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Fraga NR, Minaeian N, Kim MS. Congenital Adrenal Hyperplasia. Pediatr Rev 2024; 45:74-84. [PMID: 38296783 DOI: 10.1542/pir.2022-005617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
We describe congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, which is the most common primary adrenal insufficiency in children and adolescents. In this comprehensive review of CAH, we describe presentations at different life stages depending on disease severity. CAH is characterized by androgen excess secondary to impaired steroidogenesis in the adrenal glands. Diagnosis of CAH is most common during infancy with elevated 17-hydroxyprogesterone levels on the newborn screen in the United States. However, CAH can also present in childhood, with late-onset symptoms such as premature adrenarche, growth acceleration, hirsutism, and irregular menses. The growing child with CAH is treated with hydrocortisone for glucocorticoid replacement, along with increased stress doses for acute illness, trauma, and procedures. Mineralocorticoid and salt replacement may also be necessary. Although 21-hydroxylase deficiency is the most common type of CAH, there are other rare types, such as 11β-hydroxylase and 3β-hydroxysteroid dehydrogenase deficiency. In addition, classic CAH is associated with long-term comorbidities, including cardiometabolic risk factors, impaired cognitive function, adrenal rest tumors, and bone health effects. Overall, early identification and treatment of CAH is important for the pediatric patient.
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Affiliation(s)
- Nicole R Fraga
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA
| | - Nare Minaeian
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Mimi S Kim
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine of University of Southern California, Los Angeles, CA
- The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, CA
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Tseng T, Seagroves A, Tanawattanacharoen VK, Liang MC, Koppin CM, Keenan M, Davidowitz E, Nguyen E, Chand S, Geffner ME, Chang TP, Kim MS. Electrolyte abnormalities and stress dosing predict illness-related hospitalizations among infants and toddlers with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2023; 98:536-542. [PMID: 36593179 PMCID: PMC10006318 DOI: 10.1111/cen.14876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 12/22/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Infants and toddlers with classical congenital adrenal hyperplasia (CAH) are at high risk for morbidity/mortality arising from life-threatening adrenal crisis. Management of acute illnesses in CAH requires an understanding of factors leading to emergency department (ED) visits and hospitalizations in the first few years of life. We, therefore, examined adrenal crisis at prehospital and ED stages of illness in young children with CAH as they related to medical outcomes. PATIENTS AND DESIGN Retrospective cohort study of 39 children with CAH due to 21-hydroxylase deficiency (0-4 years of age) and 27 age-matched controls. MEASUREMENTS ED visit, acute illness symptoms (fever, vomiting, diarrhoea) and other characteristics (hospitalizations, administration of stress-dose hydrocortisone, electrolyte abnormalities). RESULTS CAH infants and toddlers had significantly higher rates of ED visits (0.50 [0.25-0.88] per person-year) than controls (0 [0-0] per person-year; p < .001). Moreover, CAH children under 6 months old had significantly higher rates of ED visits compared with older ages. Only 50% (51/102) of illness-related ED visits in CAH children were preceded by the administration of either oral (46/51) or intramuscular (11/51) stress dosing by parents. A total of 10.8% of ED visits resulted in hospital admission. Controlling for age and 17-hydroxyprogesterone at diagnosis, electrolyte abnormalities and administration of parenteral hydrocortisone in the ED significantly predicted hospital admission. Receiving a hydrocortisone injection before the ED was a significant predictor of having electrolyte abnormalities. CONCLUSIONS Infants and toddlers with classical CAH are at high risk for acute illness and hospitalizations and often do not receive adequate stress dosing before the ED.
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Affiliation(s)
- Teresa Tseng
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Amy Seagroves
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Veeraya K Tanawattanacharoen
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Mark C Liang
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Christina M Koppin
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Madison Keenan
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Elana Davidowitz
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Eugene Nguyen
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Sanjay Chand
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Mitchell E Geffner
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
- The Saban Research Institute, Los Angeles, California, USA
- Division of Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Todd P Chang
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
- The Saban Research Institute, Los Angeles, California, USA
- Division of Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Mimi S Kim
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, California, USA
- The Saban Research Institute, Los Angeles, California, USA
- Division of Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
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Lee JH, Torpy DJ. Adrenal insufficiency in pregnancy: Physiology, diagnosis, management and areas for future research. Rev Endocr Metab Disord 2023; 24:57-69. [PMID: 35816262 DOI: 10.1007/s11154-022-09745-6] [Citation(s) in RCA: 1] [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] [Accepted: 06/22/2022] [Indexed: 02/01/2023]
Abstract
Adrenal insufficiency requires prompt diagnosis in pregnancy, as untreated, it can lead to serious consequences such as adrenal crisis, intrauterine growth restriction and even foetal demise. Similarities between symptoms of adrenal insufficiency and those of normal pregnancy can complicate diagnosis. Previously diagnosed adrenal insufficiency needs monitoring and, often, adjustment of adrenal hormone replacement. Many physiological changes occur to the hypothalamic-pituitary-adrenal (HPA) axis during pregnancy, often making diagnosis and management of adrenal insufficiency challenging. Pregnancy is a state of sustained physiologic hypercortisolaemia; there are multiple contributing factors including high plasma concentrations of placental derived corticotropin-releasing hormone (CRH), adrenocorticotropin (ACTH) and increased adrenal responsiveness to ACTH. Despite increased circulating concentrations of CRH-binding protein (CRH-BP) and the major cortisol binding protein, corticosteroid binding globulin (CBG), free concentrations of both hormones are increased progressively in pregnancy. In addition, pregnancy leads to activation of the renin-angiotensin-aldosterone system. Most adrenocortical hormone diagnostic thresholds are not applicable or validated in pregnancy. The management of adrenal insufficiency also needs to reflect the physiologic changes of pregnancy, often requiring increased doses of glucocorticoid and at times mineralocorticoid replacement, especially in the last trimester. In this review, we describe pregnancy induced changes in adrenal function, the diagnosis and management of adrenal insufficiency in pregnancy and areas requiring further research.
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Affiliation(s)
- Jessica H Lee
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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Kim MS, Fraga NR, Minaeian N, Geffner ME. Components of Metabolic Syndrome in Youth With Classical Congenital Adrenal Hyperplasia. Front Endocrinol (Lausanne) 2022; 13:848274. [PMID: 35399922 PMCID: PMC8987274 DOI: 10.3389/fendo.2022.848274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/28/2022] [Indexed: 01/28/2023] Open
Abstract
Classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is the most common primary adrenal insufficiency in children, involving cortisol deficiency, hyperandrogenism, and cardiometabolic risk. Prior studies have reported that youth with classical CAH have a higher prevalence of the components of metabolic syndrome: obesity, hypertension, elevated fasting blood glucose, and dyslipidemia. Yet, the incidence of the complete metabolic syndrome itself in children and adolescents with CAH is relatively rare. Traditional cardiometabolic risk factors can surface early in children with classical CAH, and continue to present and evolve over the lifetime, although it is only recently that reports of Type 2 diabetes and adverse cardiac events have begun to surface in adults affected by this condition. The pathophysiology underlying the increased prevalence of cardiometabolic risk factors in patients with CAH is not well-understood, with disease treatments and androgen excess having been studied to date. The aim of this review is to evaluate the recent literature on traditional cardiometabolic risk factors in youth with classical CAH, and to consider non-traditional risk factors/biomarkers for subclinical atherosclerosis, inflammation, and insulin resistance. A better understanding of these traditional and non-traditional risk factors in youth with CAH could help guide treatment options and prevent the onset of metabolic syndrome in adulthood, reducing overall patient morbidity.
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Affiliation(s)
- Mimi S. Kim
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, CA, United States
- Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
- The Saban Research Institute at Children’s Hospital Los Angeles, Los Angeles, CA, United States
- *Correspondence: Mimi S. Kim,
| | - Nicole R. Fraga
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, CA, United States
| | - Nare Minaeian
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, CA, United States
- Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Mitchell E. Geffner
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, CA, United States
- Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
- The Saban Research Institute at Children’s Hospital Los Angeles, Los Angeles, CA, United States
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Weber J, Tanawattanacharoen VK, Seagroves A, Liang MC, Koppin CM, Ross HM, Bachega TASS, Geffner ME, Serrano-Gonzalez M, Bhullar G, Kim MS. Low Adrenomedullary Function Predicts Acute Illness in Infants With Classical Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2022; 107:e264-e271. [PMID: 34397083 PMCID: PMC8826013 DOI: 10.1210/clinem/dgab600] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Indexed: 01/28/2023]
Abstract
CONTEXT Youth with classical congenital adrenal hyperplasia (CAH) exhibit abnormal adrenomedullary function with decreased epinephrine levels noted in newborns and young infants. Little is known about how this relates to morbidity during the first year of life. OBJECTIVE This work aimed to study plasma epinephrine levels in infants with classical CAH and examine the clinical significance of epinephrine deficiency in the first year of life. METHODS This prospective cohort study comprised participants recruited from a pediatric tertiary care center: 36 infants with classical CAH due to 21-hydroxylase deficiency and 27 age-matched unaffected controls with congenital hypothyroidism. Main outcome measures included plasma epinephrine levels (N = 27), CYP21A2 genotype (N = 15), and incidence of acute illnesses from birth to age 1 year (N = 28). RESULTS Epinephrine levels in CAH infants independently predicted illness incidence in the first year of life (β = -0.018, R = -0.45, P = .02) and were negatively correlated with 17-hydroxyprogesterone at diagnosis (R = -0.51, P = .007). Infants with salt-wasting CAH exhibited lower epinephrine levels as newborns than simple-virilizing infants (P = .02). CAH patients had lower epinephrine as newborns than did controls (P = .007) and showed decreases in epinephrine from birth to age 1 year (P = .04). Null genotype was associated with lower newborn epinephrine and more illness in the first year of life, compared to less severe mutation categories. CONCLUSION Lower epinephrine levels are associated with increased risk of illness among CAH infants. While not currently part of clinical standard of care, measuring epinephrine levels and assessing genotype may help predict acute illness in the first year of life.
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Affiliation(s)
- Jonathan Weber
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Veeraya K Tanawattanacharoen
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Amy Seagroves
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Mark C Liang
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Christina M Koppin
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Heather M Ross
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Tania A S S Bachega
- Laboratory of Hormones and Molecular Genetics-LIM 42, Division of Endocrinology, Clinics Hospital, School of Medicine, São Paulo University, São Paulo 05508-220, Brazil
| | - Mitchell E Geffner
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
- Keck School of Medicine of University of Southern California, Los Angeles, California 90033, USA
- The Saban Research Institute at Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Monica Serrano-Gonzalez
- Keck School of Medicine of University of Southern California, Los Angeles, California 90033, USA
- Division of Pediatric Endocrinology, Hasbro Children’s Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island 02903, USA
| | - Gagandeep Bhullar
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Mimi S Kim
- Correspondence: Mimi S. Kim, MD, Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 61, Los Angeles, CA 90027, USA.
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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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Melau C, Nielsen JE, Perlman S, Lundvall L, Langhoff Thuesen L, Juul Hare K, Schou Hammerum M, Frederiksen H, Mitchell RT, Juul A, Jørgensen A. Establishment of a Novel Human Fetal Adrenal Culture Model that Supports de Novo and Manipulated Steroidogenesis. J Clin Endocrinol Metab 2021; 106:843-857. [PMID: 33212489 DOI: 10.1210/clinem/dgaa852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 12/28/2022]
Abstract
CONTEXT Disorders affecting adrenal steroidogenesis promote an imbalance in the normally tightly controlled secretion of mineralocorticoids, glucocorticoids, and androgens. This may lead to differences/disorders of sex development in the fetus, as seen in virilized girls with congenital adrenal hyperplasia (CAH). Despite the important endocrine function of human fetal adrenals, neither normal nor dysregulated adrenal steroidogenesis is understood in detail. OBJECTIVE Due to significant differences in adrenal steroidogenesis between human and model species (except higher primates), we aimed to establish a human fetal adrenal model that enables examination of both de novo and manipulated adrenal steroidogenesis. DESIGN AND SETTING Human adrenal tissue from 54 1st trimester fetuses were cultured ex vivo as intact tissue fragments for 7 or 14 days. MAIN OUTCOME MEASURES Model validation included examination of postculture tissue morphology, viability, apoptosis, and quantification of steroid hormones secreted to the culture media measured by liquid chromatography-tandem mass spectrometry. RESULTS The culture approach maintained cell viability, preserved cell populations of all fetal adrenal zones, and recapitulated de novo adrenal steroidogenesis based on continued secretion of steroidogenic intermediates, glucocorticoids, and androgens. Adrenocorticotropic hormone and ketoconazole treatment of ex vivo cultured human fetal adrenal tissue resulted in the stimulation of steroidogenesis and inhibition of androgen secretion, respectively, demonstrating a treatment-specific response. CONCLUSIONS Together, these data indicate that ex vivo culture of human fetal adrenal tissue constitutes a novel approach to investigate local effects of pharmaceutical exposures or emerging therapeutic options targeting imbalanced steroidogenesis in adrenal disorders, including CAH.
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Affiliation(s)
- Cecilie Melau
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - John E Nielsen
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Signe Perlman
- Department of Gynaecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lene Lundvall
- Department of Gynaecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lea Langhoff Thuesen
- Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Kristine Juul Hare
- Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Mette Schou Hammerum
- Departmet of Obstetrics and Gynaecology, Herlev University Hospital, Herlev, Denmark
| | - Hanne Frederiksen
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Rod T Mitchell
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Anders Juul
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne Jørgensen
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Dallos-Lara MF, Mendoza-Rojas VC. Pubertad precoz por hiperplasia adrenal congénita. Reporte de caso. REVISTA DE LA FACULTAD DE MEDICINA 2020. [DOI: 10.15446/revfacmed.v68n1.72674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. La pubarca antes de los 8 años en niñas y de los 9 años en niños, es una manifestación de la pubertad precoz asociada al aumento en la velocidad de crecimiento. La hiperplasia adrenal congénita (HAC) no clásica es una de las causas de pubertad precoz.Presentación de caso. Paciente femenina de padres consanguíneos (primos hermanos) quien inició pubarca a los cuatro años 6 meses de edad. La niña presentaba edad ósea avanzada, talla discordante con la talla media parental y sus genitales externos eran normales. Luego de realizar el test de estimulación con hormona adrenocorticotropa y otros exámenes hormonales, se encontró que sus niveles de 17-hidroxiprogesterona eran elevados, lo que permitió diagnosticarla con HAC no clásica. Con base en este diagnóstico, se inició tratamiento con glucocorticoides y luego de un año de tratamiento la paciente tuvo una buena evolución clínica, ya que no se observó progresión de los caracteres sexuales secundarios ni de la edad ósea.Conclusión. La HAC no clásica es la causa más frecuente de la PPP. Ya que este tipo de hiperplasia puede ser asintomática durante los primeros días o años de vida, se debe sospechar su diagnóstico en la infancia cuando haya pubarca precoz, mayor velocidad de crecimiento y edad ósea avanzada.
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de Oliveira DM, Vasques ACJ, Gonçalves EM, de Lemos-Marini SHV, Guerra-Junior G, Geloneze B. ENERGY EXPENDITURE IN 21-HYDROXYLASE CONGENITAL ADRENAL HYPERPLASIA PATIENTS AND COMPARISON WITH PREDICTIVE EQUATIONS. Endocr Pract 2019; 26:388-398. [PMID: 31859548 DOI: 10.4158/ep-2019-0390] [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: 11/15/2022]
Abstract
Objective: To characterize resting energy expenditure (REE) in patients with classic 21-hydroxylase congenital adrenal hyperplasia (21-OH CAH) using indirect calorimetry and compare it to the most commonly used REE predictive equations. Methods: This case-control study comprised 29 post-pubertal 21-OH CAH patients regularly followed at the University of Campinas. Elevated serum 17-hydroxyprogesterone and CYP21 gene molecular analysis confirmed the diagnosis. A healthy control group paired by age, gender, and body mass index was examined. Dual-energy X-ray absorptiometry (DEXA) measured body compositions. A bioimpedance analyzer determined fat-free mass, and indirect calorimetry using a metabolic cart measured REE. Results: Unlike our initial hypothesis, REE was similar between the groups (18.7 ± 3.1 kcal/kg/day in CAH vs. 20.3 ± 3.5 kcal/kg/day in controls; P = .728). No predictive equations reached the stipulated accuracy criteria, thus lacking validity in REE assessment in adults with the characteristics of the group studied. DEXA analysis revealed higher body fat and diminished nonbone lean mass in 21-OH CAH. Anthropometric and bioelectrical impedance parameters were not significantly different. Conclusion: Classic 21-OH CAH is generally followed in reference centers, which may facilitate indirect calorimetry use for REE measurement. Alternatively, considering our REE findings in adult 21-OH CAH patients, nutrition management based on 25 kcal/body weight/day (measured REE × activity factor 1.2 to 1.3) may be reasonable for current body weight maintenance in these patients. Abbreviations: 17-OHP = 17-hydroxyprogesterone; 21-OH CAH = classic 21-hydroxylase deficiency congenital adrenal hyperplasia; BMI = body mass index; REE = resting energy expenditure; VO2 = volume of oxygen; VCO2 = volume of carbon dioxide.
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Abstract
Congenital adrenal hyperplasia has traditionally been treated with daily oral doses of glucocorticoids and mineralocorticoid supplements. Such therapy does not precisely replicate the adrenal cortex's circadian pattern. As a consequence, patients are intermittently overtreated or undertreated leading to growth suppression in children, excess weight gain and altered metabolism. Several new treatments are on the horizon. This article will summarize some new potential therapies as adjuncts to, or replacement for, standard therapy.
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Affiliation(s)
- Phyllis W Speiser
- Pediatrics, Zucker School of Medicine at Hofstra-Northwell Health, Lake Success, New York, 11042-2062, USA
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11
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Kim MS, Koppin CM, Mohan P, Goodarzian F, Ross HM, Geffner ME, De Filippo R, Kokorowski P. Absence of Testicular Adrenal Rest Tumors in Newborns, Infants, and Toddlers with Classical Congenital Adrenal Hyperplasia. Horm Res Paediatr 2019; 92:157-161. [PMID: 31747670 PMCID: PMC7004842 DOI: 10.1159/000504135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/14/2019] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Testicular adrenal rest tumors (TART) are a known consequence for males with classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. TART are associated with potential infertility in adults. However, little is known about TART in very young males with CAH. OBJECTIVE We assessed the presence of TART in newborn, infant, and toddler males with classical CAH via scrotal ultrasound. METHODS Males with CAH had scrotal ultrasounds during the first 4 years of life, evaluating testes for morphology, blood flow, and presence of TART. Newborn screen 17-hydroxyprogesterone (17-OHP) and serum 17-OHP at the time of ultrasound were recorded. Bone ages were considered very advanced if ≥2 SD above chronological age. RESULTS Thirty-one ultrasounds in 16 males were performed. An initial ultrasound was obtained in four newborns at diagnosis (6.8 ± 2.1 days), six infants (2.2 ± 0.9 months), and six toddlers (2.4 ± 0.9 years). Eleven males had at least one repeat ultrasound. A large proportion (11/16) were in poor hormonal control with an elevated 17-OHP (325 ± 298 nmol/L). One infant was in very poor hormonal control (17-OHP 447 nmol/L) at initial ultrasound, and two toddlers had advanced bone ages (+3.2 and +4.5 SD) representing exposure to postnatal androgens. However, no TART were detected in any subjects. CONCLUSIONS TART were not found by scrotal ultrasound in males up to 4 years of age with classical CAH despite settings with expected high ACTH drive. Further research into the occurrence of TART in CAH may elucidate factors that contribute to the detection and individual predisposition to TART.
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Affiliation(s)
- Mimi S. Kim
- Corresponding Author: Mimi Kim, M.D., M.Sc., Children’s Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #61, Los Angeles, CA 90027, , Phone: +1 323-361-1358
| | - Christina M. Koppin
- Center for Endocrinology, Diabetes, and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
| | - Pankhuri Mohan
- Center for Endocrinology, Diabetes, and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
| | - Fariba Goodarzian
- Children’s Hospital Los Angeles, Los Angeles, California, United States of America,Keck School of Medicine of University of Southern California,Department of Radiology, Children’s Hospital Los Angeles
| | - Heather M. Ross
- Center for Endocrinology, Diabetes, and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
| | - Mitchell E. Geffner
- Center for Endocrinology, Diabetes, and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California, United States of America,Keck School of Medicine of University of Southern California,The Saban Research Institute
| | - Roger De Filippo
- Children’s Hospital Los Angeles, Los Angeles, California, United States of America,Keck School of Medicine of University of Southern California,Division of Pediatric Urology, Children’s Hospital Los Angeles
| | - Paul Kokorowski
- Children’s Hospital Los Angeles, Los Angeles, California, United States of America,Keck School of Medicine of University of Southern California,Division of Pediatric Urology, Children’s Hospital Los Angeles
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12
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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 505] [Impact Index Per Article: 84.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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13
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Vidmar AP, Weber JF, Monzavi R, Koppin CM, Kim MS. Improved medical-alert ID ownership and utilization in youth with congenital adrenal hyperplasia following a parent educational intervention. J Pediatr Endocrinol Metab 2018; 31:213-219. [PMID: 29315077 PMCID: PMC7140978 DOI: 10.1515/jpem-2017-0435] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 11/28/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Classical congenital adrenal hyperplasia (CAH) is a potentially life-threatening condition, and adrenal crisis is a major cause of morbidity and mortality in affected children. Medical-alert identification (ID) could prevent complications of adrenal crisis by identifying the need for time-sensitive, critical treatment. Our objectives were to evaluate usage of medical-alert IDs by CAH youth, ownership and awareness of IDs amongst their parents, and the effect of an in-clinic educational intervention on ID utilization. METHODS Fifty families of youth with classical CAH secondary to 21-hydroxylase deficiency (11.2±5.0 years old, 58% female) were prospectively studied. An in-clinic needs assessment survey was administered at baseline to parents, paired with an educational intervention, and a follow-up needs assessment phone survey 1 month post-intervention. A quality improvement (QI) framework was utilized with plan-do-study-act (PDSA) process-improvement cycles. RESULTS At baseline, 20/50 (40%) CAH families owned a medical-alert ID, of which only 10/20 (50%) of ID owners reported usage >3 days per week. Only 26/50 (52%) parents were aware of ID options. Post-intervention, ID ownership doubled to 39/50 (78%; p<0.05), usage amongst ID owners reached 100% (39/39), and awareness increased to 42/50 (84%; p<0.05). A surprising barrier reported by five Spanish-speaking families was the inability to order medical-alert IDs online. CONCLUSIONS Only a small percentage of CAH youth frequently wear a medical-alert ID, but utilization can be effectively improved with an in-clinic educational intervention. Further study is merited to assess a potential reduction in morbidity and mortality of adrenal crisis with increased medical-alert ID utilization.
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Affiliation(s)
- Alaina P Vidmar
- Center for Endocrinology, Diabetes and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jonathan F Weber
- Center for Endocrinology, Diabetes and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Roshanak Monzavi
- Center for Endocrinology, Diabetes and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Christina M Koppin
- Center for Endocrinology, Diabetes and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Mimi S Kim
- Center for Endocrinology, Diabetes and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine of University of Southern California, Los Angeles, CA, USA.,The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, CA, USA
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14
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Abstract
The congenital adrenal hyperplasias comprise a family of autosomal recessive disorders that disrupt adrenal steroidogenesis. The most common form is due to 21-hydroxylase deficiency associated with mutations in the 21-hydroxylase gene, which is located at chromosome 6p21. The clinical features associated with each disorder of adrenal steroidogenesis represent a clinical spectrum that reflect the consequences of the specific mutations. Treatment goals include normal linear growth velocity and "on-time" puberty in affected children. For adolescent and adult women, treatment goals include regularization of menses, prevention of progression of hirsutism, and preservation of fertility. For adolescent and adult men, prevention and early treatment of testicular adrenal rest tumors is beneficial. In this article key aspects regarding pathophysiology, diagnosis, and treatment of congenital adrenal hyperplasia are reviewed.
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Affiliation(s)
- Selma Feldman Witchel
- Division of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania.
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15
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Recommendations for the diagnosis and treatment of classic forms of 21-hydroxylase-deficient congenital adrenal hyperplasia. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.anpede.2016.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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16
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Rodríguez A, Ezquieta B, Labarta JI, Clemente M, Espino R, Rodriguez A, Escribano A. [Recommendations for the diagnosis and treatment of classic forms of 21-hydroxylase-deficient congenital adrenal hyperplasia]. An Pediatr (Barc) 2017; 87:116.e1-116.e10. [PMID: 28161392 DOI: 10.1016/j.anpedi.2016.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 12/05/2016] [Indexed: 11/18/2022] Open
Abstract
Congenital adrenal hyperplasia due to 21-hydroxylase deficiency is an autosomal recessive disorder caused by mutations in the CYP21A2 gene. Cortisol and aldosterone synthesis are impaired in the classic forms (adrenal insufficiency and salt-wasting crisis). Females affected are virilised at birth, and are at risk for genital ambiguity. In this article we give recommendations for an early as possible diagnosis and an appropriate and individualised treatment. A patient and family genetic study is essential for the diagnosis of the patient, and allows genetic counselling, as well as a prenatal diagnosis and treatment for future pregnancy.
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Affiliation(s)
- Amparo Rodríguez
- Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - Begoña Ezquieta
- Fundación para Investigación Gregorio Marañón, Madrid, España
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17
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Testicular Adrenal Rest Tumors in Boys and Young Adults with Congenital Adrenal Hyperplasia. J Urol 2016; 197:931-936. [PMID: 27840017 DOI: 10.1016/j.juro.2016.09.072] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE Testicular adrenal rest tumors are a well-known complication in males who have congenital adrenal hyperplasia with potential infertility in adulthood. We assessed the prevalence of testicular adrenal rest tumors in infants to young men presenting to a congenital adrenal hyperplasia Comprehensive Care Center. MATERIALS AND METHODS A total of 35 males with congenital adrenal hyperplasia due to 21-hydroxylase deficiency underwent scrotal ultrasonography, including 7 younger than 5 years, 9 who were 5 to 12 years old and 19 who were older than 12 years. Three and 35 patients had classic and nonclassic congenital adrenal hyperplasia, respectively. Bone age x-ray or advanced bone age x-ray history, glucocorticoid dose, fludrocortisone dose, and serum 17-hydroxyprogesterone, testosterone and androstenedione levels within 3 months of ultrasound were also recorded. RESULTS Testicular adrenal rest tumors were detected in 5 of 35 patients (14%), including 1 of 9 (11%) who were 5 to 12 years old and 4 of 19 (21%) who were older than 12 years. The tumors were not detected in any patients younger than 5 years, including 1 infant with poor hormonal control. The youngest patient with positive findings was 6.6 years old. All patients with positive findings had bilateral disease and only 1 had suspicious physical findings. The glucocorticoid dose and 17-hydroxyprogesterone did not differ between patients with vs without a testicular adrenal rest tumor. Those with a tumor were more likely to have advanced bone age x-ray results (100% vs 42%, p = 0.04) and higher fludrocortisone dose (p <0.01). All males with nonclassic congenital adrenal hyperplasia had negative tumor findings. CONCLUSIONS Testicular adrenal rest tumors were present in young males with classic congenital adrenal hyperplasia but not in infants or toddlers. These tumors were associated with higher fludrocortisone requirements and a history of advanced bone age x-ray results. However, the tumors did not develop in all poorly controlled males. Longitudinal studies are needed to understand the individual predisposition to testicular adrenal rest tumors and the age at which to begin screening patients with congenital adrenal hyperplasia.
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18
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Exploring the Impact of Short- and Long-Term Hydrocortisone Replacement on Cognitive Function, Quality of Life and Catecholamine Secretion: A Pilot Study. Appl Psychophysiol Biofeedback 2016; 41:341-7. [DOI: 10.1007/s10484-016-9338-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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19
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Simunkova K, Jovanovic N, Rostrup E, Methlie P, Øksnes M, Nilsen RM, Hennø H, Tilseth M, Godang K, Kovac A, Løvås K, Husebye ES. Effect of a pre-exercise hydrocortisone dose on short-term physical performance in female patients with primary adrenal failure. Eur J Endocrinol 2016; 174:97-105. [PMID: 26494876 DOI: 10.1530/eje-15-0630] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 10/21/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Many patients with primary adrenal insufficiency (Addison's disease) take extra doses of glucocorticoids during stressful events, but a benefit has not been demonstrated in controlled trials. Here, we investigated the effects of a pre-exercise hydrocortisone dose on cardiorespiratory, hormonal and metabolic parameters in response to short-term strenuous physical activity. DESIGN This was a randomized placebo-controlled, two-week cross-over clinical trial. PARTICIPANTS Ten women with Addison's disease and 10 age-matched healthy females participated in the study. MEASUREMENTS All women in the study underwent maximal incremental exercise testing. A stress dose of 10 mg hydrocortisone or placebo was given 1 h prior to exercise on two occasions. Blood samples were drawn before, and 0, 15 and 30 min post exercise. Oxygen uptake, maximal aerobic capacity, endocrine and metabolic responses to physical activity, as well as health status by questionnaires were evaluated. RESULTS Maximal aerobic capacity and duration of exercise were significantly lower in patients than in healthy subjects and did not improve with the treatment. After an extra hydrocortisone dose serum cortisol was significantly higher than in the healthy subjects (P<0.001). Post-exercise glucose and adrenaline levels were significantly lower and free fatty acids insignificantly higher in patients irrespective of stress dose. Stress dosing did not alter other metabolic or hormonal parameters or quality of life after the exercise. CONCLUSIONS The patients did not benefit from an extra dose of hydrocortisone in short strenuous exercise. Stress dosing may not be justified in this setting. Whether stress dosing is beneficial in other types of physical activity will have to be examined further.
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Affiliation(s)
- Katerina Simunkova
- Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway
| | - Nevena Jovanovic
- Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway
| | - Espen Rostrup
- Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway
| | - Paal Methlie
- Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway
| | - Marianne Øksnes
- Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway
| | - Roy Miodini Nilsen
- Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway
| | - Hanne Hennø
- Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway
| | - Mira Tilseth
- Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway
| | - Kristin Godang
- Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway
| | - Ana Kovac
- Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway
| | - Kristian Løvås
- Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway
| | - Eystein S Husebye
- Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway Department of Clinical ScienceUniversity of Bergen, N-5021 Bergen, NorwayDepartments of MedicineHeart DiseaseCenter for Clinical Research Haukeland University HospitalBergen, 5021 Bergen, NorwaySection of Specialized EndocrinologyDepartment of Endocrinology, Oslo University Hospital Rikshospitalet, N-0027 Oslo, Norway
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