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Tucci L, Fanelli F, Improta I, Bissi V, Lena C, Galante G, Mezzullo M, Magagnoli M, Lalumera AB, Colombin G, Coscia K, Rotolo L, Vicennati V, Pagotto U, Di Dalmazi G. Monitoring adrenal insufficiency through salivary steroids: a pilot study. Eur J Endocrinol 2024; 190:327-337. [PMID: 38571387 DOI: 10.1093/ejendo/lvae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/21/2024] [Accepted: 03/11/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Various glucocorticoid replacement therapies (GRTs) are available for adrenal insufficiency (AI). However, their effectiveness in restoring glucocorticoid rhythm and exposure lacks adequate biochemical markers. We described the diurnal salivary cortisol (SalF) and cortisone (SalE) rhythm among different GRTs and analysed the associations between saliva-derived parameters and life quality questionnaires. METHODS Control subjects (CSs, n = 28) and AI patients receiving hydrocortisone (HC, n = 9), cortisone acetate (CA, n = 23), and dual-release hydrocortisone once (DRHC-od, n = 10) and twice a day (DRHC-td, n = 6) collected 9 saliva samples from 07:00 to 23:00. Patients compiled Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Scale, and Addison disease-specific quality-of-life questionnaires. SalE and SalF were measured by liquid chromatography-mass spectrometry. Exposure was monitored using SalE for HC and DRHC and SalF for CA. Area under the curve (AUC) was computed. Different GRTs were compared by Z-scores calculated from saliva-derived parameters. Questionnaire results predictors were evaluated with multiple regression analysis. RESULTS Compared with controls, all GRTs resulted in glucocorticoid overexposure in the morning. Hydrocortisone, CA, and DRHC-td caused overexposure also in afternoon and evening. Compared with other treatments, CA determined increased Z-score-07:00 (P < .001), DRHC-td determined increased Z-score-AUC07:00→14:00 (P = .007), and DRHC-od induced lower Z-score-AUC14:00→23:00 (P = .015). Z-scores-AUC14:00→16:00 ≥ .619 best predicted questionnaire scores. CONCLUSIONS None of the GRTs mimics normal glucocorticoid rhythmicity and exposure. SalE, SalF, and Z-score may be useful markers for monitoring and comparing different GRTs. Excess glucocorticoid in early afternoon best associated with depressive symptoms and worse life and sleep quality.
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Affiliation(s)
- Lorenzo Tucci
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Flaminia Fanelli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Ilaria Improta
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Valentina Bissi
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Claudia Lena
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Greta Galante
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Marco Mezzullo
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Matteo Magagnoli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Anna Bianca Lalumera
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Giacomo Colombin
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Kimberly Coscia
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Laura Rotolo
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Valentina Vicennati
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Uberto Pagotto
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Guido Di Dalmazi
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
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Dineen RA, Martin-Grace J, Ahmed KMS, Taylor AE, Shaheen F, Schiffer L, Gilligan LC, Lavery GG, Frizelle I, Gunness A, Garrahy A, Hannon AM, Methlie P, Eystein SH, Stewart PM, Tomlinson JW, Hawley JM, Keevil BG, O’Reilly MW, Smith D, McDermott J, Healy ML, Agha A, Pazderska A, Gibney J, Behan LA, Thompson CJ, Arlt W, Sherlock M. Tissue Glucocorticoid Metabolism in Adrenal Insufficiency: A Prospective Study of Dual-release Hydrocortisone Therapy. J Clin Endocrinol Metab 2023; 108:3178-3189. [PMID: 37339332 PMCID: PMC10673701 DOI: 10.1210/clinem/dgad370] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/01/2023] [Accepted: 06/16/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Patients with adrenal insufficiency (AI) require life-long glucocorticoid (GC) replacement therapy. Within tissues, cortisol (F) availability is under the control of the isozymes of 11β-hydroxysteroid dehydrogenase (11β-HSD). We hypothesize that corticosteroid metabolism is altered in patients with AI because of the nonphysiological pattern of current immediate release hydrocortisone (IR-HC) replacement therapy. The use of a once-daily dual-release hydrocortisone (DR-HC) preparation, (Plenadren®), offers a more physiological cortisol profile and may alter corticosteroid metabolism in vivo. STUDY DESIGN AND METHODS Prospective crossover study assessing the impact of 12 weeks of DR-HC on systemic GC metabolism (urinary steroid metabolome profiling), cortisol activation in the liver (cortisone acetate challenge test), and subcutaneous adipose tissue (microdialysis, biopsy for gene expression analysis) in 51 patients with AI (primary and secondary) in comparison to IR-HC treatment and age- and BMI-matched controls. RESULTS Patients with AI receiving IR-HC had a higher median 24-hour urinary excretion of cortisol compared with healthy controls (72.1 µg/24 hours [IQR 43.6-124.2] vs 51.9 µg/24 hours [35.5-72.3], P = .02), with lower global activity of 11β-HSD2 and higher 5-alpha reductase activity. Following the switch from IR-HC to DR-HC therapy, there was a significant reduction in urinary cortisol and total GC metabolite excretion, which was most significant in the evening. There was an increase in 11β-HSD2 activity. Hepatic 11β-HSD1 activity was not significantly altered after switching to DR-HC, but there was a significant reduction in the expression and activity of 11β-HSD1 in subcutaneous adipose tissue. CONCLUSION Using comprehensive in vivo techniques, we have demonstrated abnormalities in corticosteroid metabolism in patients with primary and secondary AI receiving IR-HC. This dysregulation of pre-receptor glucocorticoid metabolism results in enhanced glucocorticoid activation in adipose tissue, which was ameliorated by treatment with DR-HC.
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Affiliation(s)
- Rosemary A Dineen
- Academic Department of Endocrinology, Beaumont Hospital/Royal College of Surgeons in Ireland, Dublin, D09 YD60, Ireland
| | - Julie Martin-Grace
- Academic Department of Endocrinology, Beaumont Hospital/Royal College of Surgeons in Ireland, Dublin, D09 YD60, Ireland
| | | | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Fozia Shaheen
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Lina Schiffer
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Lorna C Gilligan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Gareth G Lavery
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Isolda Frizelle
- Robert Graves Institute of Endocrinology, Tallaght University Hospital, Dublin, D24 TP66, Ireland
| | - Anjuli Gunness
- Robert Graves Institute of Endocrinology, Tallaght University Hospital, Dublin, D24 TP66, Ireland
| | - Aoife Garrahy
- Academic Department of Endocrinology, Beaumont Hospital/Royal College of Surgeons in Ireland, Dublin, D09 YD60, Ireland
| | - Anne Marie Hannon
- Academic Department of Endocrinology, Beaumont Hospital/Royal College of Surgeons in Ireland, Dublin, D09 YD60, Ireland
| | - Paal Methlie
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
| | | | - Paul M Stewart
- Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford OX3 7LE, UK
| | - James M Hawley
- Department of Clinical Biochemistry, University Hospital of South Manchester, Manchester Academic Health Science Centre, The University of Manchester, Manchester M23 9LT, UK
| | - Brian G Keevil
- Department of Clinical Biochemistry, University Hospital of South Manchester, Manchester Academic Health Science Centre, The University of Manchester, Manchester M23 9LT, UK
| | - Michael W O’Reilly
- Academic Department of Endocrinology, Beaumont Hospital/Royal College of Surgeons in Ireland, Dublin, D09 YD60, Ireland
| | - Diarmuid Smith
- Academic Department of Endocrinology, Beaumont Hospital/Royal College of Surgeons in Ireland, Dublin, D09 YD60, Ireland
| | - John McDermott
- Department of Endocrinology, Connolly Hospital, Dublin, D15 X40D, Ireland
| | - Marie-Louise Healy
- Department of Endocrinology, St James Hospital, Dublin, D08 K0Y5, Ireland
| | - Amar Agha
- Academic Department of Endocrinology, Beaumont Hospital/Royal College of Surgeons in Ireland, Dublin, D09 YD60, Ireland
| | | | - James Gibney
- Robert Graves Institute of Endocrinology, Tallaght University Hospital, Dublin, D24 TP66, Ireland
| | - Lucy-Ann Behan
- Robert Graves Institute of Endocrinology, Tallaght University Hospital, Dublin, D24 TP66, Ireland
| | - Chris J Thompson
- Academic Department of Endocrinology, Beaumont Hospital/Royal College of Surgeons in Ireland, Dublin, D09 YD60, Ireland
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Medical Research Council London, Institute of Medical Sciences, London W12 0NN, UK
| | - Mark Sherlock
- Academic Department of Endocrinology, Beaumont Hospital/Royal College of Surgeons in Ireland, Dublin, D09 YD60, Ireland
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3
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Meyer G, Gruendl M, Chifu I, Hahner S, Werner J, Weiß J, Kienitz T, Quinkler M, Badenhoop K, Herrmann E, Friedrich-Rust M, Bojunga J. Glucocorticoid Replacement for Adrenal Insufficiency and the Development of Non-Alcoholic Fatty Liver Disease. J Clin Med 2023; 12:6392. [PMID: 37835036 PMCID: PMC10573835 DOI: 10.3390/jcm12196392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/18/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023] Open
Abstract
Glucocorticoid excess is a known risk factor for non-alcoholic fatty liver disease (NAFLD). Our objective was to analyse the impact of glucocorticoid replacement therapy on the development of NAFLD and NAFLD-related fibrosis and, therefore, on cardiovascular as well as hepatic morbidity in patients with adrenal insufficiency. Two hundred and fifteen individuals with primary (n = 111) or secondary (n = 104) adrenal insufficiency were investigated for hepatic steatosis and fibrosis using the fatty liver index (FLI), NAFLD fibrosis score (NAFLD-FS), Fibrosis-4 Index (FiB-4) plus sonographic transient elastography. Results were correlated with glucocorticoid doses and cardiometabolic risk parameters. The median dose of hydrocortisone equivalent was 20 mg daily, with a median therapy duration of 15 years. The presence and grade of hepatic steatosis and fibrosis were significantly correlated with cardiometabolic risk factors. We could not find any significant correlations between single, daily or cumulative doses of glucocorticoids and the grade of liver steatosis, nor with fibrosis measured via validated sonographic techniques. In patients with adrenal insufficiency, glucocorticoid replacement within a physiological range of 15-25 mg hydrocortisone equivalent per day does not appear to pose an additional risk for the development of NAFLD, subsequent liver fibrosis, or the cardiovascular morbidity associated with these conditions.
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Affiliation(s)
- Gesine Meyer
- Division of Endocrinology, Medical Clinic 1, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany (J.B.)
| | - Madeleine Gruendl
- Division of Endocrinology, Medical Clinic 1, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany (J.B.)
| | - Irina Chifu
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Stefanie Hahner
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Johanna Werner
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Johannes Weiß
- Division of Hepatology, Department of Medicine II, University Hospital Wuerzburg, 97080 Wuerzburg, Germany
| | - Tina Kienitz
- Endocrinology in Charlottenburg, 10627 Berlin, Germany
| | | | - Klaus Badenhoop
- Division of Endocrinology, Medical Clinic 1, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany (J.B.)
| | - Eva Herrmann
- Institut for Biostatistics and Mathematic Modelling, Goethe University Frankfurt, 60590 Frankfurt, Germany
| | - Mireen Friedrich-Rust
- Division of Hepatology, Medical Clinic 1, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany
| | - Joerg Bojunga
- Division of Endocrinology, Medical Clinic 1, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany (J.B.)
- Division of Hepatology, Medical Clinic 1, University Hospital, Goethe University Frankfurt, 60590 Frankfurt, Germany
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4
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Mohammedi K, Bertherat J, Raverot G, Drui D, Reznik Y, Castinetti F, Chanson P, Fafin M, Brossaud J, Tabarin A. Evidence of Persistent Mild Hypercortisolism in Patients Medically Treated for Cushing Disease: the Haircush Study. J Clin Endocrinol Metab 2023; 108:e963-e970. [PMID: 37144820 DOI: 10.1210/clinem/dgad251] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/06/2023]
Abstract
CONTEXT Cortisol-lowering drugs may not restore a normal cortisol secretion in Cushing disease (CD). OBJECTIVE This work aimed to assess the long-term cortisol exposure in medically treated CD patients using hair-cortisol (HF) and hair-cortisone (HE) measurement. METHODS This multicenter prospective study included 3 groups of female patients: CushMed = 16 treated with a stable cortisol-lowering drug dosage and normal urinary free cortisol (UFC); CushSurg = 13 cured by pituitary surgery; CushBla = 15 receiving stable recommended doses of hydrocortisone following bilateral adrenalectomy. Patients were evaluated for 3 months with their usual treatments. Two late-night saliva and 24-hour urine samples were collected monthly in CushMed, and at study end in CushSurg and CushBla patients. A 3-cm hair sample was collected at study end from all patients. Main outcome measures included clinical score and centralized measurement of UFC, late-night salivary cortisol (LNSF), late-night salivary cortisone (LNSE), HE, HF. RESULTS Despite having almost all UFCs normalized, CushMed patients exhibited increased HE as compared to CushSurg controls (P = .003). CushMed patients also had increased clinical score (P = .001), UFC (P = .03), LNSF, LNSE (P = .0001), and variability in the latter parameters (P = .004). CushBla patients had increased HF and HE, contrasting with LNSEs similar to CushSurg patients. Six of 15 CushMed patients exhibited increased HE concentrations and had increased antihypertensive drug dosage compared to CushMed patients with normal HE (P = .05). CONCLUSION Despite normalized UFCs, a subset of medically treated CD patients displays an altered circadian rhythm of serum cortisol. A single HE measurement identifies chronic mild persistent hypercortisolism and could replace multiple saliva analyzes to monitor medical treatments in CD patients once UFC is normalized.
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Affiliation(s)
- Kamel Mohammedi
- Department of Endocrinology, French Reference Center for Adrenal Cancer, EURACAN European Expert Center on Rare Neuroendocrine Tumors, Hôpital Haut-Lévèque, CHU and University of Bordeaux, F-33604 Pessac, France
| | - Jerome Bertherat
- Department of Endocrinology, French Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Université Paris Cité, Institut Cochin, Inserm U1016, CNRS UMR8104, F-75014, Paris, France
| | - Gerald Raverot
- Department of Endocrinology, French Reference Center for Rare Pituitary Diseases HYPO, Hospices Civils de Lyon and Inserm U1052, CNRS UMR5286, Claude Bernard Lyon 1 University, Cancer Research Center of Lyon, F-69001, Lyon, France
| | - Delphine Drui
- Department of Endocrinology and Institut du thorax, CHU de Nantes, F-44000 Nantes, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte de Nacre, F-14033 Caen, France
| | - Frederic Castinetti
- Department of Endocrinology, Assistance Publique-Hopitaux de Marseille, French Reference Center for Rare Pituitary Diseases, EURACAN European Expert Center on Rare Pituitary Tumors, La Conception Hospital, Aix Marseille University, F-13385, Marseille, France
| | - Philippe Chanson
- Department of Endocrinology, Reference Center for Rare Pituitary Diseases HYPO, CHU Bicêtre, F-94270 Le Kremlin-Bicêtre, France
| | - Manon Fafin
- Department of Endocrinology, French Reference Center for Adrenal Cancer, EURACAN European Expert Center on Rare Neuroendocrine Tumors, Hôpital Haut-Lévèque, CHU and University of Bordeaux, F-33604 Pessac, France
| | - Julie Brossaud
- Laboratory of Hormonology and Tumor Markers, Nutrition and Integrated Neurobiology Laboratory, UMR 1286, CHU de Bordeaux, F-33300, Bordeaux, France
| | - Antoine Tabarin
- Department of Endocrinology, French Reference Center for Adrenal Cancer, EURACAN European Expert Center on Rare Neuroendocrine Tumors, Hôpital Haut-Lévèque, CHU and University of Bordeaux, F-33604 Pessac, France
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5
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Espiard S, McQueen J, Sherlock M, Ragnarsson O, Bergthorsdottir R, Burman P, Dahlqvist P, Ekman B, Engström BE, Skrtic S, Wahlberg J, Stewart PM, Johannsson G. Improved Urinary Cortisol Metabolome in Addison Disease: A Prospective Trial of Dual-Release Hydrocortisone. J Clin Endocrinol Metab 2021; 106:814-825. [PMID: 33236103 PMCID: PMC7947853 DOI: 10.1210/clinem/dgaa862] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Oral once-daily dual-release hydrocortisone (DR-HC) replacement therapy has demonstrated an improved metabolic profile compared to conventional 3-times-daily (TID-HC) therapy among patients with primary adrenal insufficiency. This effect might be related to a more physiological cortisol profile, but also to a modified pattern of cortisol metabolism. OBJECTIVE This work aimed to study cortisol metabolism during DR-HC and TID-HC. DESIGN A randomized, 12-week, crossover study was conducted. INTERVENTION AND PARTICIPANTS DC-HC and same daily dose of TID-HC were administered to patients with primary adrenal insufficiency (n = 50) vs healthy individuals (n = 124) as controls. MAIN OUTCOME MEASURES Urinary corticosteroid metabolites were measured by gas chromatography/mass spectrometry at 24-hour urinary collections. RESULTS Total cortisol metabolites decreased during DR-HC compared to TID-HC (P < .001) and reached control values (P = .089). During DR-HC, 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) activity measured by tetrahydrocortisol + 5α-tetrahydrocortisol/tetrahydrocortisone ratio was reduced compared to TID-HC (P < .05), but remained increased vs controls (P < .001). 11β-HSD2 activity measured by urinary free cortisone/free cortisol ratio was decreased with TID-HC vs controls (P < .01) but normalized with DR-HC (P = .358). 5α- and 5β-reduced metabolites were decreased with DR-HC compared to TID-HC. Tetrahydrocortisol/5α-tetrahydrocortisol ratio was increased during both treatments, suggesting increased 5β-reductase activity. CONCLUSIONS The urinary cortisol metabolome shows striking abnormalities in patients receiving conventional TID-HC replacement therapy, with increased 11β-HSD1 activity that may account for the unfavorable metabolic phenotype in primary adrenal insufficiency. Its change toward normalization with DR-HC may mediate beneficial metabolic effects. The urinary cortisol metabolome may serve as a tool to assess optimal cortisol replacement therapy.
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Affiliation(s)
- Stéphanie Espiard
- Department of Endocrinology, Sahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Correspondence and Reprint Requests: Stéphanie Espiard, MD, Service d’endocrinologie, diabétologie et métabolisme, Hôpital Huriez, rue Michel Polonovski, CHRU Lille, 59037 Lille Cedex, France. E-mail:
| | - Johanna McQueen
- Department of Endocrinology, Sahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mark Sherlock
- Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Co. Dublin 9, Ireland
| | - Oskar Ragnarsson
- Department of Endocrinology, Sahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ragnhildur Bergthorsdottir
- Department of Endocrinology, Sahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital Malmö, Malmö and University of Lund, Lund, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Bertil Ekman
- Department of Endocrinology, Department of Medical and Health Sciences, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Britt Edén Engström
- Department of Medical Sciences, Endocrinology and Metabolism, Uppsala University Hospital, Uppsala, Sweden
| | - Stanko Skrtic
- Department of Endocrinology, Sahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- AstraZeneca R&D, Mölndal, Sweden
| | - Jeanette Wahlberg
- Department of Endocrinology, Department of Medical and Health Sciences, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Paul M Stewart
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Gudmundur Johannsson
- Department of Endocrinology, Sahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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6
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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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Guzman V, Kenny RA, Feeney J. The impact of glucocorticoid medication use on hair cortisol and cortisone in older adults: Data from the Irish Longitudinal Study on Ageing. Psychoneuroendocrinology 2020; 118:104701. [PMID: 32474347 DOI: 10.1016/j.psyneuen.2020.104701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 04/05/2020] [Accepted: 04/21/2020] [Indexed: 11/17/2022]
Abstract
Research focusing on the hair concentration of cortisol and cortisone has significantly developed over the last two decades and has huge potential to provide relevant insights into stress-related diseases. However it is not clearly understood exactly how glucocorticoid (GC) medications, which are commonly prescribed drugs particularly among older adults, may affect hair cortisol and cortisone levels. The aim of this study was to examine associations of the use of GC medications with hair cortisol and cortisone concentrations in a sample of older adults. Hair samples and data were collected from participants at Wave 3 of The Irish Longitudinal Study of Ageing (TILDA). Results showed that before and after controlling for socio-demographic, health and hair characteristics, the use of systemic GCs was associated with decreased hair cortisone (B= -0.34 95 % CI -0.53, -0.16, p < 0.001). However, the use of local GCs was associated with increased hair cortisol (B = 0.39 95 % CI 0.18, 0.61). Further analysis suggests that the latter finding may be the result of use of topical steroid creams/ointments. These data add to the scant literature on the impact of steroid medication use on hair cortisol and cortisone in non-clinical populations, providing further evidence that future hair GC studies need to consider steroid medication use.
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Affiliation(s)
- Viveka Guzman
- The Irish Longitudinal Study on Ageing (TILDA), Lincoln Gate, Trinity College, Dublin 2, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (TILDA), Lincoln Gate, Trinity College, Dublin 2, Ireland; Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin 8, Ireland
| | - Joanne Feeney
- The Irish Longitudinal Study on Ageing (TILDA), Lincoln Gate, Trinity College, Dublin 2, Ireland.
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8
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Vulto A, Minović I, de Vries LV, Timmermans AC, van Faassen M, Gomes Neto AW, Touw DJ, de Jong MFC, van Beek AP, Dullaart RPF, Navis G, Kema IP, Bakker SJL. Endogenous urinary glucocorticoid metabolites and mortality in prednisolone-treated renal transplant recipients. Clin Transplant 2020; 34:e13824. [PMID: 32052523 PMCID: PMC7216873 DOI: 10.1111/ctr.13824] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 02/03/2020] [Accepted: 02/10/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic corticosteroid treatment suppresses HPA-axis activity and might alter activity of 11β hydroxysteroid dehydrogenases (11β-HSD). We aimed to investigate whether the endogenous glucocorticoid production and 11β-HSD activities are altered in prednisolone-treated renal transplant recipients (RTR) compared with healthy controls and whether this has implications for long-term survival in RTR. METHODS In a longitudinal cohort of 693 stable RTR and 275 healthy controls, 24-hour urinary cortisol, cortisone, tetrahydrocorisol (THF), allotetrahydrocortisol (alloTHF), and tetrahydrocortisone (THE) were measured using liquid chromatography tandem-mass spectrometry. Twenty-four-hour urinary excretion of cortisol and metabolites were used as measures of endogenous glucocorticoid production; (THF + alloTHF)/THE and cortisol/cortisone ratios were used as measures of 11β-HSD activity. RESULTS Urinary cortisol and metabolite excretion were significantly lower in RTR compared with healthy controls (P < .001), whereas (THF + alloTHF)/THE and cortisol/cortisone ratios were significantly higher (P < .001 and P = .002). Lower total urinary metabolite excretion and higher urinary (THF + alloTHF)/THE ratios were associated with increased risk of mortality, independent of age, sex, estimated glomerular filtration rate, C-reactive protein, body surface area, and daily prednisolone dose, respectively. CONCLUSIONS Endogenous glucocorticoid production and 11β-HSD activities are altered in prednisolone-treated RTR. Decreased total urinary endogenous glucocorticoid metabolite excretion and increased urinary (THF + alloTHF)/THE ratios are associated with increased risk of mortality.
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Affiliation(s)
- Annet Vulto
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Isidor Minović
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Top Institute Food and Nutrition, Wageningen, The Netherlands
| | - Laura V de Vries
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arwin C Timmermans
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martijn van Faassen
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Antonio W Gomes Neto
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margriet F C de Jong
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - André P van Beek
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robin P F Dullaart
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gerjan Navis
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ido P Kema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Top Institute Food and Nutrition, Wageningen, The Netherlands
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9
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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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10
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Müller L, Quinkler M. Adrenal disease: Imitating the cortisol profile improves the immune system. Nat Rev Endocrinol 2018; 14:137-139. [PMID: 29348474 DOI: 10.1038/nrendo.2018.5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Lisa Müller
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, 10627 Berlin, Germany
| | - Marcus Quinkler
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, 10627 Berlin, Germany
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11
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Werumeus Buning J, van Faassen M, Brummelman P, Dullaart RPF, van den Berg G, van der Klauw MM, Kerstens MN, Stegeman CA, Muller Kobold AC, Kema IP, Wolffenbuttel BHR, van Beek AP. Effects of Hydrocortisone on the Regulation of Blood Pressure: Results From a Randomized Controlled Trial. J Clin Endocrinol Metab 2016; 101:3691-3699. [PMID: 27490921 DOI: 10.1210/jc.2016-2216] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
CONTEXT Cardiovascular risk is increased in patients with secondary adrenal insufficiency, which may be ascribed to an unfavorable metabolic profile consequent to a relatively high hydrocortisone replacement dose. OBJECTIVE We determined the effects of a higher versus a lower glucocorticoid replacement dose on blood pressure (BP), the renin-angiotensin-aldosterone system, 11β-hydroxysteroid dehydrogenase enzyme activity and circulating (nor)metanephrines. DESIGN, SETTING, AND PATIENTS Forty-seven patients with secondary adrenal insufficiency from the University Medical Center Groningen participated in this randomized double-blind crossover study. INTERVENTIONS Patients randomly received 0.2-0.3 mg hydrocortisone/kg body weight followed by 0.4-0.6 mg hydrocortisone/kg body weight, or vice versa, each during 10 weeks. MAIN OUTCOME MEASURE(S) BP and regulating hormones were measured. RESULTS The higher hydrocortisone dose resulted in an increase in systolic BP of 5 (12) mm Hg (P = .011), diastolic BP of 2 (9) mm Hg (P = .050), and a median [interquartile range] drop in plasma potassium of -0.1 [-0.3; 0.1] nmol/liter (P = .048). The higher hydrocortisone dose led to decreases in serum aldosterone of -28 [-101; 9] pmol/liter (P = .020) and plasma renin of -1.3 [-4.5; 1.2 ] pg/mL (P = .051), and increased the ratio of plasma and urinary cortisol to cortisone (including their metabolites) (P < .001 for all). Furthermore, on the higher dose, plasma and urinary normetanephrine decreased by -0.101 [-0.242; 0.029] nmol/liter (P < .001) and -1.48 [-4.06; 0.29] μmol/mol creatinine (P < .001) respectively. CONCLUSIONS A higher dose of hydrocortisone increased systolic and diastolic BP and was accompanied by changes in the renin-angiotensin-aldosterone system, 11β-hydroxysteroid dehydrogenase enzyme activity, and circulating normetanephrine. This demonstrates that hydrocortisone dose even within the physiological range affects several pathways involved in BP regulation.
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Affiliation(s)
- Jorien Werumeus Buning
- Department of Endocrinology (J.W.B., P.B., R.P.F.D., G.v.d.B., M.M.v.d.K., M.N.K., A.P.v.B.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Laboratory Medicine (M.v.F., A.C.M.K., I.P.K.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology (C.A.S.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martijn van Faassen
- Department of Endocrinology (J.W.B., P.B., R.P.F.D., G.v.d.B., M.M.v.d.K., M.N.K., A.P.v.B.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Laboratory Medicine (M.v.F., A.C.M.K., I.P.K.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology (C.A.S.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Pauline Brummelman
- Department of Endocrinology (J.W.B., P.B., R.P.F.D., G.v.d.B., M.M.v.d.K., M.N.K., A.P.v.B.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Laboratory Medicine (M.v.F., A.C.M.K., I.P.K.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology (C.A.S.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robin P F Dullaart
- Department of Endocrinology (J.W.B., P.B., R.P.F.D., G.v.d.B., M.M.v.d.K., M.N.K., A.P.v.B.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Laboratory Medicine (M.v.F., A.C.M.K., I.P.K.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology (C.A.S.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerrit van den Berg
- Department of Endocrinology (J.W.B., P.B., R.P.F.D., G.v.d.B., M.M.v.d.K., M.N.K., A.P.v.B.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Laboratory Medicine (M.v.F., A.C.M.K., I.P.K.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology (C.A.S.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Melanie M van der Klauw
- Department of Endocrinology (J.W.B., P.B., R.P.F.D., G.v.d.B., M.M.v.d.K., M.N.K., A.P.v.B.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Laboratory Medicine (M.v.F., A.C.M.K., I.P.K.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology (C.A.S.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel N Kerstens
- Department of Endocrinology (J.W.B., P.B., R.P.F.D., G.v.d.B., M.M.v.d.K., M.N.K., A.P.v.B.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Laboratory Medicine (M.v.F., A.C.M.K., I.P.K.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology (C.A.S.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Coen A Stegeman
- Department of Endocrinology (J.W.B., P.B., R.P.F.D., G.v.d.B., M.M.v.d.K., M.N.K., A.P.v.B.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Laboratory Medicine (M.v.F., A.C.M.K., I.P.K.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology (C.A.S.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anneke C Muller Kobold
- Department of Endocrinology (J.W.B., P.B., R.P.F.D., G.v.d.B., M.M.v.d.K., M.N.K., A.P.v.B.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Laboratory Medicine (M.v.F., A.C.M.K., I.P.K.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology (C.A.S.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ido P Kema
- Department of Endocrinology (J.W.B., P.B., R.P.F.D., G.v.d.B., M.M.v.d.K., M.N.K., A.P.v.B.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Laboratory Medicine (M.v.F., A.C.M.K., I.P.K.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology (C.A.S.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bruce H R Wolffenbuttel
- Department of Endocrinology (J.W.B., P.B., R.P.F.D., G.v.d.B., M.M.v.d.K., M.N.K., A.P.v.B.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Laboratory Medicine (M.v.F., A.C.M.K., I.P.K.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology (C.A.S.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - André P van Beek
- Department of Endocrinology (J.W.B., P.B., R.P.F.D., G.v.d.B., M.M.v.d.K., M.N.K., A.P.v.B.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Laboratory Medicine (M.v.F., A.C.M.K., I.P.K.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology (C.A.S.), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Garrahy A, Agha A. How should we interrogate the hypothalamic-pituitary-adrenal axis in patients with suspected hypopituitarism? BMC Endocr Disord 2016; 16:36. [PMID: 27316460 PMCID: PMC4912809 DOI: 10.1186/s12902-016-0117-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 06/06/2016] [Indexed: 02/05/2023] Open
Abstract
Hypopituitarism is deficiency of one or more pituitary hormones, of which adrenocorticotrophic hormone (ACTH) deficiency is the most serious and potentially life-threatening. It may occur in isolation or, more commonly as part of more widespread pituitary failure. Diagnosis requires demonstration of subnormal cortisol rise in response to stimulation with hypoglycemia, glucagon, ACTH(1-24) or in the setting of acute illness. The choice of diagnostic test should be individualised for the patient and clinical scenario. A random cortisol and ACTH level may be adequate in making a diagnosis in an acutely ill patient with a suspected adrenal crisis e.g. pituitary apoplexy. Often however, dynamic assessment of cortisol reserve is needed. The cortisol response is both stimulus and assay- dependent and normative values should be derived locally. Results must be interpreted within clinical context and with understanding of potential pitfalls of the test used.
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Affiliation(s)
- Aoife Garrahy
- Division of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Amar Agha
- Division of Endocrinology, Beaumont Hospital, Dublin, Ireland.
- RCSI Medical School, Dublin, Ireland.
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