51
|
Schulz J, Frey KR, Cooper MS, Zopf K, Ventz M, Diederich S, Quinkler M. Reduction in daily hydrocortisone dose improves bone health in primary adrenal insufficiency. Eur J Endocrinol 2016; 174:531-8. [PMID: 26811406 DOI: 10.1530/eje-15-1096] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 01/25/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Individuals with primary adrenal insufficiency (PAI) or congenital adrenal hyperplasia (CAH) receive life-long glucocorticoid (GC) replacement therapy. Current daily GC doses are still higher than the reported adrenal cortisol production rate. This GC excess could result in long-term morbidities such as osteoporosis. No prospective trials have investigated the long-term effect of GC dose changes in PAI and CAH patients. METHODS This is a prospective and longitudinal study including 57 subjects with PAI (42 women) and 33 with CAH (21 women). Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry at baseline and after 2 years. Subjects were divided into three groups (similar baseline characteristics) depending on changes in daily hydrocortisone equivalent dose (group 1: unchanged 25.2±8.2 mg (mean±S.D., n=50); group 2: increased 18.7±10.3 to 25.9±12.0 mg (n=13); group 3: decreased 30.8±8.5 to 21.4±7.2 mg (n=27)). RESULTS Subjects in group 1 showed normal lumbar and femoral Z-scores which were unchanged over time. Group 2 subjects showed a significant decrease in femoral neck Z-scores over time (-0.15±1.1 to -0.37±1.0 (P<0.05)), whereas group 3 subjects showed a significant increase in lumbar spine and hip Z-scores (L1-L4: -0.93±1.2 to -0.65±1.5 (P<0.05); total hip: -0.40±1.0 to -0.28±1.0 (P<0.05)). No changes in BMI over time were seen within any group. Reduction in GC dose did not increase the risk of adrenal crisis. CONCLUSION This study demonstrates for the first time that cautious reduction in hydrocortisone equivalent doses leads to increases in BMD, whereas dose increments reduced BMD. These data emphasize the need for the lowest possible GC replacement dose in AI patients to maintain health and avoid long-term adverse effects.
Collapse
Affiliation(s)
- Julia Schulz
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Kathrin R Frey
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Mark S Cooper
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Kathrin Zopf
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Manfred Ventz
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Sven Diederich
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Marcus Quinkler
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| |
Collapse
|
52
|
Debono M, Mallappa A, Gounden V, Nella AA, Harrison RF, Crutchfield CA, Backlund PS, Soldin SJ, Ross RJ, Merke DP. Hormonal circadian rhythms in patients with congenital adrenal hyperplasia: identifying optimal monitoring times and novel disease biomarkers. Eur J Endocrinol 2015; 173:727-37. [PMID: 26340969 PMCID: PMC4623929 DOI: 10.1530/eje-15-0064] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 09/04/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The treatment goal in congenital adrenal hyperplasia (CAH) is to replace glucocorticoids while avoiding androgen excess and iatrogenic Cushing's syndrome. However, there is no consensus on how to monitor disease control. Our main objectives were to evaluate hormonal circadian rhythms and use these profiles to identify optimal monitoring times and novel disease biomarkers in CAH adults on intermediate- and long-acting glucocorticoids. DESIGN This was an observational, cross-sectional study at the National Institutes of Health Clinical Center in 16 patients with classic CAH. METHODS Twenty-four-hour serum sampling for ACTH, 17-hydroxyprogesterone (17OHP), androstenedione (A4), androsterone, DHEA, testosterone, progesterone and 24-h urinary pdiol and 5β-pdiol was carried out. Bayesian spectral analysis and cosinor analysis were performed to detect circadian rhythmicity. The number of hours to minimal (TminAC) and maximal (TmaxAC) adrenocortical hormone levels after dose administration was calculated. RESULTS A significant rhythm was confirmed for ACTH (r(2), 0.95; P<0.001), 17OHP (r(2), 0.70; P=0.003), androstenedione (r(2), 0.47; P=0.043), androsterone (r(2), 0.80; P<0.001), testosterone (r(2), 0.47; P=0.042) and progesterone (r(2), 0.64; P=0.006). The mean (s.d.) TminAC and TmaxAC for 17OHP and A4 were: morning prednisone (4.3 (2.3) and 9.7 (3.5) h), evening prednisone (4.5 (2.0) and 10.3 (2.4) h), and daily dexamethasone (9.2 (3.5) and 16.4 (7.2) h). AUC0-24 h progesterone, androsterone and 24-h urine pdiol were significantly related to 17OHP. CONCLUSION In CAH patients, adrenal androgens exhibit circadian rhythms influenced by glucocorticoid replacement. Measurement of adrenocortical hormones and interpretation of results should take into account the type of glucocorticoid and time of dose administration. Progesterone and backdoor metabolites may provide alternative disease biomarkers.
Collapse
Affiliation(s)
- Miguel Debono
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Ashwini Mallappa
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Verena Gounden
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Aikaterini A Nella
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Robert F Harrison
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Christopher A Crutchfield
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Peter S Backlund
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Steven J Soldin
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Richard J Ross
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Deborah P Merke
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| |
Collapse
|
53
|
Pijnenburg-Kleizen KJ, Engels M, Mooij CF, Griffin A, Krone N, Span PN, van Herwaarden AE, Sweep FCGJ, Claahsen-van der Grinten HL. Adrenal Steroid Metabolites Accumulating in Congenital Adrenal Hyperplasia Lead to Transactivation of the Glucocorticoid Receptor. Endocrinology 2015. [PMID: 26207344 DOI: 10.1210/en.2015-1087] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Patients with congenital adrenal hyperplasia (CAH) are often clinically less severely affected by cortisol deficiency than anticipated from their enzymatic defect. We hypothesize that adrenal steroid hormone precursors that accumulate in untreated or poorly controlled CAH have glucocorticoid activity and partially compensate for cortisol deficiency. We studied the in vitro effects of 17-hydroxyprogesterone (17OHP), progesterone (P), 21-deoxycortisol (21DF), and androstenedione (Δ4) on the human glucocorticoid receptor (hGR). Competitive binding assays were performed in HeLa cells. Nuclear translocation of the hGR was studied by transfection of COS-7 cells with a GFP-tagged hGR and fluorescence microscopy. Transactivation assays were performed in COS-7 cells and in HEK 293 cells after cotransfection with hGR and luciferase reporter vectors using a dual luciferase assay. 17OHP, P, and 21DF are able to bind to the hGR with binding affinities of 24-43% compared with cortisol. Δ4 has a low binding affinity. Incubation with 21DF led to complete nuclear translocation of the hGR, whereas treatment with 17OHP or P resulted in partial nuclear translocation. 21DF transactivated the hGR with an EC50 approximately 6 times the EC50 of cortisol. 17OHP and P transactivated the hGR with EC50s of more than 100 times the EC50 of cortisol. No hGR transactivation was detected after incubation with Δ4. 21DF, 17OHP, and P are able to bind, translocate, and transactivate the hGR in vitro and thus may have glucocorticoid activity. 21DF might have a clinically relevant agonistic effect on the hGR and could potentially partially compensate the cortisol deficiency in CAH patients.
Collapse
Affiliation(s)
- K J Pijnenburg-Kleizen
- Department of Pediatrics (K.J.P.-K., M.E., C.F.M., H.L.C.v.d.G.), and Department of Laboratory Medicine (M.E., A.E.v.H., F.C.G.J.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands; Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine (A.G., N.K.), University of Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Radiation Oncology (P.N.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands
| | - M Engels
- Department of Pediatrics (K.J.P.-K., M.E., C.F.M., H.L.C.v.d.G.), and Department of Laboratory Medicine (M.E., A.E.v.H., F.C.G.J.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands; Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine (A.G., N.K.), University of Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Radiation Oncology (P.N.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands
| | - C F Mooij
- Department of Pediatrics (K.J.P.-K., M.E., C.F.M., H.L.C.v.d.G.), and Department of Laboratory Medicine (M.E., A.E.v.H., F.C.G.J.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands; Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine (A.G., N.K.), University of Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Radiation Oncology (P.N.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands
| | - A Griffin
- Department of Pediatrics (K.J.P.-K., M.E., C.F.M., H.L.C.v.d.G.), and Department of Laboratory Medicine (M.E., A.E.v.H., F.C.G.J.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands; Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine (A.G., N.K.), University of Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Radiation Oncology (P.N.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands
| | - N Krone
- Department of Pediatrics (K.J.P.-K., M.E., C.F.M., H.L.C.v.d.G.), and Department of Laboratory Medicine (M.E., A.E.v.H., F.C.G.J.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands; Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine (A.G., N.K.), University of Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Radiation Oncology (P.N.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands
| | - P N Span
- Department of Pediatrics (K.J.P.-K., M.E., C.F.M., H.L.C.v.d.G.), and Department of Laboratory Medicine (M.E., A.E.v.H., F.C.G.J.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands; Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine (A.G., N.K.), University of Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Radiation Oncology (P.N.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands
| | - A E van Herwaarden
- Department of Pediatrics (K.J.P.-K., M.E., C.F.M., H.L.C.v.d.G.), and Department of Laboratory Medicine (M.E., A.E.v.H., F.C.G.J.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands; Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine (A.G., N.K.), University of Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Radiation Oncology (P.N.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands
| | - F C G J Sweep
- Department of Pediatrics (K.J.P.-K., M.E., C.F.M., H.L.C.v.d.G.), and Department of Laboratory Medicine (M.E., A.E.v.H., F.C.G.J.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands; Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine (A.G., N.K.), University of Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Radiation Oncology (P.N.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands
| | - H L Claahsen-van der Grinten
- Department of Pediatrics (K.J.P.-K., M.E., C.F.M., H.L.C.v.d.G.), and Department of Laboratory Medicine (M.E., A.E.v.H., F.C.G.J.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands; Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine (A.G., N.K.), University of Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Radiation Oncology (P.N.S.), Radboud University Medical Center, 6500HB Nijmegen, The Netherlands
| |
Collapse
|
54
|
Abstract
Congenital adrenal hyperplasia associated with deficiency of steroid 21-hydroxylase is the most common inborn error in adrenal function and the most common cause of adrenal insufficiency in the pediatric age group. As patients now survive into adulthood, adult health-care providers must also be familiar with this condition. Over the past several years, F1000 has published numerous commentaries updating research and practical guidelines for this condition. The purposes of this review are to summarize basic information defining congenital adrenal hyperplasia and to highlight current knowledge and controversies in management.
Collapse
Affiliation(s)
- Phyllis W Speiser
- Department of Pediatrics, Cohen Children's Medical Center and Hofstra North Shore LIJ School of Medicine, New Hyde Park, NY 11040, USA
| |
Collapse
|
55
|
Kok HK, Sherlock M, Healy NA, Doody O, Govender P, Torreggiani WC. Imaging features of poorly controlled congenital adrenal hyperplasia in adults. Br J Radiol 2015; 88:20150352. [PMID: 26133223 DOI: 10.1259/bjr.20150352] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) is a genetic autosomal recessive condition most frequently as a result of a mutation in the 21-hydroxylase enzyme gene. Patients with poorly controlled CAH can manifest characteristic imaging findings as a result of adrenocorticotrophic hormone stimulation or the effects of cortisol precursor excess on various target organs. We present a spectrum of imaging findings encountered in adult patients with poorly treated CAH, with an emphasis on radiological features and their clinical relevance.
Collapse
Affiliation(s)
- H K Kok
- 1 Department of Radiology, Tallaght Hospital, Dublin, Ireland
| | - M Sherlock
- 2 Department of Endocrinology, Tallaght Hospital, Dublin, Ireland
| | - N A Healy
- 1 Department of Radiology, Tallaght Hospital, Dublin, Ireland
| | - O Doody
- 1 Department of Radiology, Tallaght Hospital, Dublin, Ireland
| | - P Govender
- 1 Department of Radiology, Tallaght Hospital, Dublin, Ireland
| | - W C Torreggiani
- 1 Department of Radiology, Tallaght Hospital, Dublin, Ireland
| |
Collapse
|
56
|
Kim SH, Park JH. Bilateral adrenal incidentaloma caused by 21-hydroxylase deficiency in an adult. Endocrine 2015; 49:568-9. [PMID: 25178648 DOI: 10.1007/s12020-014-0405-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 08/23/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Sun Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonbuk National University Medical School/Chonbuk National University Hospital, Geonji-Ro 20, Deokjin-Gu, Jeonju, 561-712, Republic of Korea
| | | |
Collapse
|
57
|
Abstract
Prenatal treatment of congenital adrenal hyperplasia by administering dexamethasone to a woman presumed to be carrying an at-risk fetus remains a controversial experimental treatment. Review of data from animal experimentation and human trials indicates that dexamethasone cannot be considered safe for the fetus. In animals, prenatal dexamethasone decreases birth weight, affects renal, pancreatic beta cell and brain development, increases anxiety and predisposes to adult hypertension and hyperglycemia. In human studies, prenatal dexamethasone is associated with orofacial clefts, decreased birth weight, poorer verbal working memory, and poorer self-perception of scholastic and social competence. Numerous medical societies have cautioned that prenatal treatment of adrenal hyperplasia with dexamethasone is not appropriate for routine clinical practice and should only be done in Institutional Review Board approved, prospective clinical research settings with written informed consent. The data indicate that this treatment is inconsistent with the classic medical ethical maxim to 'first do no harm'.
Collapse
Affiliation(s)
- Walter L Miller
- Department of Pediatrics and Center for Reproductive Sciences, University of California, San Francisco, San Francisco CA 94143-0556, USA.
| |
Collapse
|
58
|
Webb EA, Krone N. Current and novel approaches to children and young people with congenital adrenal hyperplasia and adrenal insufficiency. Best Pract Res Clin Endocrinol Metab 2015; 29:449-68. [PMID: 26051302 DOI: 10.1016/j.beem.2015.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Congenital adrenal hyperplasia (CAH) represents a group of autosomal recessive conditions leading to glucocorticoid deficiency. CAH is the most common cause of adrenal insufficiency (AI) in the paediatric population. The majority of the other forms of primary and secondary adrenal insufficiency are rare conditions. It is critical to establish the underlying aetiology of each specific condition as a wide range of additional health problems specific to the underlying disorder can be found. Following the introduction of life-saving glucocorticoid replacement sixty years ago, steroid hormone replacement regimes have been refined leading to significant reductions in glucocorticoid doses over the last two decades. These adjustments are made with the aim both of improving the current management of children and young persons and of reducing future health problems in adult life. However despite optimisation of existing glucocorticoid replacement regimens fail to mimic the physiologic circadian rhythm of glucocorticoid secretion, current efforts therefore focus on optimising replacement strategies. In addition, in recent years novel experimental therapies have been developed which target adrenal sex steroid synthesis in patients with CAH aiming to reduce co-morbidities associated with sex steroid excess. These developments will hopefully improve the health status and long-term outcomes in patients with congenital adrenal hyperplasia and adrenal insufficiency.
Collapse
Affiliation(s)
- Emma A Webb
- School of Clinical & Experimental Medicine, University of Birmingham, Institute of Biomedical Research, Birmingham B15 2TT, UK.
| | - Nils Krone
- School of Clinical & Experimental Medicine, University of Birmingham, Institute of Biomedical Research, Birmingham B15 2TT, UK.
| |
Collapse
|
59
|
Turcu AF, Rege J, Chomic R, Liu J, Nishimoto HK, Else T, Moraitis AG, Palapattu GS, Rainey WE, Auchus RJ. Profiles of 21-Carbon Steroids in 21-hydroxylase Deficiency. J Clin Endocrinol Metab 2015; 100:2283-90. [PMID: 25850025 PMCID: PMC4454804 DOI: 10.1210/jc.2015-1023] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Marked elevations of 17-hydroxyprogesterone (17OHP) are characteristic of classic 21-hydroxylase deficiency (21OHD). Testing of 17OHP provides the basis for 21OHD diagnosis, although it suffers from several pitfalls. False-positive or false-negative results and poor discrimination of nonclassic 21OHD from carriers limit the utility of serum 17OHP and necessitate dynamic testing after cosyntropin stimulation when values are indeterminate. OBJECTIVE The objective was to provide a detailed characterization of 21-carbon (C21) steroids in classic 21OHD, which might identify other candidate steroids that could be employed for the diagnosis of 21OHD. SETTING AND PARTICIPANTS Patients (11 women, 10 men) with classic 21OHD and 21 sex- and age-matched controls seen in a tertiary referral center were studied. METHODS C21 steroids in the peripheral sera from all subjects, as well as in media from cultured testicular adrenal rest tumor (TART) cells and normal adrenal (NA) cells, were analyzed using liquid chromatography/tandem mass spectrometry (10 steroids). Additionally, the dynamics of C21 steroid metabolism in TART and NA cells were assessed with radiotracer studies. RESULTS Five C21 steroids were significantly higher in 21OHD patients: 17OHP (67-fold; P < .01), 21-deoxycortisol (21dF; 35-fold; P < .01), 16α-hydroxyprogesterone (16OHP; 28-fold; P < .01), progesterone (2-fold; P < .01), and 11β-hydroxyprogesterone (11OHP; not detected in controls; P < .01). The same steroids were the highest in media from TART cells relative to the NA cells: 11OHP, 58- to 65-fold; 21dF, 30- to 41-fold; 17OHP, 9-fold; progesterone, 9- to 12-fold; and 16OHP, 7-fold. CONCLUSION Measurement of 16OHP and 11OHP along with 17OHP and 21dF by liquid chromatography/tandem mass spectrometry might comprise a biomarker panel to accurately diagnose all forms of 21OHD.
Collapse
Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Juilee Rege
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Robert Chomic
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Jiayan Liu
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Hiromi K Nishimoto
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Tobias Else
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Andreas G Moraitis
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Ganesh S Palapattu
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - William E Rainey
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes (A.F.T., J.L., T.E., A.G.M., W.E.R., R.J.A.), Department of Molecular and Integrative Physiology and Medicine (J.R., H.K.N., W.E.R.), Michigan Metabolomics and Obesity Center (R.C.), Department of Urology (G.S.P.), and Department of Pharmacology (R.J.A.), University of Michigan, Ann Arbor, Michigan 48109
| |
Collapse
|
60
|
Mallappa A, Sinaii N, Kumar P, Whitaker MJ, Daley LA, Digweed D, Eckland DJA, Van Ryzin C, Nieman LK, Arlt W, Ross RJ, Merke DP. A phase 2 study of Chronocort, a modified-release formulation of hydrocortisone, in the treatment of adults with classic congenital adrenal hyperplasia. J Clin Endocrinol Metab 2015; 100:1137-45. [PMID: 25494662 PMCID: PMC5393506 DOI: 10.1210/jc.2014-3809] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Treatment of congenital adrenal hyperplasia (CAH) is suboptimal. Inadequate suppression of androgens and glucocorticoid excess are common and current glucocorticoid formulations cannot replace the cortisol circadian rhythm. OBJECTIVES The primary objective was to characterize the pharmacokinetic profile of Chronocort, a modified-release hydrocortisone formulation, in adults with CAH. Secondary objectives included examining disease control following 6 months of Chronocort with dose titration. DESIGN, SETTING, AND PATIENTS Sixteen adults (eight females) with classic CAH participated in an open-label, nonrandomized, Phase 2 study at the National Institutes of Health Clinical Center. Twenty-four-hour blood sampling was performed on conventional glucocorticoids and following 6 months of Chronocort. Chronocort was initiated at 10 mg (0700 h) and 20 mg (2300 h). Dose titration was performed based on androstenedione and 17-hydroxyprogresterone (17-OHP) levels and clinical symptomatology. MAIN OUTCOME MEASURES The primary outcome was cortisol pharmacokinetics of Chronocort and secondary outcomes included biomarkers of CAH control (androstenedione and 17-OHP). RESULTS In patients with CAH, Chronocort cortisol profiles were similar to physiologic cortisol secretion. Compared with conventional therapy, 6 months of Chronocort resulted in a decrease in hydrocortisone dose equivalent (28 ± 11.8 vs 25.9 ± 7.1 mg/d), with lower 24-hour (P = .004), morning (0700-1500 h; P = .002), and afternoon (1500-2300 h; P = .011) androstenedione area under the curve (AUC) and lower 24-hour (P = .023) and morning (0700-1500 h; P = .02) 17-OHP AUC. CONCLUSIONS Twice-daily Chronocort approximates physiologic cortisol secretion, and was well tolerated and effective in controlling androgen excess in adults with CAH. This novel hydrocortisone formulation represents a new treatment approach for patients with CAH.
Collapse
Affiliation(s)
- Ashwini Mallappa
- National Institutes of Health Clinical Center (A.M., N.S., L.A.D., P.K., C.V.R., D.P.M.), Bethesda, Maryland, USA 20892; Diurnal Ltd (M.J.W., D.D., D.J.A.E., W.A., R.J.R.), Cardiff, United Kingdom CF14 4UJ; The Eunice Kennedy Shriver National Institute of Child Health and Human Development (L.K.N., D.P.M.), Bethesda, Maryland, USA 20892; Centre for Endocrinology, Diabetes, and Metabolism, School of Clinical and Experimental Medicine (W.A.), University of Birmingham, Birmingham, United Kingdom B15 2TT; and University of Sheffield (R.J.R), Sheffield, United Kingdom S10 2RX
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
61
|
Abstract
OBJECTIVE The American Association of Clinical Endocrinologists Adrenal Scientific Committee has developed a series of articles to update members on the genetics of adrenal diseases. METHODS Case presentation, discussion of literature, table, and bullet point conclusions. RESULTS The genetic mutations associated with several familial causes of adrenal insufficiency have now been identified. The most common ones that will be discussed here include Allgrove syndrome, adrenoleukodystrophy, adrenal hypoplasia congenita, autoimmune polyglandular syndrome type 1, congenital adrenal hyperplasia (CAH), lipoid CAH, and familial glucocorticoid deficiency. Although these diseases most commonly present in childhood, some rarely present in adulthood, and thus all endocrinologists must be familiar with these syndromes. Some patients only develop glucocorticoid deficiency, and others have both glucocorticoid and mineralocorticoid deficiency. These diseases may be associated with other conditions, especially neurologic disease, hypogonadism, or dermatologic problems. Diagnosis is suspected based on clinical presentation and laboratory findings. Gene testing may be necessary for confirmation of a diagnosis and/or screening of family members. CONCLUSION This article briefly reviews the various familial adrenal insufficiency syndromes and the specific associated gene defects.
Collapse
|
62
|
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive inherited disorders caused by defective steroidogenesis. Steroid 21-hydroxylase deficiency (21OHD) is its most prevalent form, accounting for over 90% of all cases. Clinically classic 21OHD is characterised by glucocorticoid deficiency and adrenal androgen excess with (salt wasting form) or without (simple virilising form) additional mineralocorticoid deficiency. Life-saving glucocorticoid substitution therapy has been available since the 1950s and enables long-term survival, and potentially, a good quality of life. However, care of adult patients with classic congenital adrenal hyperplasia is challenging for two main reasons: firstly, there is no glucocorticoid preparation available mimicking circadian cortisol release and adaptation to stress and secondly, management of adult patients is still in its infancy. There is no evidence-based treatment and experienced centres, taking care of larger patient cohorts, are only emerging. In this article we aim to guide physicians on the treatment and monitoring of adult patients with 21OHD, based on the clinical studies available and our own clinical experience.
Collapse
Affiliation(s)
- Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Department of Endocrinology, University Hospital Munich, Ziemssenstr. 1, 80336 München, Germany.
| |
Collapse
|
63
|
Browne WV, Hindmarsh PC, Pasterski V, Hughes IA, Acerini CL, Spencer D, Neufeld S, Hines M. Working memory performance is reduced in children with congenital adrenal hyperplasia. Horm Behav 2015; 67:83-8. [PMID: 25496755 PMCID: PMC4332548 DOI: 10.1016/j.yhbeh.2014.11.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 11/14/2014] [Accepted: 11/20/2014] [Indexed: 11/19/2022]
Abstract
Individuals with classic congenital adrenal hyperplasia (CAH) experience impaired glucocorticoid production and are treated postnatally with glucocorticoids. Prior research with animals and other human populations indicates that glucocorticoids can influence memory, particularly working memory. We tested the hypothesis that children with CAH would show reduced working memory. Children in the United Kingdom, aged 7-11years, with classical CAH (31 girls, 26 boys) were compared to their unaffected relatives (30 girls, 20 boys) on a test of working memory, the Digit Span test. Vocabulary was also assessed to measure verbal intelligence for control purposes. Children with CAH showed reduced working memory performance compared to controls, on both components of the Digit Span test: p=.008 for Digit Span Forward, and p=.027 for Digit Span Backward, and on a composite score, p=.004. These differences were of moderate size (d=.53 to .70). Similar differences were also seen in a subset of 23 matched pairs of children with CAH and their relatives (d=.78 to .92). There were no group differences on Vocabulary. Glucocorticoid abnormality, including treatment effects, could be responsible for the reduced Digit Span performance in children with CAH. Other factors related to CAH, such as salt-wasting crises, could also be involved. Additional research is needed to identify the cause of the memory reduction, which will help to determine if more rapid diagnosis or more precise glucocorticoid treatment would help prevent memory reduction. Educational interventions might also be considered for children with CAH.
Collapse
Affiliation(s)
- Wendy V Browne
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge CB2 3RQ, United Kingdom
| | - Peter C Hindmarsh
- Department of Paediatric Endocrinology, University College London, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom
| | - Vickie Pasterski
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge CB2 3RQ, United Kingdom; Department of Paediatrics, University of Cambridge, Level 8/Box 116, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
| | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Level 8/Box 116, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
| | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Level 8/Box 116, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
| | - Debra Spencer
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge CB2 3RQ, United Kingdom
| | - Sharon Neufeld
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge CB2 3RQ, United Kingdom
| | - Melissa Hines
- Department of Psychology, University of Cambridge, Free School Lane, Cambridge CB2 3RQ, United Kingdom.
| |
Collapse
|
64
|
Abstract
OBJECTIVE The American Association of Clinical Endocrinologists Adrenal Scientific Committee has developed a series of articles to update members on the genetics of adrenal diseases. METHODS Case presentation, discussion of literature, table, and bullet point conclusions. RESULTS The congenital adrenal hyperplasia (CAH) syndromes are autosomal recessive defects in cortisol biosynthesis. The phenotype of each CAH patient depends on the defective enzyme and the severity of the defect. Clinical manifestations derive from both failure to synthesize hormones distal to the enzymatic block, as well as consequences from cortisol precursor accumulation proximal to the block, often with diversion to other biologically active steroids. The most common form of CAH is 21-hydroxylase deficiency, which occurs in the classic form in 1 in 16,000 newborns and in a milder or nonclassic form in at least 1 in 1,000 people. CONCLUSION This article reviews the various forms of CAH and pitfalls in the diagnosis and treatment of these conditions.
Collapse
|
65
|
Doleschall M, Szabó JA, Pázmándi J, Szilágyi Á, Koncz K, Farkas H, Tóth M, Igaz P, Gláz E, Prohászka Z, Korbonits M, Rácz K, Füst G, Patócs A. Common genetic variants of the human steroid 21-hydroxylase gene (CYP21A2) are related to differences in circulating hormone levels. PLoS One 2014; 9:e107244. [PMID: 25210767 PMCID: PMC4161435 DOI: 10.1371/journal.pone.0107244] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 08/08/2014] [Indexed: 12/01/2022] Open
Abstract
Purpose Systematic evaluation of the potential relationship between the common genetic variants of CYP21A2 and hormone levels. Methods The relationships of CYP21A2 intron 2 polymorphisms and haplotypes with diverse baseline and stimulated blood hormone levels were studied in 106 subjects with non-functioning adrenal incidentaloma (NFAI). The rationale for using NFAI subjects is dual: i) their baseline hormone profiles do not differ from those of healthy subjects and ii) hormone levels after stimulation tests are available. Results The carriers (N = 27) of a well-defined CYP21A2 haplotype cluster (c5) had significantly elevated levels of cortisol (p = 0.0110), and 17-hydroxyprogesterone (p = 0.0001) after ACTH stimulation, and 11-deoxycortisol after metyrapone administration (p = 0.0017), but the hormone values were in normal ranges. In addition, the carriers (N = 33) of the C allele of the rs6462 polymorphism had a higher baseline aldosterone level (p = 0.0006). The prevalence of these genetic variants of CYP21A2 did not differ between NFAI and healthy subjects. Conclusions The common CYP21A2 variants presumably exert the same effect on hormone levels in the healthy and disease-affected populations. Therefore, they may contribute to complex diseases such as some cardiovascular diseases, and may influence the genotype-phenotype correlation in patients with congenital adrenal hyperplasia (CAH) including the individual need for hormone substitution.
Collapse
Affiliation(s)
- Márton Doleschall
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
- Molecular Medicine Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- * E-mail:
| | - Julianna Anna Szabó
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Júlia Pázmándi
- 2nd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Ágnes Szilágyi
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Klára Koncz
- 2nd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
- “Lendület” Hereditary Endocrine Tumours Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Miklós Tóth
- 2nd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Igaz
- 2nd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Edit Gláz
- 2nd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Zoltán Prohászka
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Márta Korbonits
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Károly Rácz
- Molecular Medicine Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
- 2nd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - George Füst
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Attila Patócs
- Molecular Medicine Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
- “Lendület” Hereditary Endocrine Tumours Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| |
Collapse
|
66
|
Han TS, Conway GS, Willis DS, Krone N, Rees DA, Stimson RH, Arlt W, Walker BR, Ross RJ. Relationship between final height and health outcomes in adults with congenital adrenal hyperplasia: United Kingdom congenital adrenal hyperplasia adult study executive (CaHASE). J Clin Endocrinol Metab 2014; 99:E1547-55. [PMID: 24878054 DOI: 10.1210/jc.2014-1486] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Treatment of congenital adrenal hyperplasia (CAH) in childhood focuses on growth and development and adult final height (FH) is a measure of effective treatment. We hypothesized that shorter adults will have more severe underlying disease and worse health outcomes. METHODS This was a cross-sectional analysis of 199 adults with CAH. FH and quality of life were expressed as z-scores adjusted for midparental target height or UK population height. RESULTS FH correlated inversely with age (men, r = -0.38; women, r = -0.26, P < .01). Men and women had z-scores adjusted for midparental target height of -2 and -1, respectively, and both groups had UK population height z-scores of -1 below the UK population (P < .01). In women, FH was shorter in non-salt-wasting than salt-wasting classic CAH (P < .05) and in moderately affected genotype group B women than either more severely affected groups null and A (P < .01) or the mildest group C (P < .001). Short stature and a higher prevalence of hypertension were observed in classic CAH patients diagnosed late (after 1 y) compared with those diagnosed early and in women treated with glucocorticoid only compared with those treated with both glucocorticoids and mineralocorticoids (P < .05). FH did not associate with insulin sensitivity, lipid profile, adiposity, or quality of life. CONCLUSIONS Adult CAH patients remain short, although height prognosis has improved over time. The shortest adults are those diagnosed late with moderate severity CAH and are at increased risk of adult hypertension; we hypothesize that these patients are exposed in childhood to high androgens and/or excessive glucocorticoids with potential programming of hypertension. Another possibility is inadequate mineralocorticoid treatment early in life in the late-diagnosed patient group. Prospective studies are now required to examine these hypotheses.
Collapse
Affiliation(s)
- T S Han
- Department of Endocrinology (T.S.H.), St Peter's National Health Service Foundation Trust, Surrey KT16 0PZ, United Kingdom; Department of Endocrinology (G.S.C.), University College London Hospitals, London W1T 3AA, United Kingdom; Society for Endocrinology (D.S.W.), Bristol BS32 4JT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K., W.A.), School of Clinical and Experimental Medicine, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrine and Diabetes Sciences (D.A.R.), Institute for Molecular and Experimental Medicine, Cardiff University, Cardiff CF10 3US, United Kingdom; Endocrinology Unit (R.H.S., B.R.W.), Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4SB, United Kingdom; and Academic Unit of Diabetes, Endocrinology, and Metabolism (R.J.R.), University of Sheffield, Sheffield S10 2HF, United Kingdom
| | | | | | | | | | | | | | | | | | | |
Collapse
|
67
|
Auchus RJ, Buschur EO, Chang AY, Hammer GD, Ramm C, Madrigal D, Wang G, Gonzalez M, Xu XS, Smit JW, Jiao J, Yu MK. Abiraterone acetate to lower androgens in women with classic 21-hydroxylase deficiency. J Clin Endocrinol Metab 2014; 99:2763-70. [PMID: 24780050 PMCID: PMC4121028 DOI: 10.1210/jc.2014-1258] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CONTEXT Chronic supraphysiological glucocorticoid therapy controls the androgen excess of 21-hydroxylase deficiency (21OHD) but contributes to the high prevalence of obesity, glucose intolerance, and reduced bone mass in these patients. Abiraterone acetate (AA) is a prodrug for abiraterone, a potent CYP17A1 inhibitor used to suppress androgens in the treatment of prostate cancer. OBJECTIVE The objective of the study was to test the hypothesis that AA added to physiological hydrocortisone and 9α-fludrocortisone acetate corrects androgen excess in women with 21OHD without causing hypertension or hypokalemia. DESIGN This was a phase 1 dose-escalation study. SETTING The study was conducted at university clinical research centers. PARTICIPANTS We screened 14 women with classic 21OHD taking hydrocortisone 12.5-20 mg/d to enroll six participants with serum androstenedione greater than 345 ng/dL (>12 nmol/L). INTERVENTION AA was administered for 6 days at 100 or 250 mg every morning with 20 mg/d hydrocortisone and 9α-fludrocortisone acetate. MAIN OUTCOME MEASURE The primary endpoint was normalization of mean predose androstenedione on days 6 and 7 (< 230 ng/dL [<8 nmol/L)] in greater than 80% of participants. Secondary end points included serum 17-hydroxyprogesterone and testosterone (T), electrolytes, plasma renin activity, and urine androsterone and etiocholanolone glucuronides. RESULTS With 100 mg/d AA, mean predose androstenedione fell from 764 to 254 ng/dL (26.7-8.9 nmol/L). At 250 mg/d AA, mean androstenedione normalized in five participants (83%) and decreased from 664 to 126 ng/dL (23.2-4.4 nmol/L), meeting the primary end point. Mean androstenedione declined further during day 6 to 66 and 38 ng/dL (2.3 and 1.3 nmol/L) at 100 and 250 mg/d, respectively. Serum T and urinary metabolites declined similarly. Abiraterone exposure was strongly negatively correlated with mean androstenedione. Hypertension and hypokalemia were not observed. CONCLUSION AA 100-250 mg/d added to replacement hydrocortisone normalized several measures of androgen excess in women with classic 21OHD and elevated serum androstenedione.
Collapse
Affiliation(s)
- Richard J Auchus
- Division of Metabolism, Diabetes, and Endocrinology (R.J.A., E.O.B., G.D.H., C.R., D.M.), University of Michigan, Ann Arbor, Michigan 48109; Division of Endocrinology, Metabolism, Diabetes, and Nutrition (A.Y.C.), Mayo Clinic, Rochester, Minnesota 55905; Janssen Research and Development (G.W., M.G., X.S.X., J.J.), Raritan, New Jersey 08869; Janssen Research and Development (J.W.S.), 2340 Beerse, Belgium; and Janssen Research and Development (M.K.Y.), Los Angeles, California 90024
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
68
|
Abstract
17-Hydroxyprogesterone (17-OHP) is an intermediate steroid in the adrenal biosynthetic pathway from cholesterol to cortisol and is the substrate for steroid 21-hydroxylase. An inherited deficiency of 21-hydroxylase leads to greatly increased serum concentrations of 17-OHP, while the absence of cortisol synthesis causes an increase in adrenocorticotrophic hormone. The classical congenital adrenal hyperplasia (CAH) presents usually with virilisation of a girl at birth. Affected boys and girls can have renal salt loss within a few days if aldosterone production is also compromised. Diagnosis can be delayed in boys. A non-classical form of congenital adrenal hyperplasia (NC-CAH) presents later in life usually with androgen excess. Moderately raised or normal 17-OHP concentrations can be seen basally but, if normal and clinical suspicion is high, an ACTH stimulation test will show 17-OHP concentrations (typically >30 nmol/L) above the normal response. NC-CAH is more likely to be detected clinically in females and may be asymptomatic particularly in males until families are investigated. The prevalence of NC-CAH in women with androgen excess can be up to 9% according to ethnic background and genotype. Mutations in the 21-hydroxylase genes in NC-CAH can be found that have less deleterious effects on enzyme activity. Other less-common defects in enzymes of cortisol synthesis can be associated with moderately elevated 17-OHP. Precocious puberty, acne, hirsutism and subfertility are the commonest features of hyperandrogenism. 17-OHP is a diagnostic marker for CAH but opinions differ on the role of 17OHP or androstenedione in monitoring treatment with renin in the salt losing form. This review considers the utility of 17-OHP measurements in children, adolescents and adults.
Collapse
Affiliation(s)
- John W Honour
- Institute of Women’s Health, University College London, London, UK
| |
Collapse
|
69
|
Costa-Barbosa FA, Telles-Silveira M, Kater CE. [Congenital adrenal hyperplasia in the adult women: management of old and new challenges]. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2014; 58:124-131. [PMID: 24830589 DOI: 10.1590/0004-2730000002987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 11/25/2013] [Indexed: 06/03/2023]
Abstract
Due to major improvements in the management and therapy of patients with congenital adrenal hyperplasia owing to 21-hydroxylase deficiency (21OHD) along childhood and adolescence, affected women are able to reach adulthood. Therefore, management throughout adult life became even more complex, leading to new challenges. Both the protracted use of corticosteroids (sometimes in supraphysiologic doses), and excess androgen (due to irregular treatment and/or inadequate dosage) may impair the quality of life and health outcomes in affected adult women, causing osteoporosis, metabolic disturbances with high cardiovascular risk, cosmetic damage, infertility, and psychosocial and psychosexual changes. However, long-term follow-up studies with 21OHD adult women are still required. In this review, we discuss some important and controversial aspects of the follow-up of adult women with 21OHD, and recommend the use of a customized multi-disciplinary therapeutic approach while further studies with these patients do not provide distinct understanding and well-defined attitudes towards better quality of life.
Collapse
Affiliation(s)
- Flávia A Costa-Barbosa
- Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Mariana Telles-Silveira
- Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Claudio E Kater
- Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| |
Collapse
|
70
|
Han TS, Walker BR, Arlt W, Ross RJ. Treatment and health outcomes in adults with congenital adrenal hyperplasia. Nat Rev Endocrinol 2014; 10:115-24. [PMID: 24342885 DOI: 10.1038/nrendo.2013.239] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a genetic disorder caused by defective steroidogenesis that results in glucocorticoid deficiency; the most common underlying mutation is in the gene that encodes 21-hydroxylase. Life-saving glucocorticoid treatment was introduced in the 1950s, and the number of adult patients is now growing; however, no consensus has been reached on the management of CAH beyond childhood. Adult patients are prescribed a variety of glucocorticoids, including hydrocortisone, prednisone, prednisolone, dexamethasone and combinations of these drugs taken in either a circadian or reverse circadian regimen. Despite these personalized treatments, biochemical control of CAH is only achieved in approximately one-third of patients. Some patients have a poor health status, with an increased incidence of obesity and osteoporosis, and impaired fertility and quality of life. The majority of poor health outcomes seem to relate to inadequate treatment rather than the genotype of the patient. Patients receiving high doses of glucocorticoids and the more potent synthetic long-acting glucocorticoids are at an increased risk of obesity, insulin resistance and a reduced quality of life. Further research is required to optimize the treatment of adult patients with CAH and improve health outcomes.
Collapse
Affiliation(s)
- Thang S Han
- Department of Diabetes and Endocrinology, St Peter's NHS Foundation Trust, Guildford Road, Chertsey, Surrey KT16 0PZ, UK
| | - Brian R Walker
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Wiebke Arlt
- Centre for Endocrinology, Diabetes and Metabolism, School of Clinical & Experimental Medicine, University of Birmingham, Birmingham B15 2TT, UK
| | - Richard J Ross
- Academic Unit of Diabetes, Endocrinology & Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, UK
| |
Collapse
|
71
|
Dudzińska B, Leubner J, Ventz M, Quinkler M. Sexual well-being in adult male patients with congenital adrenal hyperplasia. Int J Endocrinol 2014; 2014:469289. [PMID: 24672547 PMCID: PMC3941169 DOI: 10.1155/2014/469289] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 12/17/2013] [Accepted: 12/21/2013] [Indexed: 01/07/2023] Open
Abstract
Introduction. Men with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency show impaired fecundity due to testicular adrenal rest tumors and/or suppression of the gonadal axis. Sexual well-being might be an additional factor; however, no data exists. Patients and Methods. Prospective longitudinal monocentric study included 20 male CAH patients (14 salt wasting, 6 simple virilizing; age 18-49 yr). Clinical assessment, testicular ultrasound, biochemical and hormonal parameters, three validated self-assessment questionnaires (SF-36, GBB-24, and HADS), and male Brief Sexual Function Inventory (BSFI) were analyzed at baseline and after two years. Results. Basal LH and testosterone levels suggested normal testicular function. LH and FSH responses to GnRH were more pronounced in patients with a good therapy control according to androstenedione/testosterone ratio < 0.2. This group had significant higher percentage of patients on dexamethasone medication. GBB-24, HADS, and SF-36 showed impaired z-scores and no changes at follow-up. BSFI revealed impairments in dimensions "sexual drive," "erections," and "ejaculations," whereas "problem assessment" and "overall satisfaction" revealed normal z-scores. Androstenedione levels correlated (P = 0.036) inversely with z-scores for "sexual drive" with higher levels associated with impaired "sexual drive." Conclusion. Male CAH patients showed a partly impaired sexual well-being which might be an additional factor for reduced fecundity.
Collapse
Affiliation(s)
- Bogna Dudzińska
- Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jonas Leubner
- Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Manfred Ventz
- Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Marcus Quinkler
- Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- *Marcus Quinkler:
| |
Collapse
|
72
|
Abstract
The management of congenital adrenal hyperplasia involves suppression of adrenal androgen production, in addition to treatment of adrenal insufficiency. Management of adolescents with congenital adrenal hyperplasia is especially challenging because changes in the hormonal milieu during puberty can lead to inadequate suppression of adrenal androgens, psychosocial issues often affect adherence to medical therapy, and sexual function plays a major part in adolescence and young adulthood. For these reasons, treatment regimen reassessment is indicated during adolescence. Patients with non-classic congenital adrenal hyperplasia require reassessment regarding the need for glucocorticoid drug treatment. No clinical trials have compared various regimens for classic congenital adrenal hyperplasia in adults, thus therapy is individualised and based on the prevention of adverse outcomes. Extensive patient education is key during transition from paediatric care to adult care and should include education of females with classic congenital adrenal hyperplasia regarding their genital anatomy and surgical history. Common issues for these patients include urinary incontinence, vaginal stenosis, clitoral pain, and cosmetic concerns; for males with classic congenital adrenal hyperplasia, common issues include testicular adrenal rest tumours. Transition from paediatric to adult care is most successful when phased over many years. Education of health-care providers on how to successfully transition patients is greatly needed.
Collapse
Affiliation(s)
- Deborah P Merke
- National Institutes of Health Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
| | - Dix P Poppas
- the Institute for Pediatric Urology, Comprehensive Center for Congenital Adrenal Hyperplasia, Komansky Center for Children's Health, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| |
Collapse
|
73
|
Abstract
Congenital adrenal hyperplasia (CAH) describes a group of autosomal recessive disorders where there is impairment of cortisol biosynthesis. CAH due to 21-hydroxylase deficiency accounts for 95% of cases and shows a wide range of clinical severity. Glucocorticoid and mineralocorticoid replacement therapies are the mainstays of treatment of CAH. The optimal treatment for adults with CAH continues to be a challenge. Important long-term health issues for adults with CAH affect both men and women. These issues may either be due to the disease or to steroid treatment and may affect final height, fertility, cardiometabolic risk, bone metabolism, neuro-cognitive development and the quality-of-life. Patients with CAH should be regularly followed-up from childhood to adulthood by multidisciplinary teams who have knowledge of CAH. Optimal replacement therapy, close clinical and laboratory monitoring, early life-style interventions, early and regular fertility assessment and continuous psychological management are needed to improve outcome.
Collapse
Affiliation(s)
- Mahdi Kamoun
- Department of Endocrinology, Hedi Chaker Hospital, Sfax, Tunisia
| | - Mouna Mnif Feki
- Department of Endocrinology, Hedi Chaker Hospital, Sfax, Tunisia
| | - Mohamed Habib Sfar
- Department of Endocrinology and Internal Medicine, Tahar Sfar Hospital, Mahdia, Tunisia
| | - Mohamed Abid
- Department of Endocrinology, Hedi Chaker Hospital, Sfax, Tunisia
| |
Collapse
|