hydroxysteroid dehydrogenase type 1(11β-HSD1) and other enzymes leading to alterations in glucocorticoid metabolism, may contribute to a deleterious effect on bone health in this patient group. METHODS Study design: An open crossover prospective study randomizing ten hypopituitary men, with severe ACTH deficiency, to three commonly used hydrocortisone dose regimens. MEASUREMENTS Following 6 weeks of each regimen, patients underwent 24-h serum cortisol/cortisone sampling, measurement of bone turnover markers, and a 24-h urine collection for measurement of urinary steroid metabolites by gas chromatography-mass spectrometry (GC-MS). Serum cortisone and cortisol were analysed by liquid chromatography-mass spectrometry (LC-MS). RESULTS Dose-related and circadian variations in serum cortisone were seen to parallel those for cortisol, indicating conversion of ingested hydrocortisone to cortisone. The median area under the curve (AUC) of serum cortisone was significantly higher in patients on dose A (20 mg/10 mg) [670.5 (IQR 621-809.2)] compared to those on dose C (10 mg/5 mg) [562.8 (IQR 520.1-619.6), p = 0.01]. A negative correlation was observed between serum cortisone and bone formation markers, OC [1-49] (r = - 0.42, p = 0.03), and PINP (r = - 0.49, p = 0.01). There was a negative correlation between the AUC of night-time serum cortisone levels with the bone formation marker, OC [1-49] (r = - 0.41, p = 0.03) but there were no significant correlations between day-time serum cortisone or cortisol with bone turnover markers. There was a negative correlation between total urinary cortisol metabolites and the bone formation markers, PINP (r = - 0.39, p = 0.04), and OC [1-49] (r = - 0.35, p = 0.06). CONCLUSION Serum cortisol and cortisone and total urinary corticosteroid metabolites are negatively associated with bone turnover markers in patients receiving replacement doses of hydrocortisone, with nocturnal glucocorticoid exposure having a potentially greater influence on bone turnover. TRIAL REGISTRATION Irish Medicines Board Clinical Trial Number - CT900/459/1 and EudraCT Number - 2007-005018-37 . Registration date: 07-09-2007.
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Affiliation(s)
- Rosemary Dineen
- Department of Endocrinology, Tallaght University Hospital, Dublin, Ireland.
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Lucy-Ann Behan
- Department of Endocrinology, Tallaght University Hospital, Dublin, Ireland
| | - Grainne Kelleher
- Department of Chemical Pathology, Beaumont Hospital, Dublin, Ireland
| | - Mark J Hannon
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jennifer J Brady
- Metabolism Laboratory, St Vincent's University Hospital, Dublin, Ireland
| | - Bairbre Rogers
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Brian G Keevil
- Manchester Academic Health Science Centre, University Hospital of South Manchester, The University of Manchester, Manchester, UK
- Biochemistry Department, University Hospital of South Manchester, Manchester, UK
| | - William Tormey
- Department of Chemical Pathology, Beaumont Hospital, Dublin, Ireland
| | - Diarmuid Smith
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Malachi J McKenna
- Metabolism Laboratory, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | | | - Amar Agha
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mark Sherlock
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
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24
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Kiko N, Kalhan A. Comparison of Various Glucocorticoid Replacement Regimens Used in Chronic Adrenal Insufficiency: A Systematic Review. DUBAI DIABETES AND ENDOCRINOLOGY JOURNAL 2020. [DOI: 10.1159/000508321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
<b><i>Objective:</i></b> Patients with adrenal insufficiency require life-long glucocorticoid replacement therapy. Hydrocortisone (15–30 mg/day) and prednisolone (3–7.5 mg/day) are the preferred agents used although there is a lack of consensus among endocrinologists regarding the impact of different steroid regimens on quality of life, bone metabolism, cardiometabolic outcomes, adrenal crisis and infections. We carried out a retrospective systematic review of the literature to compare the efficacy and side effects of various glucocorticoid replacement regimens in patients with chronic adrenal insufficiency. <b><i>Methods:</i></b> We searched PubMed, Cochrane Reviews and Google Scholar databases up to March 14, 2019, for studies evaluating various clinical outcomes with glucocorticoid replacement therapy. The abstracts and full studies were appraised and data extracted from the eligible studies. The quality of evidence was evaluated and risk of bias carried out. <b><i>Results:</i></b> A total of 47 studies including 9 randomised controlled trials (RCTs) and 38 observational studies were evaluated in this systematic review. Prednisolone therapy was observed to be safe as well as efficacious as hydrocortisone although a higher dose was associated with an increased risk of cardiovascular (CV) disease. A lower hydrocortisone dose (15–20 mg/day) was associated with a reduction of blood pressure and improved clinical outcomes although this observation was based on a solitary RCT. Modified release hydrocortisone was observed to reduce the risk of CV disease based upon results from 2 of the RCTs. However, there was no conclusive evidence of benefit of modified release hydrocortisone and continuous subcutaneous hydrocortisone infusion in improving subjective health status. <b><i>Conclusion:</i></b> Prednisolone therapy remains a safe and efficacious alternative to hydrocortisone although there are concerns of dyslipidaemia and CV disease with higher doses. There is limited level I evidence suggestive of a positive effect of modified release hydrocortisone on CV and metabolic outcomes, particularly weight reduction.
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Mazziotti G, Rodari M, Gelardi F, Tosi G, Zucali PA, Pepe G, Chiti A. Morphometric vertebral fractures in patients with castration-resistant prostate cancer undergoing treatment with radium-223: a longitudinal study in the real-life clinical practice. Endocrine 2020; 69:204-211. [PMID: 32239451 DOI: 10.1007/s12020-020-02277-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/17/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE Radium-223 was associated with high incidence of non-vertebral fractures in patients with castration-resistant prostate cancer (CRPC). However, it is still unclear whether radium-223 may induce skeletal fragility regardless of other therapies for CRPC. We aimed at evaluating the prevalence, incidence, and determinants of vertebral fractures (VFs), i.e., the most frequent complication of skeletal fragility, in CRCP patients undergoing radium-223 therapy in the real-life clinical practice. METHODS We retrospectively reviewed 49 CRPC patients with symptomatic bone metastases treated with radium-223. Patients received median number of four radium-223 doses (range: 2-6) and were followed-up for a median period of 11 months (range: 6-44). VFs were assessed by a quantitative morphometry using lateral images of spine 11C-Choline PET/CT, excluding from the analysis the vertebral bodies affected by bone metastases. RESULTS Before radium-223 administration, 24 patients (49%) had VFs significantly associated with duration of androgen deprivation therapy (ADT; odds ratio 1.29) and previous abiraterone therapy (odds ratio 3.80). During radium-223 therapy, incident VFs occurred in 25% of patients, in relationship with prevalent VFs (hazard ratio 6.89) and change in serum total alkaline phosphatase values (hazard ratio 0.97), whereas the correlations with ADT and abiraterone therapy were lost. Noteworthy, the risk of VFs did not correlate with the therapeutic end points of radium-223. CONCLUSIONS This study provides a first evidence that in real-life clinical practice, radium-223 therapy may induce skeletal fragility with high risk of VFs, likely by inhibition of bone formation and independently of ADT and abiraterone therapy.
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Affiliation(s)
- Gherardo Mazziotti
- Endocrinology, Diabetology and Andrology Unit, Metabolic Bone Diseases and Osteoporosis Section, Humanitas Clinical and Research Center, IRCCS, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.
| | - Marcello Rodari
- Unit of Nuclear Medicine, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
| | - Fabrizia Gelardi
- Unit of Nuclear Medicine, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
| | - Giovanni Tosi
- Unit of Nuclear Medicine, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
| | - Paolo A Zucali
- Department of Oncology, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
| | - Giovanna Pepe
- Unit of Nuclear Medicine, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
| | - Arturo Chiti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Unit of Nuclear Medicine, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
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Dineen R, Martin-Grace J, Thompson CJ, Sherlock M. The management of glucocorticoid deficiency: Current and future perspectives. Clin Chim Acta 2020; 505:148-159. [DOI: 10.1016/j.cca.2020.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 01/10/2023]
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Riehl G, Reisch N, Roehle R, Claahsen van der Grinten H, Falhammar H, Quinkler M. Bone mineral density and fractures in congenital adrenal hyperplasia: Findings from the dsd-LIFE study. Clin Endocrinol (Oxf) 2020; 92:284-294. [PMID: 31886890 DOI: 10.1111/cen.14149] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/26/2019] [Accepted: 12/28/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND In patients with congenital adrenal hyperplasia (CAH) type and doses of glucocorticoids used as well as sex hormone secretion during puberty have important actions on bone mineral density (BMD) in adulthood. AIM To evaluate BMD in adult CAH patients depending on current glucocorticoid therapy and on androgen levels in adulthood and at age 16 years. METHODS We included 244 CAH patients from the dsd-LIFE cohort (women n = 147, men n = 97; salt-wasting n = 148, simple-virilizing n = 71, nonclassical n = 25) in which BMD and bloods were available. Clinical and hormonal data at age 16years were retrieved from patients' files. RESULTS Simple-virilizing women showed lower BMD compared to salt-wasting women at trochanter (0.65 ± 0.12 vs 0.75 ± 0.15 g/cm2 ; P < .050), whole femur T-score (-0.87 ± 1.08 vs -0.16 ± 1.24; P < .05) and lumbar T-score (-0.81 ± 1.34 vs 0.09 ± 1.3; P < .050). Fracture prevalence did not differ significantly between the CAH groups. Prednisolone vs. hydrocortisone only therapy caused worse trochanter Z-score (-1.38 ± 1.46 vs -0.47 ± 1.16; P < .050). In women lumbar spine, BMD correlated negatively with hydrocortisone-equivalent dose per body surface (r2 = 0.695, P < .001). Furthermore, BMI at age 16years correlated positively with lumbar spine T-score (r2 = 0.439, P = .003) and BMD (r2 = 0.420, P = .002) in women. The androstenedione/testosterone ratio at age 16years correlated positively with lumbar spine Z-score in women (r2 = 0.284, P = .024) and trochanter Z-score in men (r2 = 0.600, P = .025). CONCLUSION Higher glucocorticoid doses seemed to cause lower BMD especially in women. Prednisolone appeared to have more detrimental effects on BMD than hydrocortisone. Higher glucocorticoid doses (lower androstenedione/testosterone ratio) during adolescence may cause lower BMD in adulthood.
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Affiliation(s)
| | - Nicole Reisch
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität, Munich, Germany
| | - Robert Roehle
- Charité Universitätsmedizin Berlin, Coordinating Center for Clinical Studies, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Hedi Claahsen van der Grinten
- Department of Pediatric Endocrinology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
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Rothe R, Schulze S, Neuber C, Hauser S, Rammelt S, Pietzsch J. Adjuvant drug-assisted bone healing: Part I – Modulation of inflammation. Clin Hemorheol Microcirc 2020; 73:381-408. [DOI: 10.3233/ch-199102] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Rebecca Rothe
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Department of Radiopharmaceutical and Chemical Biology, Dresden, Germany
| | - Sabine Schulze
- University Center of Orthopaedics & Traumatology (OUC), University Hospital Carl Gustav Carus, Dresden, Germany
- Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus and Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Christin Neuber
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Department of Radiopharmaceutical and Chemical Biology, Dresden, Germany
| | - Sandra Hauser
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Department of Radiopharmaceutical and Chemical Biology, Dresden, Germany
| | - Stefan Rammelt
- University Center of Orthopaedics & Traumatology (OUC), University Hospital Carl Gustav Carus, Dresden, Germany
- Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus and Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Center for Regenerative Therapies Dresden (CRTD), Dresden, Germany
| | - Jens Pietzsch
- Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Institute of Radiopharmaceutical Cancer Research, Department of Radiopharmaceutical and Chemical Biology, Dresden, Germany
- Technische Universität Dresden, School of Science, Faculty of Chemistry and Food Chemistry, Dresden, Germany
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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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Rangaswamaiah S, Gangathimmaiah V, Nordenstrom A, Falhammar H. Bone Mineral Density in Adults With Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2020; 11:493. [PMID: 32903805 PMCID: PMC7438951 DOI: 10.3389/fendo.2020.00493] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
Background: Decreased bone mineral density (BMD) is a concern in patients with congenital adrenal hyperplasia (CAH) due to lifelong glucocorticoid replacement. Studies till date have yielded conflicting results. We wanted to systematically evaluate the available evidence regarding BMD in adult patients with CAH. Methods: We searched Medline, Embase and Cochrane Central Register of Controlled Trials to identify eligible studies. Studies comparing BMD in CAH patients with age- and sex-matched controls were included. Age <16 years and absence of controls were exclusion criteria. Two authors independently reviewed abstracts, read full-text articles, extracted data, assessed risk of bias using Newcastle-Ottawa scale, and determined level of evidence using Grading of Recommendations Assessment, Development, and Evaluation methodology. Results: Nine case-control studies with a total sample of 598 (cases n = 254, controls n = 344) met eligibility criteria. Median age was 31 years (IQR 23.9-37) and 65.7% were female. Total body BMD (Mean Difference [MD]-0.06; 95%CI -0.07, -0.04), lumbar spine BMD (MD -0.05; 95%CI -0.07, -0.03) and femoral neck BMD (MD -0.07; 95%CI -0.10, -0.05) was lower in cases compared to controls. Lumbar spine T-scores (MD -0.86; 95%CI -1.16, -0.56) and Z-scores (MD -0.66; 95%CI -0.99, -0.32) and femoral neck T-scores (MD -0.75 95%CI -0.95, -0.56) and Z-scores (MD -0.27 95%CI -0.58, 0.04) were lower in cases. Conclusion: BMD in adult patients with CAH was lower compared to controls. Although insufficient data precludes a dose-response relationship between glucocorticoid dose and BMD, it would be prudent to avoid overtreatment with glucocorticoids.
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Affiliation(s)
- Swetha Rangaswamaiah
- Department of Diabetes and Endocrinology, The Townsville University Hospital, Townsville, QLD, Australia
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- *Correspondence: Swetha Rangaswamaiah
| | - Vinay Gangathimmaiah
- Department of Emergency Medicine, The Townsville University Hospital, Townsville, QLD, Australia
| | - Anna Nordenstrom
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Wellbeing and Chronic Preventable Diseases Division, Menzies School of Health Research, Darwin, NT, Australia
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Ahmed SEAM, Soliman AT, Ramadan MA, Elawwa A, Abugabal AMS, Emam MHA, De Sanctis V. Long-term prednisone versus hydrocortisone treatment in children with classic Congenital Adrenal Hyperplasia (CAH) and a brief review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:360-369. [PMID: 31580328 PMCID: PMC7233741 DOI: 10.23750/abm.v90i3.8732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 07/31/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Debate still exist about the safety of long-term use of prednisone (PD) versus hydrocortisone (HC) for treating children with congenital adrenal hyperplasia -21OH D (CAH). Despite recent developments in congenital adrenal hyperplasia -21OH D (CAH), several issues related to patient growth and final height remain unsolved. Debate still exist about the safety of long-term use of PD versus HC for treating children with CAH. The mechanism by which glucocorticoid therapy interferes with growth is complex and multifactorial. Relatively slight supra-physiologic levels may be enough to blunt growth velocity. An increased risk of developing obesity is another possible consequence of hyper-cortisolism in children with CAH. OBJECTIVES OF THE STUDY To evaluate the anthropometric and biochemical effects of long-term PD versus HC treatment in children with CAH-21OHD. A brief review of the literature is also reported. PATIENTS AND METHODS This retrospective study evaluated linear growth and biochemical data of thirty children with classic CAH (19 females and 11 males), who were on PD (n=22) or HC (n=8) treatment, since their first diagnosis. Clinical data included age, gender, duration of therapy, dose of HC and or equivalent dose of HC in the PD group, blood pressure, height (Ht) and weight. Ht-SDS and BMI were also calculated. Biochemical data included measurement of 17- OH progesterone, cholesterol, triglycerides (TG), HDL, LDL, fasting glucose, and insulin concentrations. HOMA-IR was calculated. Carotid intima-media thickness (CIMT) was measured using high-resolution B-mode ultrasonography. Thirty normal age matched children were used as controls for the anthropometric and CIMT data. RESULTS The age of children and duration of treatment did not differ among the two treatment groups. After a mean of 6 years of treatment, the Ht-SDS and BMI did not differ between the three groups of children. The equivalent hydrocortisone dose of children on prednisone was significantly higher than the dose for the hydrocortisone group. Both systolic and diastolic blood pressures (BP) of children on PD was slightly higher compared to those on hydrocortisone group. However, the BP of the 2 treatment groups was not different compared to control children. Fasting blood glucose, homeostatic model assessment insulin resistance (HOMA-IR), plasma TG, HDL, and cholesterol did not differ among the two treatment groups. LDL levels were significantly higher in the PD group versus the HC group. The mean CIMT did not differ among the two treatment groups but was significantly higher in the treated groups versus controls. There was a significant linear correlation between BMI-SDS and CIMT (r=0.37, p=0.047). CONCLUSIONS Children with CAH-21OHD who were kept on PD therapy for 6.4±2.7 years, since the beginning of diagnosis, have maintained normal linear growth. No difference in BMI, HOMA-IR, or CIMT was detected among the two treated groups. The efficiency, safety and convenience of a single daily dose of PD could be a good and relatively safe alternative to HC for the continuing medical treatment of patients with CAH-21OHD. However, more prospective studies across childhood and adolescence are necessary to draw definitive conclusions.
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Al Alawi AM, Nordenström A, Falhammar H. Clinical perspectives in congenital adrenal hyperplasia due to 3β-hydroxysteroid dehydrogenase type 2 deficiency. Endocrine 2019; 63:407-421. [PMID: 30719691 PMCID: PMC6420607 DOI: 10.1007/s12020-018-01835-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 12/27/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE 3β-hydroxysteroid dehydrogenase type 2 deficiency (3βHSD2D) is a very rare variant of congenital adrenal hyperplasia (CAH) causing less than 0.5% of all CAH. The aim was to review the literature. METHODS PubMed was searched for relevant articles. RESULTS 3βHSD2D is caused by HSD3B2 gene mutations and characterized by impaired steroid synthesis in the gonads and the adrenal glands and subsequent increased dehydroepiandrosterone (DHEA) concentrations. The main hormonal changes observed in patients with 3βHSD2D are elevated ratios of the Δ5-steroids over Δ4-steroids but molecular genetic testing is recommended to confirm the diagnosis. Several deleterious mutations in the HSD3B2 gene have been associated with salt-wasting (SW) crisis in the neonatal period, while missense mutations have been associated with a non-SW phenotype. Boys may have ambiguous genitalia, whereas girls present with mild or no virilization at birth. The existence of non-classic 3βHSD2D is controversial. In an acute SW crisis, the treatment includes prompt rehydration, correction of hypoglycemia, and parenteral hydrocortisone. Similar to other forms of CAH, glucocorticoid and mineralocorticoid replacement is needed for long-term management. In addition, sex hormone replacement therapy may be required if normal progress through puberty is failing. Little is known regarding possible negative long-term consequences of 3βHSD2D and its treatments, e.g., fertility, final height, osteoporosis and fractures, adrenal and testicular tumor risk, and mortality. CONCLUSION Knowledge is mainly based on case reports but many long-term outcomes could be presumed to be similar to other types of CAH, mainly 21-hydroxylase deficiency, although in 3βHSD2D it seems to be more difficult to suppress the androgens.
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Affiliation(s)
- Abdullah M Al Alawi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatric Endocrinology, Astrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia.
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
- Menzies School of Health Research, Darwin, NT, Australia.
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Dineen R, Stewart PM, Sherlock M. Factors impacting on the action of glucocorticoids in patients receiving glucocorticoid therapy. Clin Endocrinol (Oxf) 2019; 90:3-14. [PMID: 30120786 DOI: 10.1111/cen.13837] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/27/2018] [Accepted: 08/15/2018] [Indexed: 01/16/2023]
Abstract
Glucocorticoids (GCs) are steroid hormones, which are essential for life. They are secreted by the adrenal cortex under the control of the hypothalamic-pituitary-adrenal (HPA) axis. Glucocorticoids are essential for the normal function of most organ systems and, in both, excess and deficiency can lead to significant adverse consequences. Adrenal insufficiency (AI) is a rare, life-threatening disorder characterized by insufficient production of corticosteroid hormones. Primary AI is defined by the inability of the adrenal cortex to produce sufficient amounts of glucocorticoids and/or mineralocorticoids despite normal or increased adrenocorticotropin hormone (ACTH). Secondary AI is adrenal hypofunction due to insufficient amount of ACTH produced by the pituitary gland. Conventional treatment of both primary and secondary adrenal insufficiencies involves lifelong glucocorticoid replacement therapy. The role of cortisol deficiency and the impact of hydrocortisone replacement on morbidity and mortality in this patient group are under increasing scrutiny. Established glucocorticoid replacement regimens do not completely mirror endogenous hormonal production, and their monitoring to ensure optimum therapy is hampered by the lack of reliable biomarkers of hormone sufficiency. A further confounding issue is the tissue-specific regulation of glucocorticoid through the two isozymes of 11β-hydroxysteroid dehydrogenase (11β-HSD) with research focusing on the role of this prereceptor regulation in the development of adverse metabolic features in patients. This review defines the factors influencing glucocorticoid action in patients with adrenal insufficiency receiving glucocorticoid therapy.
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Affiliation(s)
- Rosemary Dineen
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul M Stewart
- Department of Endocrinology, University of Leeds, Leeds, UK
| | - Mark Sherlock
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
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Tajima T. Health problems of adolescent and adult patients with 21-hydroxylase deficiency. Clin Pediatr Endocrinol 2018; 27:203-213. [PMID: 30393437 PMCID: PMC6207803 DOI: 10.1297/cpe.27.203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/02/2018] [Indexed: 12/30/2022] Open
Abstract
Twenty-one-hydroxylase deficiency (21-OHD) is one of the most common forms of congenital adrenal hyperplasias. Since the disease requires life-long steroid hormone replacement, transition from pediatric clinical care to adolescent and adult care is necessary. Recently, several studies have shown that morbidity and quality of life in adolescent and adult patients with 21-OHD are impaired by obesity, hypertension, diabetes mellitus, impaired glucose tolerance, dyslipidemia, and osteoporosis. In addition, excess adrenal androgen impairs fertility in both females and males. This mini review discusses the current health problems in adolescent and adult patients with 21-OHD and ways to prevent them.
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Affiliation(s)
- Toshihiro Tajima
- Jichi Medical University Children's Medical Center Tochigi, Tochigi, Japan
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Hardy RS, Zhou H, Seibel MJ, Cooper MS. Glucocorticoids and Bone: Consequences of Endogenous and Exogenous Excess and Replacement Therapy. Endocr Rev 2018; 39:519-548. [PMID: 29905835 DOI: 10.1210/er.2018-00097] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/08/2018] [Indexed: 02/02/2023]
Abstract
Osteoporosis associated with long-term glucocorticoid therapy remains a common and serious bone disease. Additionally, in recent years it has become clear that more subtle states of endogenous glucocorticoid excess may have a major impact on bone health. Adverse effects can be seen with mild systemic glucocorticoid excess, but there is also evidence of tissue-specific regulation of glucocorticoid action within bone as a mechanism of disease. This review article examines (1) the role of endogenous glucocorticoids in normal bone physiology, (2) the skeletal effects of endogenous glucocorticoid excess in the context of endocrine conditions such as Cushing disease/syndrome and autonomous cortisol secretion (subclinical Cushing syndrome), and (3) the actions of therapeutic (exogenous) glucocorticoids on bone. We review the extent to which the effect of glucocorticoids on bone is influenced by variations in tissue metabolizing enzymes and glucocorticoid receptor expression and sensitivity. We consider how the effects of therapeutic glucocorticoids on bone are complicated by the effects of the underlying inflammatory disease being treated. We also examine the impact that glucocorticoid replacement regimens have on bone in the context of primary and secondary adrenal insufficiency. We conclude that even subtle excess of endogenous or moderate doses of therapeutic glucocorticoids are detrimental to bone. However, in patients with inflammatory disorders there is a complex interplay between glucocorticoid treatment and underlying inflammation, with the underlying condition frequently representing the major component underpinning bone damage.
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Affiliation(s)
- Rowan S Hardy
- University of Birmingham, Birmingham, United Kingdom
| | - Hong Zhou
- Bone Research Program, ANZAC Research Institute, Sydney, New South Wales, Australia
| | - Markus J Seibel
- Bone Research Program, ANZAC Research Institute, Sydney, New South Wales, Australia.,Department of Endocrinology and Metabolism, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mark S Cooper
- Department of Endocrinology and Metabolism, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Adrenal Steroid Laboratory, ANZAC Research Institute, Sydney, New South Wales, Australia
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36
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Cirillo N. Role of tissue-specific steroid metabolism in oral disease: Is there any clinical implication? Oral Dis 2018; 24:224-227. [PMID: 29480615 DOI: 10.1111/odi.12767] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 08/22/2017] [Indexed: 12/21/2022]
Abstract
The discovery of an oral glucocorticoid system has provided novel conceptual frameworks for understanding the effects of endogenous and exogenous corticosteroids in the oral cavity. For example, liquorice derivatives have long been used in the treatment of oral inflammatory conditions and it is now known that a chief constituent of liquorice root, glycyrrhetinic acid, inhibits 11β-hydroxysteroid dehydrogenase (11β-HSD) type 2 thus increasing local cortisol levels. Hence, targeting the local interconversion between inactive cortisone and active cortisol by 11β-HSD inhibitors/activators offers potentially advantageous strategies for the treatment of oral inflammatory and autoimmune conditions. The recent characterisation of a cancer-associated glucocorticoid system has further extended the implications of cortisol metabolism in oral disease. New evidence now questions the use of synthetic corticosteroids in patients with cancer and, possibly, in oral potentially malignant disorders. For example, cortisol production by cancer cells has been shown to inhibit tumour-specific CD8+ T cells, to promote migration and invasion and to induce chemoresistance in vitro. This viewpoint briefly summarises the recent evidence for a role of the local steroid metabolism in oral oncology and immunology and its potential clinical implications.
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Affiliation(s)
- N Cirillo
- Melbourne Dental School and Oral Health CRC, The University of Melbourne, Melbourne, VIC, Australia
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Frey KR, Kienitz T, Schulz J, Ventz M, Zopf K, Quinkler M. Prednisolone is associated with a worse bone mineral density in primary adrenal insufficiency. Endocr Connect 2018; 7:811-818. [PMID: 29720511 PMCID: PMC5987359 DOI: 10.1530/ec-18-0160] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 12/30/2022]
Abstract
CONTEXT Patients with primary adrenal insufficiency (PAI) or congenital adrenal hyperplasia (CAH) receive life-long glucocorticoid (GC) therapy. Daily GC doses are often above the physiological cortisol production rate and can cause long-term morbidities such as osteoporosis. No prospective trial has investigated the long-term effect of different GC therapies on bone mineral density (BMD) in those patients. OBJECTIVES To determine if patients on hydrocortisone (HC) or prednisolone show changes in BMD after follow-up of 5.5 years. To investigate if BMD is altered after switching from immediate- to modified-release HC. DESIGN AND PATIENTS Prospective, observational, longitudinal study with evaluation of BMD by DXA at visit1, after 2.2 ± 0.4 (visit2) and after 5.5 ± 0.8 years (visit3) included 36 PAI and 8 CAH patients. Thirteen patients received prednisolone (age 52.5 ± 14.8 years; 8 women) and 31 patients received immediate-release HC (age 48.9 ± 15.8 years; 22 women). Twelve patients on immediate-release switched to modified-release HC at visit2. RESULTS Prednisolone showed significantly lower Z-scores compared to HC at femoral neck (-0.85 ± 0.80 vs -0.25 ± 1.16, P < 0.05), trochanter (-0.96 ± 0.62 vs 0.51 ± 1.07, P < 0.05) and total hip (-0.78 ± 0.55 vs 0.36 ± 1.04, P < 0.05), but not at lumbar spine, throughout the study. Prednisolone dose decreased by 8% over study time, but no significant effect was seen on BMD. BMD did not change significantly after switching from immediate- to modified-release HC. CONCLUSIONS The use of prednisolone as hormone replacement therapy results in significantly lower BMD compared to HC. Patients on low-dose HC replacement therapy showed unchanged Z-scores within the normal reference range during the study period.
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Affiliation(s)
- Kathrin R Frey
- Department of Medicine IEndocrine and Diabetes Unit, University Hospital, University of Würzburg, Würzburg, Germany
| | - Tina Kienitz
- Charité - Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Julia Schulz
- Charité - Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Manfred Ventz
- Charité - Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Kathrin Zopf
- Charité - Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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38
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Falhammar H. Skeletal fragility induced by overtreatment of adrenal insufficiency. Endocrine 2018; 59:239-241. [PMID: 29275534 DOI: 10.1007/s12020-017-1501-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Camozzi V, Betterle C, Frigo AC, Zaccariotto V, Zaninotto M, De Caneva E, Lucato P, Gomiero W, Garelli S, Sabbadin C, Salvà M, Costa MD, Boscaro M, Luisetto G. Vertebral fractures assessed with dual-energy X-ray absorptiometry in patients with Addison's disease on glucocorticoid and mineralocorticoid replacement therapy. Endocrine 2018; 59:319-329. [PMID: 28795340 DOI: 10.1007/s12020-017-1380-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 07/21/2017] [Indexed: 12/30/2022]
Abstract
PURPOSE to assess bone damage and metabolic abnormalities in patients with Addison's disease given replacement doses of glucocorticoids and mineralocorticoids. METHODS A total of 87 patients and 81 age-matched and sex-matched healthy controls were studied. The following parameters were measured: urinary cortisol, serum calcium, phosphorus, creatinine, 24-h urinary calcium excretion, bone alkaline phosphatase, parathyroid hormone, serum CrossLaps, 25 hydroxyvitamin D, and 1,25 dihydroxyvitamin D. Clear vertebral images were obtained with dual-energy X-ray absorptiometry in 61 Addison's disease patients and 47 controls and assessed using Genant's classification. RESULTS Nineteen Addison's disease patients (31.1%) had at least one morphometric vertebral fracture, as opposed to six controls (12.8%, odds ratio 3.09, 95% confidence interval 1.12-8.52). There were no significant differences in bone mineral density parameters at any site between patients and controls. In Addison's disease patients, there was a positive correlation between urinary cortisol and urinary calcium excretion. Patients with fractures had a longer history of disease than those without fractures. Patients taking fludrocortisone had a higher bone mineral density than untreated patients at all sites except the lumbar spine. CONCLUSIONS Addison's disease patients have more fragile bones irrespective of any decrease in bone mineral density. Supra-physiological doses of glucocorticoids and longer-standing disease (with a consequently higher glucocorticoid intake) might be the main causes behind patients' increased bone fragility. Associated mineralocorticoid treatment seems to have a protective effect on bone mineral density.
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Affiliation(s)
- Valentina Camozzi
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Corrado Betterle
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy.
| | - Anna Chiara Frigo
- Department of Cardiac, Thoracic and Vascular Sciences, Biostatistics, Epidemiology and Public Health Unit, University of Padua, Via Loredan 18, Padua, 35131, Italy
| | - Veronica Zaccariotto
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University of Padua, Via Giustiniani 2, Padua, 35128, Italy
| | - Erica De Caneva
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Paola Lucato
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Walter Gomiero
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Silvia Garelli
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Chiara Sabbadin
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Monica Salvà
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Miriam Dalla Costa
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Marco Boscaro
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Giovanni Luisetto
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
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Rapp AE, Hachemi Y, Kemmler J, Koenen M, Tuckermann J, Ignatius A. Induced global deletion of glucocorticoid receptor impairs fracture healing. FASEB J 2018; 32:2235-2245. [PMID: 29217668 PMCID: PMC5893166 DOI: 10.1096/fj.201700459rr] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although endogenous glucocorticoids (GCs) are important regulators of bone integrity and the immune system, their role in bone repair after fracture-a process highly dependent on inflammation and bone formation-is unclear. Because most effects of GCs are mediated by the glucocorticoid receptor (GR), we used an inducible global GR knockout (GRgtROSACreERT2) mouse model to eliminate endogenous GC action in all cells contributing to bone repair. The healing process was analyzed by cytokine/chemokine multiplex analysis, flow cytometry, histology, gene-expression analysis, microcomputed tomography, and biomechanical analysis. We observed increased early systemic and local inflammatory responses, as well as a significantly higher number of T cells infiltrating the fracture callus. Later in the healing process, we found impaired endochondral ossification in the absence of the GR, leading to persistent cartilage in the calli of the GRgtROSACreERT2 mice, decreased bending stiffness, and a significantly lower proportion of healed bones. Collectively, our data show that the absence of the GR significantly impairs fracture healing associated with a defective cartilage-to-bone transition, underscoring an important role of GCs during fracture healing.-Rapp, A. E., Hachemi, Y., Kemmler, J., Koenen, M., Tuckermann, J., Ignatius, A. Induced global deletion of glucocorticoid receptor impairs fracture healing.
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Affiliation(s)
- Anna E Rapp
- Institute of Orthopaedic Research and Biomechanics, Centre for Trauma Research Ulm, Ulm University Medical Centre
| | - Yasmine Hachemi
- Institute of Comparative Molecular Endocrinology, Ulm University, Ulm, Germany
| | - Julia Kemmler
- Institute of Orthopaedic Research and Biomechanics, Centre for Trauma Research Ulm, Ulm University Medical Centre
| | - Mascha Koenen
- Institute of Comparative Molecular Endocrinology, Ulm University, Ulm, Germany
| | - Jan Tuckermann
- Institute of Comparative Molecular Endocrinology, Ulm University, Ulm, Germany
| | - Anita Ignatius
- Institute of Orthopaedic Research and Biomechanics, Centre for Trauma Research Ulm, Ulm University Medical Centre
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Guignat L, Proust-Lemoine E, Reznik Y, Zenaty D. Group 6. Modalities and frequency of monitoring of patients with adrenal insufficiency. Patient education. ANNALES D'ENDOCRINOLOGIE 2017; 78:544-558. [DOI: 10.1016/j.ando.2017.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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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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Winkler BK, Lehnert H, Oster H, Kirchner H, Harbeck B. FKBP5 methylation as a possible marker for cortisol state and transient cortisol exposure in healthy human subjects. Epigenomics 2017; 9:1279-1286. [PMID: 28875708 DOI: 10.2217/epi-2017-0057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Current glucocorticoid replacement regimens, in adrenal insufficiency, fail to mimic the physiological cortisol secretion, thereby fostering serious side effects. AIM To experimentally evaluate the impact of CpG methylation within the FKBP5 gene as a possible short- and long-term marker for cortisol exposure in humans. MATERIALS & METHODS An ACTH-stimulation test was carried out and methylation status of the FKBP5 gene in leukocytes was determined. RESULTS A negative correlation between basal levels of methylation and serum cortisol was observed. Individual changes in FKBP5 methylation after 24 h correlated with cortisol responses. CONCLUSION Considering previous studies conducted with murine leucocytes, FKBP5 methylation may be suitable as a long-term biomarker, rather than acute glucocorticoid exposure, also in humans.
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Affiliation(s)
- Britta K Winkler
- Department of Internal Medicine I, University of Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany
| | - Hendrik Lehnert
- Department of Internal Medicine I, University of Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany
| | - Henrik Oster
- Department of Internal Medicine I, University of Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany
| | - Henriette Kirchner
- Department of Internal Medicine I, University of Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany
| | - Birgit Harbeck
- Department of Internal Medicine I, University of Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany
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Murray RD, Ekman B, Uddin S, Marelli C, Quinkler M, Zelissen PMJ. Management of glucocorticoid replacement in adrenal insufficiency shows notable heterogeneity - data from the EU-AIR. Clin Endocrinol (Oxf) 2017; 86:340-346. [PMID: 27801983 DOI: 10.1111/cen.13267] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 10/17/2016] [Accepted: 10/27/2016] [Indexed: 11/29/2022]
Abstract
CONTEXT AND OBJECTIVE Treatment for adrenal insufficiency (AI) remains suboptimal. Despite glucocorticoid replacement, patients with AI have reduced life expectancy and quality of life. This study aimed to describe the spectrum of management of glucocorticoid replacement in patients with AI enrolled in the European Adrenal Insufficiency Registry (EU-AIR). DESIGN, SETTING AND PATIENTS EU-AIR is a prospective, multinational, multicentre, observational study initiated in August 2012 to monitor the long-term safety of glucocorticoid replacement in routine clinical practice in Germany, the Netherlands, Sweden and the UK (ClinicalTrials.gov identifier: NCT01661387). This analysis included 1166 patients with primary and secondary AI (mean disease duration 16·1 ± 11·6 years) receiving long-term glucocorticoid replacement therapy. MAIN OUTCOME MEASURE Glucocorticoid type, dose, frequency and treatment regimen were examined. RESULTS Most patients (87·4%) were receiving hydrocortisone. The most common dose range, taken by 42·2% of patients, was 20 to <25 mg/day; however, 12·6% were receiving doses of ≥30 mg/day. Hydrocortisone was being taken once daily by 5·5%, twice daily by 48·7%, three times daily by 43·6% and four times daily by 2·1%. Patients with primary AI received higher replacement doses than those with secondary AI (23·4 ± 8·9 and 19·6 ± 5·9 mg/day, respectively). Twenty-five different regimens were being used to deliver a daily hydrocortisone dose of 20 mg. CONCLUSIONS We have shown significant heterogeneity in the type, dose, frequency and timing of glucocorticoid replacement in real-world clinical practice. This reflects dose individualization based on patient symptoms and lifestyle in the absence of data supporting the optimal regimen.
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Affiliation(s)
- Robert D Murray
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Bertil Ekman
- Department of Endocrinology, Linköping University, Linköping, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | | | | | - Pierre M J Zelissen
- Department of Internal Medicine and Endocrinology, University Medical Center Utrecht, Utrecht, The Netherlands
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Quinkler M, Ekman B, Marelli C, Uddin S, Zelissen P, Murray RD. Prednisolone is associated with a worse lipid profile than hydrocortisone in patients with adrenal insufficiency. Endocr Connect 2017; 6:1-8. [PMID: 27864317 PMCID: PMC5148794 DOI: 10.1530/ec-16-0081] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 11/18/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Prednisolone is used as glucocorticoid replacement therapy for adrenal insufficiency (AI). Recent data indicate that its use in AI is associated with low bone mineral density. Data on risk factors for cardiovascular disease in patients with AI treated with prednisolone are scarce, despite this condition being the predominant cause of excess mortality. We aimed to address this question using real-world data from the European Adrenal Insufficiency Registry (EU-AIR). DESIGN/METHODS EU-AIR, comprising of 19 centres across Germany, the Netherlands, Sweden and the UK, commenced enrolling patients with AI in August 2012. Patients receiving prednisolone (3-6 mg/day, n = 50) or hydrocortisone (15-30 mg/day, n = 909) were identified and grouped at a ratio of 1:3 (prednisolone:hydrocortisone) by matching for gender, age, duration and type of disease. Data from baseline and follow-up visits were analysed. Data from patients with congenital adrenal hyperplasia were excluded. RESULTS Significantly higher mean ± s.d. total (6.3 ± 1.6 vs 5.4 ± 1.1 mmol/L; P = 0.003) and low-density lipoprotein (LDL) cholesterol levels (3.9 ± 1.4 vs 3.2 ± 1.0 mmol/L; P = 0.013) were identified in 47 patients on prednisolone vs 141 receiving hydrocortisone at baseline and at follow-up (P = 0.005 and P = 0.006, respectively). HbA1c, high-density lipoprotein and triglyceride levels, body mass index, systolic and diastolic blood pressure and waist circumference were not significantly different. CONCLUSIONS This is the first matched analysis of its kind. Significantly higher LDL levels in patients receiving prednisolone relative to hydrocortisone could predict a higher relative risk of cardiovascular disease in the former group.
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Affiliation(s)
| | - Bertil Ekman
- Departments of Endocrinology and Medical and Health SciencesLinköping University, Linköping, Sweden
| | | | | | - Pierre Zelissen
- Department of Internal Medicine and EndocrinologyUniversity Medical Center Utrecht, Utrecht, the Netherlands
| | - Robert D Murray
- Department of EndocrinologyLeeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
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Chiodini I, Vainicher CE, Morelli V, Palmieri S, Cairoli E, Salcuni AS, Copetti M, Scillitani A. MECHANISMS IN ENDOCRINOLOGY: Endogenous subclinical hypercortisolism and bone: a clinical review. Eur J Endocrinol 2016; 175:R265-R282. [PMID: 27412441 DOI: 10.1530/eje-16-0289] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/13/2016] [Indexed: 01/11/2023]
Abstract
In recent years, the condition of subclinical hypercortisolism (SH) has become a topic of growing interest. This is due to the fact that SH prevalence is not negligible (0.8-2% in the general population) and that, although asymptomatic, this subtle cortisol excess is not harmless, being associated with an increased risk of complications, in particular of osteoporosis and fragility fractures. As specific symptoms of hypercortisolism are absent in SH, the SH diagnosis relies only on biochemical tests and it is a challenge for physicians. As a consequence, even the indications for the evaluation of bone involvement in SH patients are debatable and guidelines are not available. Finally, the relative importance of bone density, bone quality and glucocorticoid sensitivity in SH is a recent field of research. On the other hand, SH prevalence seems to be increased in osteoporotic patients, in whom a vertebral fracture may be the presenting symptom of an otherwise asymptomatic cortisol excess. Therefore, the issue of who and how to screen for SH among the osteoporotic patients is widely debated. The present review will summarize the available data regarding the bone turnover, bone mineral density, bone quality and risk of fracture in patients with endogenous SH. In addition, the role of the individual glucocorticoid sensitivity in SH-related bone damage and the problem of diagnosing and managing the bone consequences of SH will be reviewed. Finally, the issue of suspecting and screening for SH patients with apparent primary osteoporosis will be addressed.
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Affiliation(s)
- I Chiodini
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - C Eller Vainicher
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - V Morelli
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - S Palmieri
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - E Cairoli
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - A S Salcuni
- Endocrine UnitDepartment of Medical Sciences, University of Cagliari, Cagliari, Italy
| | | | - A Scillitani
- Unit of Endocrinology"Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
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Jublanc C, Bruckert E. L’insuffisance surrénalienne chez l’adulte. Rev Med Interne 2016; 37:820-826. [DOI: 10.1016/j.revmed.2016.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 02/23/2016] [Indexed: 12/17/2022]
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Chihaoui M, Yazidi M, Chaker F, Belouidhnine M, Kanoun F, Lamine F, Ftouhi B, Sahli H, Slimane H. Bone Mineral Density in Sheehan's Syndrome; Prevalence of Low Bone Mass and Associated Factors. J Clin Densitom 2016; 19:413-418. [PMID: 26993664 DOI: 10.1016/j.jocd.2016.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 02/15/2016] [Accepted: 02/22/2016] [Indexed: 11/16/2022]
Abstract
Hypopituitarism is a known cause of bone mineral loss. This study aimed to evaluate the frequency of osteopenia and osteoporosis in patients with Sheehan's syndrome (SS) and to determine the risk factors. This is a retrospective study of 60 cases of SS that have had a bone mineral density (BMD) measurement. Clinical, biological, and therapeutic data were collected. The parameters of osteodensitometry at the femoral neck and the lumbar spine of 60 patients with SS were compared with those of 60 age-, height-, and weight-matched control women. The mean age at BMD measurement was 49.4 ± 9.9 yr (range: 25-76 yr). The mean duration of SS was 19.3 ± 8.5 yr (range: 3-41 yr). All patients had corticotropin deficiency and were treated with hydrocortisone at a mean daily dose of 26.3 ± 4.1 mg. Fifty-seven patients (95%) had thyrotropin deficiency and were treated with thyroxine at a mean daily dose of 124.3 ± 47.4 µg. Thirty-five of the 49 patients, aged less than 50 yr at diagnosis and having gonadotropin deficiency (71.4%), had estrogen-progesterone substitution. Osteopenia was present in 25 patients (41.7%) and osteoporosis in 21 (35.0%). The BMD was significantly lower in the group with SS than in the control group (p < 0.001). The odds ratio of osteopenia-osteoporosis was 3.1 (95% confidence interval: 1.4-6.8) at the femoral neck and 3.7 (95% confidence interval: 1.7-7.8) at the lumbar spine. The lumbar spine was more frequently affected by low bone mineral mass (p < 0.05). The duration of the disease and the daily dose of hydrocortisone were independently and inversely associated with BMD at the femoral neck. The daily dose of thyroxine was independently and inversely associated with BMD at the lumbar spine. Estrogen-progesterone replacement therapy was not associated with BMD. Low bone mineral mass was very common in patients with SS. The lumbar spine was more frequently affected. The duration of the disease and the doses of hydrocortisone and thyroxine were involved in bone mineral loss.
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Affiliation(s)
- Melika Chihaoui
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia.
| | - Meriem Yazidi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Manel Belouidhnine
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Faouzi Kanoun
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Faiza Lamine
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Bochra Ftouhi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Hela Sahli
- Department of Rheumatology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Hedia Slimane
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
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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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Williams EL, Choudhury S, Tan T, Meeran K. Prednisolone Replacement Therapy Mimics the Circadian Rhythm More Closely Than Other Glucocorticoids. ACTA ACUST UNITED AC 2016; 1:152-161. [DOI: 10.1373/jalm.2016.020206] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 06/29/2016] [Indexed: 11/06/2022]
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