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Troger T, Sommer G, Lang-Muritano M, Konrad D, Kuhlmann B, Zumsteg U, Flück CE. Characteristics of Growth in Children With Classic Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency During Adrenarche and Beyond. J Clin Endocrinol Metab 2022; 107:e487-e499. [PMID: 34599587 PMCID: PMC8764343 DOI: 10.1210/clinem/dgab701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with classic congenital adrenal hyperplasia (CAH) often do not achieve their full growth potential. Adrenarche may accelerate bone maturation and thereby result in decreased growth in CAH. OBJECTIVE The study aimed to analyze the impact of growth during adrenarche on final height of adequately treated classic CAH patients. METHODS This retrospective, multicenter study (4 academic pediatric endocrinology centers) included 41 patients with classical CAH, born 1990-2012. We assessed skeletal maturation (bone age), growth velocity, and (projected) adult height outcomes, and analyzed potential influencing factors, such as sex, genotype, and glucocorticoid therapy. RESULTS Patients with classic CAH were shorter than peers (-0.4 SDS ± 0.8 SD) and their parents (corrected final height -0.6 SDS ± 1.0 SD). Analysis of growth during adrenarche revealed 2 different growth patterns: patients with accelerating bone age (49%), and patients with nonaccelerating bone age relative to chronological age (BA-CA). Patients with accelerating BA-CA were taller than the normal population during adrenarche years (P = 0.001) and were predicted to achieve lower adult height SDS (-0.9 SDS [95% CI, -1.3; -0.5]) than nonaccelerating patients when assessed during adrenarche (0.2 SDS [95% CI, -0.3; 0.8]). Final adult height was similarly reduced in both accelerating and nonaccelerating BA-CA groups (-0.4 SDS [95% CI, -0.9; 0.1] vs -0.3 SDS [95% CI, [-0.8; 0.1]). CONCLUSION Patients with and without significant bone age advancement, and thus differing height prediction during adrenarche, showed similar (predicted) final height when reassessed during pubertal years. Bone age alone should not be used during adrenarche as clinical marker for metabolic control in CAH treatment.
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Affiliation(s)
- Tobias Troger
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department of Biomedical Research, University of Bern, 3010 Bern, Switzerland
| | - Grit Sommer
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department of Biomedical Research, University of Bern, 3010 Bern, Switzerland
| | - Mariarosaria Lang-Muritano
- Department of Pediatric Endocrinology and Diabetology and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zürich, Switzerland
| | - Daniel Konrad
- Department of Pediatric Endocrinology and Diabetology and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, 8032 Zürich, Switzerland
| | | | - Urs Zumsteg
- Pediatric Endocrinology and Diabetology, University Children’s Hospital Basel UKBB, University of Basel, 4056 Basel, Switzerland
| | - Christa E Flück
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department of Biomedical Research, University of Bern, 3010 Bern, Switzerland
- Correspondence: Christa E. Flück, MD, Pediatric Endocrinology, Diabetology and Metabolism, University Children’s Hospital, Freiburgstrasse 15/ C845, 3010 Bern, Switzerland.
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Auchus RJ, Courtillot C, Dobs A, El-Maouche D, Falhammar H, Lacroix A, Farrar M, O’Donoghue C, Anatchkova M, Cutts K, Taylor N, Yonan C, Lamotte M, Touraine P. Treatment patterns and unmet needs in adults with classic congenital adrenal hyperplasia: A modified Delphi consensus study. Front Endocrinol (Lausanne) 2022; 13:1005963. [PMID: 36465641 PMCID: PMC9717438 DOI: 10.3389/fendo.2022.1005963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is a rare autosomal recessive condition characterized by cortisol deficiency and excess androgen production. The current standard of care is glucocorticoid (GC) therapy, and sometimes mineralocorticoids, to replace endogenous cortisol deficiency; however, supraphysiologic GC doses are usually needed to reduce excess androgen production. Monitoring/titrating GC treatment remains a major challenge, and there is no agreement on assessment of treatment adequacy. This study surveyed expert opinions on current treatment practices and unmet needs in adults with classic CAH. METHODS A modified two-round Delphi process with adult endocrinologists was conducted via online questionnaire. Survey questions were organized into three categories: practice characteristics/CAH experience, GC management, and unmet needs/complications. Anonymized aggregate data from Round 1 were provided as feedback for Round 2. Responses from both rounds were analyzed using descriptive statistics. Consensus was defined a priori as: full consensus (100%, n=9/9); near consensus (78% to <100%, n=7/9 or 8/9); no consensus (<78%, n<7/9). RESULTS The same nine panelists participated in both survey rounds; five (56%) were based in North America and four (44%) in Europe. Most panelists (78%) used hydrocortisone in the majority of patients, but two (22%) preferred prednisone/prednisolone. Panelists agreed (89%) that adequate control is best evaluated using a balance of clinical presentation and androgen/precursor laboratory values; no consensus was reached on optimal timing of collecting samples for androgen testing or laboratory values indicating good control. Despite lack of consensus on many aspects of CAH management, panelists agreed on the importance of many disease- and GC-related complications, and that there is a large unmet need for new treatments. With currently available treatments, panelists reported that 46% of classic CAH patients did not have optimized androgen levels, regardless of GC dose. CONCLUSIONS The limited areas of consensus obtained in this study reflect the variability in treatment practices for adults with classic CAH, even among clinicians with expertise in treating this population. However, all panelists agreed on the need for new treatments for classic CAH and the importance of many disease- and GC-related complications, which are difficult to manage with currently available treatments.
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Affiliation(s)
- Richard J. Auchus
- Departments of Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI, United States
- *Correspondence: Richard J. Auchus,
| | - Carine Courtillot
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine and Gynecological Disorders, Groupe Hospitalier Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Adrian Dobs
- Department of Medicine, Division of Endocrinology and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Diala El-Maouche
- Division of Endocrinology and Metabolism, George Washington University, Washington, DC, United States
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Andre Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
| | - Mallory Farrar
- Neurocrine Biosciences, Inc., Health Economics and Outcomes Research, San Diego, CA, United States
| | - Conor O’Donoghue
- Neurocrine Biosciences, Inc., New Product Commercialization, San Diego, CA, United States
| | | | - Katelyn Cutts
- Evidera, Patient-Centered Research, Bethesda, MD, United States
| | - Natalie Taylor
- Evidera, Patient-Centered Research, Bethesda, MD, United States
| | - Chuck Yonan
- Neurocrine Biosciences, Inc., Health Economics and Outcomes Research, San Diego, CA, United States
| | - Mark Lamotte
- IQVIA, Global Health Economics and Outcomes Research (HEOR), Zaventem, Belgium
| | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine and Gynecological Disorders, Groupe Hospitalier Pitié-Salpêtrière, Sorbonne Université, Paris, France
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Khattab A, Haider S, Kumar A, Dhawan S, Alam D, Romero R, Burns J, Li D, Estatico J, Rahi S, Fatima S, Alzahrani A, Hafez M, Musa N, Razzghy Azar M, Khaloul N, Gribaa M, Saad A, Charfeddine IB, Bilharinho de Mendonça B, Belgorosky A, Dumic K, Dumic M, Aisenberg J, Kandemir N, Alikasifoglu A, Ozon A, Gonc N, Cheng T, Kuhnle-Krahl U, Cappa M, Holterhus PM, Nour MA, Pacaud D, Holtzman A, Li S, Zaidi M, Yuen T, New MI. Clinical, genetic, and structural basis of congenital adrenal hyperplasia due to 11β-hydroxylase deficiency. Proc Natl Acad Sci U S A 2017; 114:E1933-E1940. [PMID: 28228528 PMCID: PMC5347606 DOI: 10.1073/pnas.1621082114] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH), resulting from mutations in CYP11B1, a gene encoding 11β-hydroxylase, represents a rare autosomal recessive Mendelian disorder of aberrant sex steroid production. Unlike CAH caused by 21-hydroxylase deficiency, the disease is far more common in the Middle East and North Africa, where consanguinity is common often resulting in identical mutations. Clinically, affected female newborns are profoundly virilized (Prader score of 4/5), and both genders display significantly advanced bone ages and are oftentimes hypertensive. We find that 11-deoxycortisol, not frequently measured, is the most robust biochemical marker for diagnosing 11β-hydroxylase deficiency. Finally, computational modeling of 25 missense mutations of CYP11B1 revealed that specific modifications in the heme-binding (R374W and R448C) or substrate-binding (W116C) site of 11β-hydroxylase, or alterations in its stability (L299P and G267S), may predict severe disease. Thus, we report clinical, genetic, hormonal, and structural effects of CYP11B1 gene mutations in the largest international cohort of 108 patients with steroid 11β-hydroxylase deficiency CAH.
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Affiliation(s)
- Ahmed Khattab
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Shozeb Haider
- School of Pharmacy, University College London, London WC1N 4AX, United Kingdom
| | - Ameet Kumar
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Samarth Dhawan
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Dauood Alam
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Raquel Romero
- School of Pharmacy, University College London, London WC1N 4AX, United Kingdom
| | - James Burns
- School of Pharmacy, University College London, London WC1N 4AX, United Kingdom
| | - Di Li
- School of Pharmacy, University College London, London WC1N 4AX, United Kingdom
| | - Jessica Estatico
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Simran Rahi
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Saleel Fatima
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Ali Alzahrani
- King Faisal Specialist Hospital and Research Centre, Riyadh 12713, Saudi Arabia
| | - Mona Hafez
- Diabetes, Endocrine, and Metabolism Pediatrics Unit, Department of Pediatrics, Cairo University, 11617 Cairo, Egypt
| | - Noha Musa
- Diabetes, Endocrine, and Metabolism Pediatrics Unit, Department of Pediatrics, Cairo University, 11617 Cairo, Egypt
| | - Maryam Razzghy Azar
- Ali Asghar Children's Hospital, Iran University of Medical Sciences, 10000 Tehran, Iran
| | - Najoua Khaloul
- Laboratory of Human Cytogenetic Molecular Genetics and Biology of Reproduction, Farhat Hached University Hospital, Sousse, Tunisia
| | - Moez Gribaa
- Laboratory of Human Cytogenetic Molecular Genetics and Biology of Reproduction, Farhat Hached University Hospital, Sousse, Tunisia
| | - Ali Saad
- Laboratory of Human Cytogenetic Molecular Genetics and Biology of Reproduction, Farhat Hached University Hospital, Sousse, Tunisia
| | - Ilhem Ben Charfeddine
- Laboratory of Human Cytogenetic Molecular Genetics and Biology of Reproduction, Farhat Hached University Hospital, Sousse, Tunisia
| | - Berenice Bilharinho de Mendonça
- Developmental Endocrinology Unit, Hormone and Molecular Genetics Laboratory, University of São Paulo, Sao Paulo 05508, Brazil
| | | | - Katja Dumic
- University Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Miroslav Dumic
- University Hospital Centre Zagreb, 10000 Zagreb, Croatia
| | - Javier Aisenberg
- Pediatric Endocrinology and Diabetes Medicine, Hackensack University Medical Center, Hackensack, NJ 07601
| | - Nurgun Kandemir
- Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
| | | | - Alev Ozon
- Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
| | - Nazli Gonc
- Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
| | - Tina Cheng
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | | | | | - Paul-Martin Holterhus
- Department of Pediatrics, University Hospital of Schleswig-Holstein, 24105 Kiel, Germany
| | - Munier A Nour
- Department of Pediatrics, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada S7N 0W8
| | - Daniele Pacaud
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada T3B 6A8
| | - Assaf Holtzman
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Sun Li
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Mone Zaidi
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Tony Yuen
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - Maria I New
- Division of Adrenal Steroid Disorders, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029;
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029
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