Morning salivary cortisol versus short Synacthen test as a test of adrenal suppression

Background: The short Synacthen test (SST) is the most commonly used test for the assessment of adrenal suppression. We investigated the potential of a simpler and more cost-effective procedure [morning salivary cortisol (MSC)] as an outpatient screening tool to detect adrenal suppression in patients using topical intranasal corticosteroids for rhinosinusitis.

Method: Forty-eight patients who were using topical corticosteroids underwent adrenal function assessment by way of SST and MSC measurement.

Results: Sixteen of the 48 patients had impaired MSCs. Of these 16 patients, 15 had an impaired SST (sensitivity 100%) and one had a normal SST. All patients with normal MSCs also had normal SSTs (specificity 97%).

Conclusion: The morning salivary cortisol measurement is a useful screening tool for adrenal suppression in this setting.

Synthetic ACTH in High Risk Patients with Idiopathic Membranous Nephropathy: A Prospective, Open Label Cohort Study

New therapeutic agents are warranted in idiopathic membranous nephropathy. Synthetic ACTH may be advantageous with reported remission rates up to 85% and few side effects. We conducted a prospective open label cohort study from 2008 till 2010 (NCT00694863). We prospectively selected patients with idiopathic membranous nephropathy and high risk for progression (defined as βeta-2-microglobulin (β2m) excretion of >500 ng/min). For comparison, we selected matched historical controls treated with cyclophosphamide. The prospectively selected patients received intramuscular injections of synthetic ACTH during 9 months (maximal dose 1 mg twice a week). The primary endpoints concerned the feasibility and incidence of remissions as a primary event. Secondary endpoints included side effects of treatment and the incidence of remissions and relapses at long-term follow-up. Twenty patients (15 men) were included (age 54±14 years, serum creatinine 104 μmol/l [IQR 90–113], urine protein:creatinine ratio 8.7 g/10 mmol creatinine [IQR 4.3–11.1]). Seventeen patients (85%) completed treatment. 97% of injections were administered correctly. Cumulative remission rate was 55% (complete remission in 4 patients, partial remission 7 patients). In a group of historical controls treated with cyclophosphamide and steroids, 19 of 20 patients (95%) developed a remission (complete remission in 13 patients, partial remission in 6 patients) (p<0.01). The main limitation of our study is its small size and the use of a historical control group. We show that treatment with intramuscular injections of synthetic ACTH is feasible. Our data suggest that synthetic ACTH is less effective than cyclophosphamide in inducing a remission in high risk patients with idiopathic membranous nephropathy. The use of synthetic ACTH was also associated with many adverse events. Therefore, we advise against synthetic ACTH as standard treatment in membranous nephropathy.

Risk of catecholaminergic crisis following glucocorticoid administration in patients with an adrenal mass: a literature review

BACKGROUND

Glucocorticoids as diagnostic or therapeutic agents have been reported to carry an increased risk of catecholaminergic crisis (CC) in patients with pheochromocytoma or paraganglioma (PPGL).

METHODS

We searched literature databases using the following terms: pheochromocytoma, paraganglioma, adrenal incidentaloma, steroids, glucocorticoids, dexamethasone suppression test (DST), hypertensive crisis, cosyntropin and CRH. From all published case reports (1962-2013), we reviewed medical history, presenting symptoms, dose and route of steroid administration, location and size of adrenal mass, biochemical phenotype and outcome.

RESULTS

Twenty-five case reports describing a CC were identified. Three patients with an adrenal incidentaloma suffered a CC following high-dose DST, and in one case, this was fatal. In two of these patients, biochemical testing missed the diagnosis, and in the third, a DST was done despite elevated urinary metanephrines. No CC has been reported for patients undergoing a low-dose DST. Three of 16 patients who received therapeutic glucocorticoids and four of six patients following cosyntropin testing died. No specific biochemical phenotype was related to adverse events.

CONCLUSIONS

Although a causal relationship cannot be established from this review, it seems prudent to exclude a PPGL in patients with a large incidentaloma or when high-dose DST is considered in a patient with an incidentaloma of any size. Our literature review does not support the need for biochemical testing for PPGL prior to a low-dose (1 mg) DST. Finally, before starting therapeutic glucocorticoids, any clinical signs or symptoms of a potential PPGL should prompt reliable biochemical testing to rule out a PPGL.

Therapeutic efficacy and adverse effects of adrenocorticotropic hormone therapy in west syndrome: differences in dosage of adrenocorticotropic hormone, onset of age, and cause

OBJECTIVES

To determine the dosage and factors influencing efficacy of adrenocorticotropic hormone (ACTH) for West syndrome.

STUDY DESIGN

A retrospective study of 135 patients receiving ACTH therapy with a synthetic analogue for initial effect, seizure outcome 1 year after therapy, and adverse effects. Efficacy and adverse effects were compared among the groups divided by clinical factors: dosage, treatment lag, onset age, and cause.

RESULTS

One hundred thirteen patients had seizure control with ACTH. For more than 1 year after ACTH, 59 remained seizure free. Adverse effects were observed in 57, and ACTH therapy was discontinued in 23. The lowest dosage group (0.0125 mg/kg/d) had fewer episodes of discontinuation (P<.05), whereas differences in efficacy between different dosages were insignificant. None of the clinical factors correlated with initial effect. The earlier-onset group (<4 months) showed unfavorable seizure outcome 1 year after ACTH (P<.01). The cryptogenic patients showed better seizure outcome (P<.05) compared with the symptomatic.

CONCLUSION

Synthetic ACTH therapy at a lower dosage is as effective as natural ACTH therapy at a higher dosage. Considering the adverse effects and the benefits for seizure control, the ACTH dosage of 0.0125 mg/kg/d (synthetic analogue) is more favorable than larger dosage.

The United Kingdom Infantile Spasms Study comparing vigabatrin with prednisolone or tetracosactide at 14 days: a multicentre, randomised controlled trial

BACKGROUND

Infantile spasms, which comprise a severe infantile seizure disorder, have a high morbidity and are difficult to treat. Hormonal treatments (adrenocorticotropic hormone and prednisolone) have been the main therapy for decades, although little evidence supports their use. Vigabatrin has been recorded to have a beneficial effect in this disorder. We aimed to compare the effects of vigabatrin with those of prednisolone and tetracosactide in the treatment of infantile spasms.

METHODS

The United Kingdom Infantile Spasms Study assessed these treatments in a multicentre, randomised controlled trial in 150 hospitals in the UK. The primary outcome was cessation of spasms on days 13 and 14. Minimum doses were vigabatrin 100 mg/kg per day, oral prednisolone 40 mg per day, or intramuscular tetracosactide depot 0.5 mg (40 IU) on alternate days. Analysis was by intention to treat.

FINDINGS

Of 208 infants screened and assessed, 107 were randomly assigned to vigabatrin (n=52) or hormonal treatments (prednisolone n=30, tetracosactide n=25). None was lost to follow-up. Proportions with no spasms on days 13 and 14 were: 40 (73%) of 55 infants assigned hormonal treatments (prednisolone 21/30 [70%], tetracosactide 19/25 [76%]) and 28 (54%) of 52 infants assigned vigabatrin (difference 19%, 95% CI 1%-36%, p=0.043). Two infants allocated tetracosactide and one allocated vigabatrin received prednisolone. Adverse events were reported in 30 (55%) of 55 infants on hormonal treatments and 28 (54%) of 52 infants on vigabatrin. No deaths were recorded.

INTERPRETATION

Cessation of spasms was more likely in infants given hormonal treatments than those given vigabatrin. Adverse events were common with both treatments.

[Inaugural unilateral adrenal hematoma of an antiphospholipid syndrome]

INTRODUCTION

A primary antiphospholipid syndrome is a very rare cause of adrenal haemorrhage.

OBSERVATION

A 51 year-old man presented with a unilateral adrenal haemorrhage, enhanced by the prescription of Synacthène during the 4 days that preceded. There was no adrenal deficiency but the immunological control revealed the presence of anti-phospholipid antibodies. After 2 years of follow-up, adrenal controls have not shown any underlying tumour or endocrine insufficiency.

COMMENTS

Adrenal involvement is described in the anti-phospholipid syndrome and may present in the form of adrenal deficiency in the case of occasionally only microscopic bilateral haemorrhages. Furthermore, Synacthène is known to induce adrenal haemorrhages although this complication remains rare. Moreover, any unilateral adrenal haemorrhage requires subsequent follow-up for several months or even years in order to eliminate any underlying tumour and to control the absence of any adrenal deficiency if the involvement is bilateral.

Elevated intraocular pressure associated with steroid treatment for infantile spasms

PURPOSE

To evaluate the ocular changes and medical and surgical therapy after high-dose systemic steroid treatment in babies with infantile spasm and hypsarrhythmia.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

In 5 of the 9 (55%) babies with infantile spasm exposed to systemic corticosteroid treatment, an increase in intraocular pressure (IOP) and optic disc cupping was observed.

INTERVENTION

Ophthalmic examination under mild sedation was conducted 3 to 4 weeks after initiation of systemic therapy. Antiglaucoma treatment was given to the patients found to have high IOPs and cup-to-disc ratio changes. Routine follow-up was continued until systemic therapy was completed.

MAIN OUTCOME MEASURES

Controlled IOP with a decrease in cupping damage after antiglaucoma therapy.

RESULTS

Five patients required antiglaucoma treatment; one also underwent augmented trabeculectomy. Mean IOP decreased in this subgroup from 30.1 +/- 9.5 mmHg to 15.4 +/- 4.2 mmHg in the right eye (P = 0.043) and from 32.6 +/- 7.4 mmHg to 15.2 +/- 1.8 mmHg in the left eye (P = 0.043). Mean cup-to-disc ratio improved from 0.53 +/- 0.2 to 0.37 +/- 0.04 in the right eye (P = 0.06) and from 0.57 +/- 0.12 to 0.35 +/- 0.05 in the left eye (P = 0.042).

CONCLUSIONS

The rapid onset of IOP and cup-to-disc ratio changes in patients with infantile spasm and hypsarrhythmia treated by high-dose corticosteroids necessitates early and intensive monitoring to prevent anatomic ocular damage and visual impairment in the future.

Low-dose ACTH therapy for West syndrome: initial effects and long-term outcome

BACKGROUND

Most Japanese pediatric neurologists attempt other treatments before using adrenocorticotropic hormone (ACTH) therapy for West syndrome (WS), and even then, they use only a low-dose synthetic ACTH to avoid serious adverse effects. In this multi-institutional study, the authors analyzed the initial effects, adverse effects, and long-term outcome in patients treated with low-dose synthetic ACTH in Japan.

METHODS

The medical records of 138 patients with WS, who were treated with low-dose synthetic ACTH therapy for the first time at the authors' institutions between 1989 and 1998, were analyzed.

RESULTS

At the end of ACTH therapy, excellent effect on seizures was noted in 106 of 138 (76%) patients, good effect in 23 (17%), and poor effect in 9 (7%). Initial effects on EEG were excellent in 53 of 138 (38%) patients, good in 76 (55%), and poor in 9 (7%). As for seizure prognosis at the time of follow-up, 51 of 99 (52%) patients were seizure-free, whereas 48 (48%) patients had seizures. Mental outcome was normal in 6 of 98 (6%) patients, mild mental retardation in 16 (16%), moderate mental retardation in 26 (27%), and severe mental retardation in 50 (51%). The initial effects of ACTH on seizures and long-term outcome were not dose dependent (daily dosage 0.005 to 0.032 mg/kg, 0.2 to 1.28 IU/kg; total dosage 0.1 to 0.87 mg/kg, 4 to 34.8 IU/kg). The severity of adverse effects correlated with total dosage of ACTH, and the severity of brain volume loss due to ACTH correlated well with the daily dosage and total dosage of ACTH.

CONCLUSION

Low-dose synthetic ACTH therapy is as effective for the treatment of WS as the higher doses used in previous studies. The dosage of synthetic ACTH used in the treatment of WS can be decreased as much as possible to avoid serious adverse effects.

Central serous retinopathy associated with adrenocorticotrophic hormone therapy. A case report and a hypothesis

BACKGROUND

Central serous retinopathy (CSR) has been linked by several authors to the therapeutic use of adrenocorticotrophic hormone (ACTH) or corticosteroids or to endogenous ACTH hypersecretion. Various pathogenic mechanisms have been suggested to explain this phenomenon; all relate to the steroids as the causative agents.

CASE REPORT

A simultaneous, bilateral central serous retinopathy developed in a woman treated by intramuscular injections of a synthetic ACTH analog for arthritis. The condition resolved 2 months after stopping the use of this drug.

DISCUSSION

Many investigators consider CSR to be either a disorder of the retinal pigment epithelium (RPE) ion-pump function or a result of choroidal vascular hyperpermeability. ACTH has a melanotrophic part, melanocyte-stimulating hormone (MSH), that may affect RPE cells, which are melanin-pigmented cells of neuroectoderm origin, and alter their ionic pumping properties. This is supported by evidence in the literature for the effect of MSH on animal RPE cells, as well as on other secreting epithelia. MSH is known to act through increasing intracellular cAMP levels. Based on the current concepts regarding the pathogenesis of CSR, two possible mechanisms for ACTH/MSH-associated CSR are suggested. In the first, MSH increases intracellular cAMP levels in RPE cells, thereby inducing pump dysfunction and a reversal of ionic current direction, leading to subretinal fluid accumulation. An alternative mechanism is based on the known ability of MSH to increase the permeability of blood-aqueous and blood-brain barriers. It is hypothesized that MSH disrupts the outer blood-retinal barrier or causes leakage from choroidal vessels.

[Analysis of adverse factors affecting the result of therapy for West syndrome in children]

West syndrome is a from of epileptic attacks of infants. Diagnosis of West syndrome includes: presence of the sudden violent flexion of the trunk and limbs, psychomotoric development retardation, especially after the onset of attacks, abnormal EEG records, and therapeutical problems. Clinical course and results of therapy were analysed in 66 children with West syndrome (39 boys and 27 girls). Children were divided into four groups, depending on etiology of the disease. Group 1 included 39 children with lesions to CNS during pregnancy; group 2-8 children with developmental CNS disorders, group 3-6 children with a history of encephalitis or meningitis, and group 4-13 children in whom etiology of West syndrome was unclear. Patients were treated with Synacthen-Depot in a daily dose of 0.03 mg/kg combined with other anti-epileptic agents. The most difficult to treat were those children in whom West syndrome occurred below 6 months of life, were psychomotor retarded before the onset of symptoms, hormonal treatment was introduced with delay, there were additional seizures of different etiology, and there were frequently recurrent infections.

Severe hyperkalemia in two patients with diabetes after cosyntropin administration

Some patients with diabetes mellitus are at increased risk for the development of hyperkalemia. Included in this group are patients with glucose-induced hyperkalemia who may have renal insufficiency, hyporeninemic hypoaldosteronism, or other impediments to the release or action of aldosterone. In an unusual demonstration of this abnormality, two patients with diabetes, who form the basis of our report, became markedly hyperglycemic and hyperkalemic after cosyntropin administration. To our knowledge, this complication of adrenocorticotropic hormone (ACTH) stimulation testing has not been previously reported. It should therefore be emphasized that the use of cosyntropin as a diagnostic agent can provoke severe hyperglycemia and hyperkalemia in a susceptible subgroup of patients with diabetes mellitus.

[Tetracosactide (Synacthen Depot) in patients with multiple sclerosis]

In a group of 292 patients, clinically definite cases of multiple sclerosis, 91 of them were administered Tetracosactrin (Synacthen Depot) during the initial or exacerbation attack of the disease. Two female patients developed typical anaphylaxis during the drug use: the first patient after the twenty-second injection and the second one after the sixth injection. Negativity of the cutaneous test to zinc oxide in these two female patients, increased IgE immunoglobulin concentration and positive RAST to the drug suggested to the feature of immediate allergy conditioned by reagins.

Tetracosactrin vs. methylprednisolone in the prevention of emesis in patients receiving FEC regimen for breast cancer

0.5 mg tetracosactrin is considered to be equivalent to 40 mg methylprednisolone with regard to the induced cortisol secretion. 97 female breast cancer patients who received their first two FEC courses (epirubicin 50-75 mg/m2, 5-fluorouracil 500 mg/m2, cyclophosphamide 500 mg/m2) entered this randomised crossover study (76 had previously received an adjuvant treatment); tetracosactrin was administered intramuscularly and methylprednisolone intravenously immediately before chemotherapy administration. The tolerability was evaluated using a diary card during 5 days and patients were asked for their preference at the end of the two cycles. There was no difference either for vomiting (dry heaves were included) or nausea between the two treatments (the analysis was performed on day 1, the worse day of days 2 and 3 and the worse day of days 4 and 5). At day 1, 49% of the patients experienced no or mild nausea after tetracosactrin and 62% after methylprednisolone (not significant) (first period analysis); a complete control of vomiting (including dry heaves) was observed in 49% of the patients after tetracosactrin and 53% after methylprednisolone (not significant). No difference was observed between patients with or without previous chemotherapy. However, slightly more patients preferred tetracosactrin (P = 0.048).

[Fatal legionellosis in an infant treated with ACTH]

A new case of fatal systemic legionnaires' disease is reported in an infant. This 8 month-old boy was given a protracted treatment with adrenocorticotropic hormones for infantile spasms. Legionella pneumophila type I was found in tracheal secretions and there was multivisceral involvement at autopsy. The mode of contamination and the severity of the disease are discussed in the light of the immunosuppressive properties of the glucocorticoids administered over a period of 4 weeks.

[The family physician and drug side-effects. Observations from general practice--conclusions for general practice]

Several side effects of drugs observed in an office of a general practitioner are described. The cause of these side effects, their prevention and their treatment are discussed.

Possible steroid withdrawal syndrome following short Synacthen test--a personal report

Symptoms not attributable either to disease rebound or to adrenal suppression have been reported both in patients receiving steroids when long-term therapy has been stopped and in normal volunteers after single oral doses of prednisolone or intravenous equivalents. This so-called steroid withdrawal syndrome remains poorly understood. It has not previously been reported following exposure to increased levels of endogenous steroids after diagnostic administration of synthetic adrenocorticotrophic hormone (ACTH). The author's personal experience of an apparent steroid withdrawal reaction following a short Synacthen test is described. It is suggested that as yet unidentified individual factors must play a role in determining whether steroid withdrawal symptoms occur. Closer observation of other subjects after the Synacthen test might reveal other instances of steroid withdrawal symptomatology following this common diagnostic procedure.

Hyperkalemia as a late side effect of prolonged adrenocorticotropic hormone therapy for infantile spasms

Two infants developed hyperkalemia shortly after cessation of prolonged ACTH therapy for infantile spasms. We wish to call for cautious approach at time of cessation of prolonged ACTH therapy because of possible unexpected and only partially understood hazardous side effects such as hyperkalemia.

[Fatal complication of intravenous administration of synthetic adrenocorticotrophin]

Synthetic 1-24adrenocorticotrophin (tetracosactid, Synacthen) is used in clinical medicine for diagnostic and therapeutic purposes. Side effects may occur due to unphysiological stimulation of endogenous adrenocortical hormone production. Allergic reactions to tetracosactid are rare. Anaphylactic shock leading to death was observed after intravenous injection of tetracosactid in a 14-year-old girl with bronchial asthma. Adrenocorticotrophin antibodies could be demonstrated after death in serum and ascitic fluid using the double antibody method.

Apparent brain atrophy and subdural hematoma following ACTH therapy

A case of subdural hematoma following ACTH-Z therapy for infantile spasms was presented. A female baby of 5 months old showed little clinical evidence of cerebral dysfunction associated with subdural hematoma. There have been several reports about the relationship between steroid treatment and apparent brain atrophy on the CT brain scans. Then, we studied the CT brain scans before and after ACTH-Z therapy for infantile spasms, atonic seizure or Lennox syndrome and showed some relationship between apparent brain atrophy on the CT brain scans and ACTH-Z treatment. We also discussed the possible etiology of apparent brain atrophy and subdural hematoma, and stressed the necessity of extreme caution with long-term ACTH-Z administration.

Drug-related deaths among medical inpatients

Among 26,462 carefully monitored medical inpatients, 24, or 0.9 per 1,000, were considered to have died as a result of a drug or group of drugs. Most of the patients were seriously ill prior to the event that caused death. Six of the deaths-five from fluid overload and one from excessive potassium therapy-may have been preventable.

[Experiences with depot-ACTH (Tetracosactide) in bronchial obstruction]

The difficulties of long term treatment of chronic obstructive lung disease demand knowledge and use of every reasonable therapeutic regimen. In this study effectivity and side effects of Depot-ACTH (Tetracosactid) are presented. The main indications for the use of Depot-ACTH seem to be the uneffectiveness of usual therapy and the attempt of avoiding or reducing corticosteroids. The study confirms the excellent usefulness of Depot-ACTH which did not diminish during long-term application. The side effects are rare and mostly inferior. Only allergic reactions may be serious and must be accounted for.

Corticotrophin and tetracosactrin depot-self-administered for the treatment of eczema

The prolonged use of self-administered corticotrophin in the form of 'CMC ACTH' (Crookes) or 'Synacthen Depot' (Ciba) has been considered in twenty-seven patients with severe subactute of chronic eczema. Complications were not troublesome and the therapeutic response was good. Many of the patients were able to control their disease fully without the effort and discomfort of additional local treatment and patients' acceptance of the treatment was high.

[Synthetic ACTH in theumatic diseases: (author's transl)]

44 patients with acute irritations of degenerative articular diseases and 66 patients with soft tissue rheumatism were treated with Synacthen Depot (tetracosactide hexacetate 1 mg/ml). During the first three days of treatment the patients received an average of 2 ampoulbs Synacthen Depot, then treatment was continued at 3-4 day intervals. In the degenerative joint disease group 86.4% and 89.4% in the group with soft tissue rheumatism became free of complaints or improved with the ACTH treatment. Most of the patients with degenerative joint diseases needed a 4 week treatment; 1/3 of the patients with soft tissue rheumatism were already free of complai

Adverse reactions to Zn1-24 ACTH therapy associated with specific cellular immunity

Lymphocyte transformation to 1-24ACTH, as assessed by the incorporation of tritiated thymidine, has been demonstrated to be associated with severe adverse reactions occurring in patients receiving a Zn-linked 1-24ACTH preparation (Tetra cosactrin depot, 'Synacthen'). Antibodies measured with an isotope-binding assay occurred commonly in all patients receiving therapy and did not correlate with adverse reactions. Lymphocyte transformation with the 1-24ACTH polypeptide, a part of the naturally occurring ACTH molecule, has not been previously recorded. The significance of antibodies and cell-mediated immunity to this polypeptide hormone is discussed.