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Szczepanska-Sadowska E, Czarzasta K, Bogacki-Rychlik W, Kowara M. The Interaction of Vasopressin with Hormones of the Hypothalamo-Pituitary-Adrenal Axis: The Significance for Therapeutic Strategies in Cardiovascular and Metabolic Diseases. Int J Mol Sci 2024; 25:7394. [PMID: 39000501 PMCID: PMC11242374 DOI: 10.3390/ijms25137394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/27/2024] [Accepted: 07/02/2024] [Indexed: 07/16/2024] Open
Abstract
A large body of evidence indicates that vasopressin (AVP) and steroid hormones are frequently secreted together and closely cooperate in the regulation of blood pressure, metabolism, water-electrolyte balance, and behavior, thereby securing survival and the comfort of life. Vasopressin cooperates with hormones of the hypothalamo-pituitary-adrenal axis (HPA) at several levels through regulation of the release of corticotropin-releasing hormone (CRH), adrenocorticotropic hormone (ACTH), and multiple steroid hormones, as well as through interactions with steroids in the target organs. These interactions are facilitated by positive and negative feedback between specific components of the HPA. Altogether, AVP and the HPA cooperate closely as a coordinated functional AVP-HPA system. It has been shown that cooperation between AVP and steroid hormones may be affected by cellular stress combined with hypoxia, and by metabolic, cardiovascular, and respiratory disorders; neurogenic stress; and inflammation. Growing evidence indicates that central and peripheral interactions between AVP and steroid hormones are reprogrammed in cardiovascular and metabolic diseases and that these rearrangements exert either beneficial or harmful effects. The present review highlights specific mechanisms of the interactions between AVP and steroids at cellular and systemic levels and analyses the consequences of the inappropriate cooperation of various components of the AVP-HPA system for the pathogenesis of cardiovascular and metabolic diseases.
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Affiliation(s)
- Ewa Szczepanska-Sadowska
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, 02-097 Warsaw, Poland
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2
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Salam RA, Khan MH, Meerza SSA, Das JK, Lewis-Watts L, Bhutta ZA. An evidence gap map of interventions for noncommunicable diseases and risk factors among children and adolescents. Nat Med 2024; 30:290-301. [PMID: 38195753 DOI: 10.1038/s41591-023-02737-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 11/27/2023] [Indexed: 01/11/2024]
Abstract
Substance misuse, obesity, mental health conditions, type 1 diabetes, cancers, and cardiovascular and chronic respiratory diseases together account for 41% of disability-adjusted life years linked to noncommunicable diseases (NCDs) among children and adolescents worldwide. However, the evidence on risk factors and interventions for this age group is scarce. Here we searched four databases to generate an evidence gap map of existing interventions and research gaps for these risk factors and NCDs. We mapped 159 reviews with 2,611 primary studies; most (96.2%) were conducted in high-income countries, and only 100 studies (3.8%) were from low- and middle-income countries (LMICs). The efficacy of therapeutic interventions on biomarkers and adverse events for NCDs appears to be well evidenced. Interventions for mental health conditions appear to be moderately evidenced, while interventions for obesity and substance misuse appear to be moderate to very low evidenced. Priority areas for future research include evaluating digital health platforms to support primary NCD prevention and management, and evaluating the impact of policy changes on the prevalence of obesity and substance misuse. Our findings highlight the wide disparity of evidence between high-income countries and LMICs. There is an urgent need for increased, targeted financing to address the research gaps in LMICs.
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Affiliation(s)
- Rehana A Salam
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Maryam Hameed Khan
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Syed Saqlain Ali Meerza
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Jai K Das
- Institute for Global Health and Development, Aga Khan University Hospital, Karachi, Pakistan
| | - Laura Lewis-Watts
- Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.
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Ekpa QL, Akahara PC, Anderson AM, Adekoya OO, Ajayi OO, Alabi PO, Okobi OE, Jaiyeola O, Ekanem MS. A Review of Acute Lymphocytic Leukemia (ALL) in the Pediatric Population: Evaluating Current Trends and Changes in Guidelines in the Past Decade. Cureus 2023; 15:e49930. [PMID: 38179374 PMCID: PMC10766210 DOI: 10.7759/cureus.49930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
Acute lymphocytic leukemia (ALL) is a commonly diagnosed cancer in children. Despite technological advancements to improve treatment and survival rates, there has been a steady increase in the incidence of ALL and treatment failures. This paper discusses the pathogenic interaction between genetic and environmental factors leading to childhood ALL. It evaluates the current treatment guidelines and notable obstacles leading to resistance, relapse, and treatment toxicities. The review evaluates a 10-year trend in the management guidelines of pediatric ALL through a systematic literature review of records from 2012 to 2023. Findings show that improvement in the five-year survival rates, notwithstanding rates of relapse and incurable diseases, is still high. Furthermore, several risk factors, including an interplay between genetic and environmental factors, are largely contributory to the outcome of ALL treatments and its overall incidence. Moreover, huge financial costs have remained a significant challenge in outcomes. There remains a need to provide individualized treatment plans, shared decision-making, and goals of care as parts of the management guidelines for the best possible outcomes. We expect that future advancements will increase overall survival rates and disease-free years.
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Affiliation(s)
- Queen L Ekpa
- General Practice, Conestoga College, Kitchener, CAN
| | | | - Alexis M Anderson
- Pediatric Medicine, St. George's University, School of Medicine, St. George's, GRD
| | | | - Olamide O Ajayi
- Pediatrics, Medway Maritime Hospital, Kent, GBR
- Internal Medicine, Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University, Sagamu, NGA
| | - Peace O Alabi
- Pediatrics, University of Abuja Teaching Hospital, Abuja, NGA
| | - Okelue E Okobi
- Family Medicine, Larkin Community Hospital Palm Springs Campus, Hialeah, USA
- Family Medicine, Medficient Health Systems, Laurel, USA
- Family Medicine, Lakeside Medical Center, Belle Glade, USA
| | | | - Medara S Ekanem
- General Medicine, Babcock University Teaching Hospital, Ilishan-Remo, NGA
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Holterhus PM, Kulle A, Till AM, Stille C, Lamprecht T, Vieth S, Lauten M. Pilot study shows suppression of mineralocorticoid precursors under high-dose glucocorticoid therapy in pediatric acute lymphoblastic leukemia. Endocr Connect 2023; 12:e230002. [PMID: 37523248 PMCID: PMC10503231 DOI: 10.1530/ec-23-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 07/31/2023] [Indexed: 08/02/2023]
Abstract
Glucocorticoids represent a key element in the treatment of pediatric acute lymphoblastic leukemia (ALL) and lead to adrenal suppression. We aimed to assess the differential response profile of adrenal steroids in children with ALL during BFM (Berlin-Frankfurt-Münster) induction treatment. Therefore, we performed liquid chromatography tandem-mass spectrometry (LC-MS/MS)-based steroid profiling of up to seven consecutive leftover morning serum samples derived from 11 patients (pts) with ALL before (day 0) and during induction therapy at days 1-5, 6-12, 13-26, 27-29, 30-35 and 36-40. 17-hydroxyprogesterone (17OHP), 11-deoxycortisol (11S), cortisol, 11-deoxycorticosterone (DOC), corticosterone and aldosterone were determined in parallel. Subsequently, steroid concentrations were normalized by multiples of median (MOM) to adequately consider pediatric age- and sex-specific reference ranges. MOM-cortisol and its precursors MOM-11S and MOM-17OHP were significantly suppressed by glucocorticoid treatment until day 29 (P < 8.06 × 10-10, P < 5.102 × 10-5, P < 0.0076, respectively). Cortisol recovered in one of four pts at days 27-29 and in two of five pts at days 36-40. Among the mineralocorticoids, corticosterone was significantly suppressed (P < 3.115 × 10-6). Aldosterone and DOC showed no significant changes when comparing day 0 to the treatment time points. However, two ALL patients with ICU treatment due to the sepsis showed significantly lower MOM-DOC (P = 0.006436) during that time and almost always the lowest aldosterone compared to all other time points. Suppression of mineralocorticoid precursors under high-dose glucocorticoid therapy suggests a functional cross talk of central glucocorticoid regulation and adrenal mineralocorticoid synthesis. Our data should stimulate prospective investigation to assess potential clinical relevance.
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Affiliation(s)
- Paul-Martin Holterhus
- Department of Pediatrics I, Pediatric Endocrinology and Diabetology, University Hospital of Schleswig-Holstein, UKSH, Campus Kiel and Christian Albrechts University, CAU, Kiel, Germany
| | - Alexandra Kulle
- Department of Pediatrics I, Pediatric Endocrinology and Diabetology, University Hospital of Schleswig-Holstein, UKSH, Campus Kiel and Christian Albrechts University, CAU, Kiel, Germany
| | - Anne-Marie Till
- Department of Pediatrics, Pediatric Hematology and Oncology, University Hospital of Schleswig-Holstein, UKSH, Campus Lübeck, Germany
| | - Caroline Stille
- Department of Pediatrics, Pediatric Hematology and Oncology, University Hospital of Schleswig-Holstein, UKSH, Campus Lübeck, Germany
| | - Tabea Lamprecht
- Department of Pediatrics I, Pediatric Endocrinology and Diabetology, University Hospital of Schleswig-Holstein, UKSH, Campus Kiel and Christian Albrechts University, CAU, Kiel, Germany
| | - Simon Vieth
- Department of Pediatrics I, Pediatric Hematology and Oncology, University Hospital of Schleswig-Holstein, UKSH, Campus Kiel and Christian-Albrechts-University, CAU, Kiel, Germany
| | - Melchior Lauten
- Department of Pediatrics, Pediatric Hematology and Oncology, University Hospital of Schleswig-Holstein, UKSH, Campus Lübeck, Germany
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Alhammadi NA, Mohammed Al Oudhah SM, Mofareh Asiri MA, Alshehri MA, Almutairi BAB, Mohammed Abdullah Thalibah A, Asiri FNM, Alshahrani ASA. Public awareness of side effects of systemic steroids in Asir region, Saudi Arabia. J Family Med Prim Care 2023; 12:1854-1858. [PMID: 38024924 PMCID: PMC10657041 DOI: 10.4103/jfmpc.jfmpc_2202_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/14/2022] [Accepted: 04/10/2023] [Indexed: 12/01/2023] Open
Abstract
Background Corticosteroids have been used since the 50s and it represent the most important and frequently used class of anti-inflammatory and immunosuppressive drugs for the treatment of several diseases such as numerous neoplastic, asthma, allergy, rheumatoid arthritis, and dermatological disorders. This study aims to determine the public awareness of side effects of systemic steroids in Asir region, Saudi Arabia. Methods A descriptive cross-sectional web-based study was used. An online questionnaire was developed by the study researchers based on the literature review and consultations of the field experts. The questionnaire included the following components: Participants demographic data, medical history, and steroids use. Also, it covered participants awareness regarding systemic steroids and side effects. Results A total of 439 participants fulfilling the inclusion criteria completed the study questionnaire. Ages ranged from 18 to 65 years with mean age of 26.1 ± 13.9 years old, of those, 227 (51.7%) respondents were males. Around 346 (78.8%) had poor overall awareness level while only 93 (21.2%) had good awareness regarding systematic steroids. The study also showed that awareness was significantly higher among young aged participants in the health care field and among those who previously used steroids. Two hundred and eighty two (64.2%) of the respondents reported previous use of steroids. Conclusion In conclusion, the current study showed that nearly one out of each five people know about systemic steroids and related side effects which is below the satisfactory level. Higher awareness was observed with regards drug associated side effects and long-term use consequences.
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Affiliation(s)
- Nouf Ahmed Alhammadi
- Department of Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia
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Choo KS, Yew J, Tan EJH, Puar THK. Case Report: Hypercalcemia as a manifestation of acute adrenal crisis precipitated by fluconazole use, and a review of the literature. Front Endocrinol (Lausanne) 2023; 14:1168797. [PMID: 37274338 PMCID: PMC10232950 DOI: 10.3389/fendo.2023.1168797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/04/2023] [Indexed: 06/06/2023] Open
Abstract
Acute adrenal crisis classically presents with vomiting, altered sensorium, and hypotension. We describe a unique case manifesting with severe hypercalcemia. Addisonian crisis was unusually precipitated by fluconazole use. We reviewed other reported cases and discuss the possible mechanisms of hypercalcemia in adrenal insufficiency. This 67-year-old man presented with fever, cough, and vomiting for 1 week and with anorexia and confusion for 3 weeks. He was hypotensive and clinically dehydrated. Investigations revealed left-sided lung consolidation, acute renal failure, and severe non-parathyroid hormone (PTH)-mediated hypercalcemia (calcium, 3.55mol/L; PTH, 0.81pmol/L). Initial impression was pneumonia complicated by septic shock and hypercalcemia secondary to possible malignancy. He received mechanical ventilation; treatment with intravenous fluids, inotropes, and hydrocortisone for septic shock; and continuous renal replacement therapy with low-calcium dialysate. Although hypercalcemia resolved and he was weaned off inotropes, dialysis, and hydrocortisone, his confusion persisted. When hypercalcemia recurred on day 19 of admission, early morning cortisol was <8 nmol/L, with low ACTH level (3.2 ng/L). Other pituitary hormones were normal. Hypercalcemia resolved 3 days after reinstating stress doses of hydrocortisone, and his mentation normalized. On further questioning, he recently received fluconazole for a forearm abscess. He previously consumed traditional medications but stopped several years ago, which may have contained glucocorticoids. He was discharged on oral hydrocortisone. Cortisol levels improved gradually, and glucocorticoid replacement was ceased after 8 years, without any recurrence of hypercalcemia or Addisonian crisis. Both hypercalcemia and adrenal insufficiency may present with similar non-specific symptoms. It is important to consider adrenal insufficiency in hypercalcemia of unclear etiology.
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Affiliation(s)
- Kuan Swen Choo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Jielin Yew
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Eberta Jun Hui Tan
- Raffles Diabetes and Endocrine Centre, Raffles Medical Group, Singapore, Singapore
| | - Troy Hai Kiat Puar
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
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Monge Chacón AG, Wang C, Waqar D, Syeda SA, Kumar R, Meghana DR. Long-Term Usage of Oral Glucocorticoids Leading to Adrenal Insufficiency: A Comprehensive Review of the Literature. Cureus 2023; 15:e38948. [PMID: 37309331 PMCID: PMC10257969 DOI: 10.7759/cureus.38948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/14/2023] Open
Abstract
Systemic glucocorticoid therapy is used worldwide by one to three percent of the general population and 0.5-1.8% on long-term oral glucocorticoid use. It is widely used in conditions such as inflammation, autoimmune diseases, and cancer to inhibit inflammatory responses. One of the possible undesirable side effects of exogenous corticosteroid treatment is adrenal suppression upon discontinuation of the medication and adrenal insufficiency after utilizing the supraphysiologic doses for more than one month. To prevent patients from the unwanted signs and symptoms of adrenal insufficiency, including fatigue, gastrointestinal upset, anorexia/weight loss, etc., better management of the quantity and frequency of exogenous corticosteroid use, as well as better education before starting its use, is needed. For patients actively on exogenous corticosteroids, a close follow-up must be in place to avoid adrenal suppression after the eventual discontinuation of their use. This review article summarizes the important studies to date on this subject, especially oral glucocorticoid use, and analyzes risks such as dose, duration of exposure, and comorbidities of adrenal insufficiency associated with oral glucocorticoid use. We comprehensively include information on those with primary adrenal insufficiency and pediatric patients, hoping to provide better insight and clinical reference.
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Affiliation(s)
| | - Chen Wang
- Medicine, China Medical University, Taichung, TWN
| | - Danish Waqar
- Internal Medicine, Nephrology, Loyola University Medical Center, Chicago, USA
| | | | - Rohan Kumar
- Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
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Robb SL, Russ KA, Holochwost SJ, Stegenga K, Perkins SM, Jacob SA, Henley AK, MacLean JA. Protocol and biomarker strategy for a multi-site randomized controlled trial examining biological mechanisms and dosing of active music engagement in children with acute lymphoblastic leukemia and lymphoma and parents. BMC Complement Med Ther 2023; 23:90. [PMID: 36973774 PMCID: PMC10041701 DOI: 10.1186/s12906-023-03909-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/04/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Music therapy is a standard palliative care service in many pediatric and adult hospitals; however, most research has focused on the use of music to improve psychosocial dimensions of health, without considering biological dimensions. This study builds on prior work examining psychosocial mechanisms of action underlying an Active Music Engagement (AME) intervention, designed to help manage emotional distress and improve positive health outcomes in young children with cancer and parents (caregivers), by examining its effects on biomarkers of stress and immune function. METHODS This two-group randomized controlled trial (R01NR019190) is designed to examine biological mechanisms of effect and dose-response relationships of AME on child/parent stress during the consolidation phase of Acute B- or T-cell Lymphoblastic Leukemia (ALL) and T-cell Lymphoblastic Lymphoma (TLyLy) treatment. Child/parent dyads (n = 228) are stratified (by age, site, risk level) and randomized in blocks of four to the AME or attention control condition. Each group receives one session (30-minutes AME; 20-minutes control) during weekly clinic visits (4 weeks standard risk B-cell ALL; 8 weeks high risk B-cell ALL/T-cell ALL/TLyLy). Parents complete questionnaires at baseline and post-intervention. Child/parent salivary cortisol samples are taken pre- and post-session (sessions 1-4). Child blood samples are reserved from routine draws before sessions 1 and 4 (all participants) and session 8 (high risk participants). We will use linear mixed models to estimate AME's effect on child/parent cortisol. Examining child/parent cortisol as mediators of AME effects on child and parent outcomes will be performed in an ANCOVA setting, fitting the appropriate mediation models using MPlus and then testing indirect effects using the percentile bootstrap approach. Graphical plots and non-linear repeated measures models will be used to examine dose-response relationship of AME on child/parent cortisol. DISCUSSION During pediatric cancer treatment there are special challenges that must be considered when measuring cortisol and immune function. In this manuscript we discuss how we addressed three specific challenges through our trial design. Findings from this trial will increase mechanistic understanding of the effects of active music interventions on multiple biomarkers and understanding of dose-response effects, with direct implications for clinical practice. TRIAL REGISTRATION ClinicalTrials.gov: NCT04400071.
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Affiliation(s)
- Sheri L Robb
- School of Nursing, Indiana University, 600 Barnhill Drive, Indianapolis, IN, 46202, USA.
| | - Kristen A Russ
- School of Medicine, Indiana University , 351 W 10th Street, Indianapolis, IN, 46202, USA
| | - Steven J Holochwost
- Department of Psychology, Lehman College, City University of New York, 250 Bedford Park Boulevard, West Bronx, NY, 10468, USA
| | - Kristin Stegenga
- Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Susan M Perkins
- School of Medicine, Indiana University, 340 W 10th Street, Indianapolis, IN, 46202, USA
| | - Seethal A Jacob
- School of Medicine, Indiana University, 410 W 10th Street, Indianapolis, IN, 46202, USA
| | - Amanda K Henley
- Purdue School of Engineering and Technology, IUPUI, 535 W. Michigan Street, Indianapolis, IN, 46202, USA
| | - Jessica A MacLean
- School of Nursing, Indiana University, 600 Barnhill Drive, Indianapolis, IN, 46202, USA
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Ludwig M, Basti A, Yalçin M, Schulte JH, Relógio A. Molecular characterization of the circadian clock in paediatric leukaemia patients: a prospective study protocol. BMC Pediatr 2023; 23:105. [PMID: 36870963 PMCID: PMC9985245 DOI: 10.1186/s12887-023-03921-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 02/17/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND In many organisms, including humans, the timing of cellular processes is regulated by the circadian clock. At the molecular level the core-clock consists of transcriptional-translational-feedback loops including several genes such as BMAL1, CLOCK, PERs and CRYs generating circa 24-h rhythms in the expression of about 40% of our genes across all tissues. Previously these core-clock genes have been shown to be differentially expressed in various cancers. Albeit a significant effect in treatment optimization of chemotherapy timing in paediatric acute lymphoblastic leukaemia has previously been reported, the mechanistic role played by the molecular circadian clock in acute paediatric leukaemia remains elusive. METHODS To characterize the circadian clock, we will recruit patients with newly diagnosed leukaemia and collect time course saliva and blood samples, as well as a single bone marrow sample. From the blood and bone marrow samples nucleated cells will be isolated and further undergo separation into CD19+ and CD19- cells. qPCR is performed on all samples targeting the core-clock genes including BMAL1, CLOCK, PER2 and CRY1. Resulting data will be analysed for circadian rhythmicity using the RAIN algorithm and harmonic regression. DISCUSSION To the best of our knowledge this is the first study aiming to characterize the circadian clock in a cohort of paediatric patients with acute leukaemia. In the future we hope to contribute to uncovering further vulnerabilities of cancers associated with the molecular circadian clock and in particular adjust chemotherapy accordingly, leading to more targeted toxicity, and hence decreased systemic toxicities.
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Affiliation(s)
- Marius Ludwig
- Department of Pediatric Hematology and Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, 10117, Berlin, Germany.,Institute for Theoretical Biology (ITB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, 10117, Berlin, Germany
| | - Alireza Basti
- Institute for Theoretical Biology (ITB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, 10117, Berlin, Germany.,Molecular Cancer Research Center (MKFZ), Medical Department of Hematology, Oncology, and Tumour Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, 10117, Berlin, Germany.,Institute for Systems Medicine and Faculty of Human Medicine, MSH Medical School Hamburg, 20457, Hamburg, Germany
| | - Müge Yalçin
- Institute for Theoretical Biology (ITB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, 10117, Berlin, Germany.,Molecular Cancer Research Center (MKFZ), Medical Department of Hematology, Oncology, and Tumour Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, 10117, Berlin, Germany
| | - Johannes H Schulte
- Department of Pediatric Hematology and Oncology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, 10117, Berlin, Germany.,German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany.,Berlin Institute of Health, 10117, Berlin, Germany
| | - Angela Relógio
- Institute for Theoretical Biology (ITB), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, 10117, Berlin, Germany. .,Molecular Cancer Research Center (MKFZ), Medical Department of Hematology, Oncology, and Tumour Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, 10117, Berlin, Germany. .,Institute for Systems Medicine and Faculty of Human Medicine, MSH Medical School Hamburg, 20457, Hamburg, Germany.
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10
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Boekstegers A, Schmidt H, Kurzay M, Vallée T, Jung E, Dubinski I, Maxwell R, Schmid I. Cortisol response in children with cancer and fever during chemotherapy: A prospective, observational study using random serum cortisol levels. Cancer Med 2023; 12:9247-9259. [PMID: 36734317 PMCID: PMC10166925 DOI: 10.1002/cam4.5667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 12/19/2022] [Accepted: 01/20/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Glucocorticoids are crucial components of the treatment of leukemia and lymphoma. High doses can lead to suppression of the hypothalamic-pituitary-adrenal (HPA) axis and be causative for an impaired stress response during infection. This study aims to evaluate the cortisol response in pediatric oncologic patients during febrile episodes. METHODS Totally, 75 children and adolescents (5 months-18 years) with fever during chemotherapy were consecutively enrolled in this study. In total, 47 patients received glucocorticoids as part of their treatment. Random serum cortisol and adrenocorticotropic hormone (ACTH) were analyzed in every patient. A low cortisol response (LCR) was defined as a cortisol level < 14.6 μg/dL. RESULTS In total, 52 (69%) patients had a cortisol level < 14.6 μg/dL during fever. There was no significant difference between patients who received glucocorticoids and those who did not. Significantly lower cortisol levels were measured ≤7 days after last glucocorticoid intake compared to later time points. Nearly all patients treated with dexamethasone or prophylactic posaconazole demonstrated a LCR under stress (fever). CONCLUSION The incidence of an impaired HPA axis in pediatric cancer patients might be underestimated since 69% of the children in our study had a LCR during fever. Intake of dexamethasone, posaconazole and a time period of ≤7 days from the last glucocorticoid intake were additional risk factors for an LCR. However, we could not confirm that patients with a LCR fared worse than patients with a high cortisol response (HCR). Therefore, a different cortisol threshold may be necessary for defining an impaired HPA axis in febrile oncologic patients without concomitant symptoms of AI.
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Affiliation(s)
- Ann Boekstegers
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Heinrich Schmidt
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Mathias Kurzay
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Tanja Vallée
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Eva Jung
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Ilja Dubinski
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Rebecca Maxwell
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Irene Schmid
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
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Touitou Y, Selmaoui B, Lambrozo J. Assessment of cortisol secretory pattern in workers chronically exposed to ELF-EMF generated by high voltage transmission lines and substations. ENVIRONMENT INTERNATIONAL 2022; 161:107103. [PMID: 35121496 DOI: 10.1016/j.envint.2022.107103] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/20/2021] [Accepted: 01/17/2022] [Indexed: 06/14/2023]
Abstract
We investigated the effects of extremely-low frequency electromagnetic fields (ELF-EMFs; 50 Hz) on the secretion of cortisol in 14 men (mean age = 38.0 ± 0.9 years) working in extra-high voltage (EHV) substations. The workers dwelt in houses that were close to substations and high-voltage lines. Thus, they had long histories (1-20 years) of long-yerm exposure to ELF-EMFs. Magnetic field strength was recorded using Emdex dosimeters worn by the volunteers day and night for seven days; the one-week geometric mean ranged from 0.1 to 2.6 μT. Blood samples were taken hourly from 20:00 to 08:00 the next morning. Cortisol concentrations and patterns were compared to age-matched, unexposed control subjects whose exposure level was ten times lower. The comparison of the control group (n = 15) and the groups exposed to fields of 0.1-0.3 μT (n = 5) and > 0.3 μT (n = 9), respectively, revealed a significant effect of field intensity on the cortisol secretory pattern. This study strongly suggests that chronic exposure to ELF-EMFs alters the peak-time serum cortisol levels. Studies are required on the effect of this disruption in high-risk populations such as children, elderly people, and patients with cancer.
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Affiliation(s)
- Yvan Touitou
- Unité de Chronobiologie, Fondation Ophtalmologique A. de Rothschild, 75019 Paris, France.
| | - Brahim Selmaoui
- Department of Experimental Toxicology, Institut National de l'Environnement Industriel et des Risques (INERIS), Verneuil-en-Halatte, France and PériTox Laboratory, UMR-I 01 INERIS, Picardie Jules Verne University, Amiens, France
| | - Jacques Lambrozo
- Unité de Chronobiologie, Fondation Ophtalmologique A. de Rothschild, 75019 Paris, France
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12
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Erickson SJ, Dinces S, Kubinec N, Annett RD. Pediatric Cancer Survivorship: Impact Upon Hair Cortisol Concentration and Family Functioning. J Clin Psychol Med Settings 2022; 29:943-953. [PMID: 35150359 DOI: 10.1007/s10880-022-09858-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 12/30/2022]
Abstract
A clearer understanding of the association between a biomarker of long-term stress reactivity and family functioning among pediatric cancer survivors may guide both survivorship research and clinical practice. The current study examined the relationship between a long-term measure of hypothalamic-pituitary-adrenal (HPA) activity (cortisol concentration; CORTHAIR) and parent-reported family functioning (Family Environment Scale; FES) in a cross-sectional sample of survivors (n = 26) and controls (n = 53). Child CORTHAIR was not different in survivors and controls, though treatment severity was significantly related to child survivor CORTHAIR. Child CORTHAIR and parent CORTHAIR were positively correlated. Cancer survivor parents reported greater FES Organization. Child CORTHAIR was inversely associated with FES Independence, while parent CORTHAIR was inversely correlated with FES Organization. Parent CORTHAIR and FES Independence were significant and unique predictors of child CORTHAIR. Our results provide preliminary evidence for a relationship between a stress biomarker, child CORTHAIR, and family functioning among pediatric cancer survivors and controls.
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Affiliation(s)
- Sarah J Erickson
- Department of Psychology, Logan Hall, University of New Mexico, MSC03 2220, Albuquerque, NM, 87131, USA.
| | | | - Nicole Kubinec
- Department of Psychology, Logan Hall, University of New Mexico, MSC03 2220, Albuquerque, NM, 87131, USA
| | - Robert D Annett
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
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13
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Prevalence and Risk Factors for Adrenal Insufficiency in Patients with Multiple Myeloma Receiving Long-Term Chemotherapy including Corticosteroids: A Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:2330417. [PMID: 34938804 PMCID: PMC8687836 DOI: 10.1155/2021/2330417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 11/16/2021] [Indexed: 11/18/2022]
Abstract
Multiple myeloma (MM) is the second most common hematologic malignancy and requires long-term and high-dose corticosteroid-based chemotherapy. The aim of this study was to investigate the prevalence and clinical predictors of corticosteroid-associated adrenal insufficiency (AI) in patients with MM receiving long-term chemotherapy. This retrospective study included patients with MM who were administered corticosteroid-based chemotherapy and underwent a rapid adrenocorticotropic hormone (ACTH) stimulation test between 2005 and 2018. AI was determined by a peak cortisol value < 18 μg/dL after ACTH stimulation. Demographic, clinical, and laboratory parameters were evaluated, and the prevalence and clinical risk factors of AI were examined. Of 282 patients with MM who received corticosteroid-based chemotherapy, 142 patients (50.4%) were classified as having AI. There were no differences in age, sex, body mass index, comorbidities, and laboratory findings, including serum sodium levels between the AI and no-AI groups. In univariate analysis, the cumulative dose of corticosteroid (odds ratio (OR) = 0.99, 95% confidence interval (CI) 0.98-0.99; P = 0.020) and megestrol acetate use (OR = 2.63, 95% CI 1.48-4.67; P = 0.001) were associated with the occurrence of AI. Cumulative duration and cumulative dose per duration of corticosteroid use were not associated with the occurrence of AI. However, in the multivariate analysis, only megestrol acetate use was associated with an increased risk of AI (OR = 2.54, 95% CI 1.41-4.60; P = 0.002). Approximately 95.8% of patients with AI had suspicious symptoms or signs of AI. Although clinical symptoms and signs are usually nonspecific, symptomatic patients with MM receiving long-term corticosteroid therapy have sufficient potential for developing AI, particularly when receiving megestrol acetate. These findings can help alert clinicians to consider adrenal suppression following corticosteroid-based chemotherapy in patients with MM.
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14
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Stress Axis in the Cancer Patient: Clinical Aspects and Management. ENDOCRINES 2021. [DOI: 10.3390/endocrines2040044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hypothalamus–pituitary–adrenal (HPA) axis alterations are common in cancer patients, mainly due to the different antitumoral therapies, which lead to several acute and late endocrine side effects. This review summarizes the most recent evidence regarding HPA derangement, both in patients with active neoplasms and in cancer survivors, with particular attention to the impact of the different antitumoral treatments, focusing on the major clinical aspects. While acute hormone failure usually results from injury caused directly by tumor burden or surgical interventions, short- and long-term effects are generally due to chemotherapy, radiotherapy and, as more recently shown, to different types of targeted- and immuno-therapy. Adrenal insufficiency (AI) is mostly caused by pituitary or hypothalamic injury rather than a direct damage of the adrenal gland. Moreover, other treatments commonly employed as supportive therapy or in the context of palliative care (i.e., glucocorticoids, opioids) can lead to HPA dysfunction. Epidemiology and pathophysiology of stress axis alterations in cancer patients still require clarification. Since AI may represent a life-threatening condition, monitoring adrenal function in cancer patients is mandatory, especially in subjects who experience fatigue or during stress conditions, in order to promptly start replacement treatment when needed.
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15
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Ahmet A, Rowan-Legg A, Pancer L. Adrenal suppression from exogenous glucocorticoids: Recognizing risk factors and preventing morbidity. Paediatr Child Health 2021; 26:242-254. [PMID: 34630779 DOI: 10.1093/pch/pxab015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 06/08/2020] [Indexed: 11/12/2022] Open
Abstract
Adrenal suppression (AS), a potential side effect of glucocorticoid therapy (including inhaled corticosteroids), can be associated with significant morbidity and even death. In Canada, adrenal crisis secondary to AS continues to be reported in children. Being aware of symptoms associated with AS, understanding the risk factors for developing this condition, and familiarity with potential strategies to reduce risks associated with AS, are essential starting points for any clinician prescribing glucocorticoids.
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Affiliation(s)
- Alexandra Ahmet
- Canadian Paediatric Society, Community Paediatrics Committee and Canadian Pediatric Endocrine Group, Ottawa, Ontario, Canada
| | - Anne Rowan-Legg
- Canadian Paediatric Society, Community Paediatrics Committee and Canadian Pediatric Endocrine Group, Ottawa, Ontario, Canada
| | - Larry Pancer
- Canadian Paediatric Society, Community Paediatrics Committee and Canadian Pediatric Endocrine Group, Ottawa, Ontario, Canada
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16
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Abstract
Synthetic glucocorticoids are widely used for their anti-inflammatory and immunosuppressive actions. A possible unwanted effect of glucocorticoid treatment is suppression of the hypothalamic-pituitary-adrenal axis, which can lead to adrenal insufficiency. Factors affecting the risk of glucocorticoid induced adrenal insufficiency (GI-AI) include the duration of glucocorticoid therapy, mode of administration, glucocorticoid dose and potency, concomitant drugs that interfere with glucocorticoid metabolism, and individual susceptibility. Patients with exogenous glucocorticoid use may develop features of Cushing's syndrome and, subsequently, glucocorticoid withdrawal syndrome when the treatment is tapered down. Symptoms of glucocorticoid withdrawal can overlap with those of the underlying disorder, as well as of GI-AI. A careful approach to the glucocorticoid taper and appropriate patient counseling are needed to assure a successful taper. Glucocorticoid therapy should not be completely stopped until recovery of adrenal function is achieved. In this review, we discuss the factors affecting the risk of GI-AI, propose a regimen for the glucocorticoid taper, and make suggestions for assessment of adrenal function recovery. We also describe current gaps in the management of patients with GI-AI and make suggestions for an approach to the glucocorticoid withdrawal syndrome, chronic management of glucocorticoid therapy, and education on GI-AI for patients and providers.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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17
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Ahmet A, Rowan-Legg A, Pancer L. La suppression surrénalienne causée par les glucocorticoïdes exogènes : en reconnaître les facteurs de risque et en prévenir les effets. Paediatr Child Health 2021; 26:248-254. [PMID: 34136054 DOI: 10.1093/pch/pxab016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 06/08/2020] [Indexed: 11/14/2022] Open
Abstract
Résumé
La suppression surrénalienne, un effet secondaire potentiel du traitement aux glucocorticoïdes (y compris les corticostéroïdes inhalés), peut avoir des conséquences graves et même fatales. Au Canada, on continue de déclarer des poussées d’insuffisance corticosurrénalienne consécutives à une suppression surrénalienne chez les enfants. Avant de prescrire des glucocorticoïdes, le clinicien doit absolument connaître les symptômes de suppression surrénalienne, comprendre les facteurs de risque de cette affection et être au courant des stratégies susceptibles d’en réduire les risques.
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Affiliation(s)
- Alexandra Ahmet
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire et Groupe canadien d'endocrinologie pédiatrique, Ottawa (Ontario), Canada
| | - Anne Rowan-Legg
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire et Groupe canadien d'endocrinologie pédiatrique, Ottawa (Ontario), Canada
| | - Larry Pancer
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire et Groupe canadien d'endocrinologie pédiatrique, Ottawa (Ontario), Canada
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18
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Liu X, Chai Y, Liu G, Su W, Guo Q, Lv X, Gao P, Yu B, Ferbeyre G, Cao X, Wan M. Osteoclasts protect bone blood vessels against senescence through the angiogenin/plexin-B2 axis. Nat Commun 2021; 12:1832. [PMID: 33758201 PMCID: PMC7987975 DOI: 10.1038/s41467-021-22131-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 02/27/2021] [Indexed: 01/31/2023] Open
Abstract
Synthetic glucocorticoids (GCs), one of the most effective treatments for chronic inflammatory and autoimmune conditions in children, have adverse effects on the growing skeleton. GCs inhibit angiogenesis in growing bone, but the underlying mechanisms remain unclear. Here, we show that GC treatment in young mice induces vascular endothelial cell senescence in metaphysis of long bone, and that inhibition of endothelial cell senescence improves GC-impaired bone angiogenesis with coupled osteogenesis. We identify angiogenin (ANG), a ribonuclease with pro-angiogenic activity, secreted by osteoclasts as a key factor for protecting the neighboring vascular cells against senescence. ANG maintains the proliferative activity of endothelial cells through plexin-B2 (PLXNB2)-mediated transcription of ribosomal RNA (rRNA). GC treatment inhibits ANG production by suppressing osteoclast formation in metaphysis, resulting in impaired endothelial cell rRNA transcription and subsequent cellular senescence. These findings reveal the role of metaphyseal blood vessel senescence in mediating the action of GCs on growing skeleton and establish the ANG/PLXNB2 axis as a molecular basis for the osteoclast-vascular interplay in skeletal angiogenesis.
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MESH Headings
- Animals
- Apoptosis/drug effects
- Bone Development/drug effects
- Cell Proliferation/drug effects
- Cellular Senescence/drug effects
- Cellular Senescence/genetics
- Endothelial Cells/drug effects
- Endothelial Cells/metabolism
- Glucocorticoids/pharmacology
- Human Umbilical Vein Endothelial Cells
- Humans
- Immunohistochemistry
- In Situ Hybridization, Fluorescence
- Methylprednisolone/pharmacology
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C57BL
- Neovascularization, Pathologic
- Neovascularization, Physiologic/drug effects
- Nerve Tissue Proteins/genetics
- Nerve Tissue Proteins/metabolism
- Osteoclasts/drug effects
- Osteoclasts/enzymology
- Osteoclasts/metabolism
- Osteogenesis/drug effects
- RNA, Ribosomal/biosynthesis
- RNA, Small Interfering
- Recombinant Proteins
- Ribonuclease, Pancreatic/genetics
- Ribonuclease, Pancreatic/metabolism
- Ribonuclease, Pancreatic/pharmacology
- Signal Transduction/drug effects
- Signal Transduction/genetics
- Tomography Scanners, X-Ray Computed
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Affiliation(s)
- Xiaonan Liu
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yu Chai
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Guanqiao Liu
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Weiping Su
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Qiaoyue Guo
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Xiao Lv
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peisong Gao
- Johns Hopkins Asthma & Allergy Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bin Yu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Gerardo Ferbeyre
- Department of Biochemistry and Molecular Medicine, Université de Montréal, Montreal, QC, Canada
| | - Xu Cao
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mei Wan
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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19
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Claessen KMJA, Andela CD, Biermasz NR, Pereira AM. Clinical Unmet Needs in the Treatment of Adrenal Crisis: Importance of the Patient's Perspective. Front Endocrinol (Lausanne) 2021; 12:701365. [PMID: 34354671 PMCID: PMC8329717 DOI: 10.3389/fendo.2021.701365] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/30/2021] [Indexed: 12/25/2022] Open
Abstract
Adrenal crisis is the most severe manifestation of adrenal insufficiency (AI), but AI can present with variable signs and symptoms of gradual severity. Despite current hormone replacement strategies, adrenal crisis is still one of the leading causes of mortality in AI patients. Although underlying factors explaining differences in interindividual susceptibility are not completely understood, several subgroups are particularly vulnerable to adrenal crises, such as patients with primary AI, and patients treated for Cushing's syndrome. Currently, the health care professional faces several challenges in the care for AI patients, including the lack of reliable biomarkers measuring tissue cortisol concentrations, absence of a universally used definition for adrenal crisis, and lack of clinical tools to identify individual patients at increased risk. Also from the patient's perspective, there are a number of steps to be taken in order to increase and evaluate self-management skills and, finally, improve health-related quality of life (HR-QoL). In this respect, the fact that inadequate handling of AI patients during stressful situations is a direct consequence of not remembering how to act due to severe weakness and cognitive dysfunction in the context of the adrenal crisis is quite underexposed. In this narrative review, we give an overview of different clinical aspects of adrenal crisis, and discuss challenges and unmet needs in the management of AI and the adrenal crisis from both the doctor's and patient's perspective. For the latter, we use original focus group data. Integration of doctor's and patient's perspectives is key for successful improvement of HR-QoL in patients with AI.
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20
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Ehren R, Benz MR, Brinkkötter PT, Dötsch J, Eberl WR, Gellermann J, Hoyer PF, Jordans I, Kamrath C, Kemper MJ, Latta K, Müller D, Oh J, Tönshoff B, Weber S, Weber LT. Pediatric idiopathic steroid-sensitive nephrotic syndrome: diagnosis and therapy -short version of the updated German best practice guideline (S2e) - AWMF register no. 166-001, 6/2020. Pediatr Nephrol 2021; 36:2971-2985. [PMID: 34091756 PMCID: PMC8445869 DOI: 10.1007/s00467-021-05135-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 01/21/2023]
Abstract
Idiopathic nephrotic syndrome is the most frequent glomerular disease in children in most parts of the world. Children with steroid-sensitive nephrotic syndrome (SSNS) generally have a good prognosis regarding the maintenance of normal kidney function even in the case of frequent relapses. The course of SSNS is often complicated by a high rate of relapses and the associated side effects of repeated glucocorticoid (steroid) therapy. The following recommendations for the treatment of SSNS are based on the comprehensive consideration of published evidence by a working group of the German Society for Pediatric Nephrology (GPN) based on the systematic Cochrane reviews on SSNS and the guidelines of the KDIGO working group (Kidney Disease - Improving Global Outcomes).
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Affiliation(s)
- Rasmus Ehren
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany.
| | - Marcus R Benz
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
| | - Paul T Brinkkötter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), Cologne, Germany
| | - Jörg Dötsch
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
| | - Wolfgang R Eberl
- Department of Pediatrics, Städtisches Klinikum Braunschweig, Braunschweig, Germany
| | - Jutta Gellermann
- Pediatric Nephrology, Charité Children's Hospital, Berlin, Germany
| | - Peter F Hoyer
- Center for Children and Adolescents, Pediatric Clinic II, University of Duisburg-Essen, Essen, Germany
| | - Isabelle Jordans
- Bundesverband Niere eV (German National Kidney-Patients Association), Mainz, Germany
| | - Clemens Kamrath
- Division of Pediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Markus J Kemper
- Department of Pediatrics, Asklepios Medical School, Hamburg, Germany
| | - Kay Latta
- Clementine Kinderhospital Frankfurt, Frankfurt, Germany
| | - Dominik Müller
- Pediatric Nephrology, Charité Children's Hospital, Berlin, Germany
| | - Jun Oh
- Division of Pediatric Nephrology, Hepatology and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Stefanie Weber
- Department of Pediatrics II, University Children's Hospital, Philipps-University Marburg, Marburg, Germany
| | - Lutz T Weber
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
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21
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Steroid-Induced Iatrogenic Adrenal Insufficiency in Children: A Literature Review. ENDOCRINES 2020. [DOI: 10.3390/endocrines1020012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The present review focuses on steroid-induced adrenal insufficiency (SIAI) in children and discusses the latest findings by surveying recent studies. SIAI is a condition involving adrenocorticotropic hormone (ACTH) and cortisol suppression due to high doses or prolonged administration of glucocorticoids. While its chronic symptoms, such as fatigue and loss of appetite, are nonspecific, exposure to physical stressors, such as infection and surgery, increases the risk of adrenal crisis development accompanied by hypoglycemia, hypotension, or shock. The low-dose ACTH stimulation test is generally used for diagnosis, and the early morning serum cortisol level has also been shown to be useful in screening for the condition. Medical management includes gradually reducing the amount of steroid treatment, continuing administration of hydrocortisone corresponding to the physiological range, and increasing the dosage when physical stressors are present.
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22
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Holochwost SJ, Robb SL, Henley AK, Stegenga K, Perkins SM, Russ KA, Jacob SA, Delgado D, Haase JE, Krater CM. Active Music Engagement and Cortisol as an Acute Stress Biomarker in Young Hematopoietic Stem Cell Transplant Patients and Caregivers: Results of a Single Case Design Pilot Study. Front Psychol 2020; 11:587871. [PMID: 33224077 PMCID: PMC7667234 DOI: 10.3389/fpsyg.2020.587871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/30/2020] [Indexed: 11/13/2022] Open
Abstract
This paper reports the results of a single case design pilot study of a music therapy intervention [the Active Music Engagement (AME)] for young children (age 3.51 to 4.53 years) undergoing hematopoietic stem cell transplantation (HCST) and their caregivers. The primary aims of the study were to determine feasibility/acceptability of the AME intervention protocol and data collection in the context of HCST. Secondary aims were to examine caregivers' perceptions of the benefit of AME and whether there were changes in child and caregiver cortisol levels relative to the AME intervention. Results indicated that the AME could be implemented in this context and that data could be collected, though the collection of salivary cortisol may constitute an additional burden for families. Nevertheless, data that were collected suggest that families derive benefit from the AME, which underscores the need for devising innovative methods to understand the neurophysiological impacts of the AME.
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Affiliation(s)
| | - Sheri L Robb
- School of Nursing, Indiana University, Indianapolis, IN, United States
| | - Amanda K Henley
- School of Nursing, Indiana University, Indianapolis, IN, United States
| | | | - Susan M Perkins
- School of Medicine, Indiana University, Indianapolis, IN, United States.,Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, United States
| | - Kristen A Russ
- Melvin and Bren Simon Comprehensive Cancer Center, Indiana University, Indianapolis, IN, United States
| | - Seethal A Jacob
- School of Medicine, Indiana University, Indianapolis, IN, United States.,Riley Hospital for Children at Indiana University Health, Indianapolis, IN, United States
| | - David Delgado
- Astellas Pharma Global Development, Northbrook, IL, United States
| | - Joan E Haase
- School of Nursing, Indiana University, Indianapolis, IN, United States
| | - Caitlin M Krater
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, United States
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23
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Hyponatremia in Patients with Hematologic Diseases. J Clin Med 2020; 9:jcm9113721. [PMID: 33228240 PMCID: PMC7699475 DOI: 10.3390/jcm9113721] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 11/10/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022] Open
Abstract
Hyponatremia is the most common electrolyte disorder in clinical practice and is associated with increased morbidity and mortality. It is frequently encountered in hematologic patients with either benign or malignant diseases. Several underlying mechanisms, such as hypovolemia, infections, toxins, renal, endocrine, cardiac, and liver disorders, as well as the use of certain drugs appear to be involved in the development or the persistence of hyponatremia. This review describes the pathophysiology of hyponatremia and discusses thoroughly the contributing factors and mechanisms that may be encountered specifically in patients with hematologic disorders. The involvement of the syndrome of inappropriate antidiuretic hormone (SIADH) secretion and renal salt wasting syndrome (RSWS) in the development of hyponatremia in such patients, as well as their differential diagnosis and management, are also presented. Furthermore, the distinction between true hyponatremia and pseudohyponatremia is explained. Finally, a practical algorithm for the evaluation of hyponatremia in hematologic patients, as well as the principles of hyponatremia management, are included in this review.
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24
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Russ KA, Holochwost SJ, Perkins SM, Stegenga K, Jacob SA, Delgado D, Henley AK, Haase JE, Robb SL. Cortisol as an Acute Stress Biomarker in Young Hematopoietic Cell Transplant Patients/Caregivers: Active Music Engagement Protocol. J Altern Complement Med 2020; 26:424-434. [PMID: 32073877 PMCID: PMC7232696 DOI: 10.1089/acm.2019.0413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective: Primary aims of the proposed protocol are to determine the feasibility/acceptability of the active music engagement intervention protocol during hematopoietic stem cell transplantation (HSCT) and clinical feasibility/acceptability of the biological sample collection schedule. Design: The authors propose a single-case, alternating treatment design to compare levels of child and caregiver cortisol in blood and saliva collected on alternating days, when the dyad receives and does not receive AME sessions. Included are the scientific rationale for this design and detailed intervention and sample collection schedules based on transplant type. Setting/Location: Pediatric inpatient HSCT unit. Subjects: Eligible participants are dyads of children 3–8 years old, hospitalized for HSCT, and their caregiver. Children with malignant and nonmalignant conditions will be eligible, regardless of transplant type. Intervention: AME intervention is delivered by a board-certified music therapist who tailors music-based play experiences to encourage active engagement in, and independent use of, music play to manage the inter-related emotional distress experienced by children and their caregivers during HSCT. Dyads will receive two 45-min AME sessions each week during hospitalization. Outcome Measures: Eight collections of blood (child) and saliva (child/caregiver) will be performed for cortisol measurement. The authors will also collect self-report and caregiver proxy measures for dyad emotional distress, quality of life, and family function. At study conclusion, qualitative caregiver interviews will be conducted. Results: Planned analyses will be descriptive and evaluate the feasibility of participant recruitment, cortisol collection, planned evaluations, and AME delivery. Analysis of qualitative interviews will be used to gain an understanding about the ease/burden of biological sample collection and any perceived benefit of AME. Conclusions: Behavioral intervention studies examining biological mechanisms of action in pediatric transplant populations are rare. Findings will provide important information about the feasibility/acceptability of collecting cortisol samples during a high-intensity treatment and advance understanding about the use of active music interventions to mitigate child/caregiver distress during the transplant period.
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Affiliation(s)
- Kristen A Russ
- Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
| | | | - Susan M Perkins
- Indiana University School of Medicine, Indianapolis, IN, USA.,Richard M. Fairbanks School of Public Health, Indianapolis, IN, USA
| | | | - Seethal A Jacob
- Indiana University School of Medicine, Indianapolis, IN, USA.,Riley Hospital for Children at IU Health, Indianapolis, IN, USA
| | - David Delgado
- Astellas Pharma Global Development, Northbrook, IL, USA
| | | | - Joan E Haase
- Indiana University School of Nursing, Indianapolis, IN, USA
| | - Sheri L Robb
- Indiana University School of Nursing, Indianapolis, IN, USA
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25
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Loimijoki T, Lapatto R, Taskinen M. Adrenal function after induction therapy for acute lymphoblastic leukemia in children short: adrenal function in ALL. Eur J Pediatr 2020; 179:1453-1459. [PMID: 32193656 PMCID: PMC7413907 DOI: 10.1007/s00431-020-03624-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/26/2020] [Accepted: 02/25/2020] [Indexed: 12/02/2022]
Abstract
Prednisolone used in the induction phase of the treatment of acute lymphoblastic leukemia (ALL) may suppress hypothalamic-pituitary-adrenal axis and require hydrocortisone substitution. In this retrospective analysis, we reviewed altogether 371 ACTH stimulation tests of 352 children after a uniform NOPHO (Nordic Society of Pediatric Hematology and Oncology) ALL induction. Both low- and standard-dose ACTH tests were used. Full recovery of adrenal function was defined by both normal basal and stimulated cortisol levels. Sixty-two percent of patients were detected with normal adrenal function in median of 15 days after tapering of prednisolone. Both low basal and stimulated cortisol levels were detected in 13% of patients. The median time to normal adrenal function was 31 days (95% CI 28-34), 24 days (95% CI 18-30), and 12 days (95% CI 10-14) for those with basal cortisol <107, 107-183, and >183 nmol/L at first ACTH testing, respectively. Patients with fluconazole prophylaxis had higher median baseline cortisol levels compared to patients without prophylaxis (207 nmol/L, range 21-839 nmol/L vs. 153 nmol/L, range 22-832 nmol/L, P = 0.003).Conclusion: These data can be used to reduce unnecessary substitution or testing, but also to guarantee hydrocortisone substitution for those at risk. What is Known: •These data can be used to reduce unnecessary hydrocortisone substitution or ACTH testing. •Our data helps to guarantee hydrocortisone substitution for those at risk of adrenal insufficiency. What is New: •Full recovery of adrenal function after ALL induction is detected in 62% of patients already at 15 days after tapering of prednisolone. •Both basal and stimulated cortisol testing are required for detection of full adrenal recovery. •Recovery time of adrenal function is extended over 3-4 weeks after tapering of prednisolone in patients with low basal cortisol levels (<107 nmol/L) at first testing.
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Affiliation(s)
- Tiia Loimijoki
- New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Stenbackinkatu 9, P.O. Box 347, FIN-00029HUS Helsinki, Finland
| | - Risto Lapatto
- New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Stenbackinkatu 9, P.O. Box 347, FIN-00029HUS Helsinki, Finland
| | - Mervi Taskinen
- New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Stenbackinkatu 9, P.O. Box 347, FIN-00029HUS Helsinki, Finland
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26
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Ahmad N, Abosoudah IF, Sobaihi MM, Algiraigri AH, Roujouleh F, Ghurab F, Chanoine JP. Adrenal function following acute discontinuation of glucocorticoids in children with acute lymphocytic leukemia: A prospective study. Pediatr Hematol Oncol 2019; 36:422-431. [PMID: 31429623 DOI: 10.1080/08880018.2019.1652710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Children with acute lymphocytic leukemia (ALL) are enrolled in advanced treatment protocols involving high doses of glucocorticoids (GCs). Current protocols do not advocate tapering of GCs doses postinduction phase. Prolonged administration of supra-physiologic doses of GCs can induce transient suppression of the hypothalamic pituitary adrenal axis (HPA). Timely recognition of adrenal insufficiency is important in order to ensure that children at risk receive the necessary treatment and follow-up including stress coverage during illness and surgical procedures. Methods: 21 newly diagnosed patients with ALL aged 3-10 years old were prospectively enrolled in the study over a 2-year period. All enrolled patients received high doses of GCs as part of a chemotherapy treatment protocol. The HPA axis was assessed prior to the induction phase of chemotherapy and 1-2 weeks after un-tapered discontinuation of GCs. Results: All children had normal HPA axis at baseline. Postinduction 1 mcg ACTH stimulation test result was normal (cortisol > 500 nmol/L) in 75% of children and partially responsive in 25% (cortisol 300-500 nmol/L). None of the participants demonstrated clinically significant adrenal insufficiency following abrupt cessation of GCs. Conclusion: All children in our cohort had either normal or subnormal cortisol response during a low dose ACTH stimulation test 1 to 2 weeks following abrupt discontinuation of GCs, suggesting that any inhibition of the HPA axis is of short duration. We suggest that future studies investigate the timing of adrenal function recovery following GC discontinuation as well as whether tapering of the GC should be recommended.
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Affiliation(s)
- Noman Ahmad
- Consultant Pediatric Endocrinology, King Faisal Specialist Hospital and Research Center , Jeddah , Saudi Arabia
| | - Ibraheem Faisal Abosoudah
- Consultant Pediatric Oncology, King Faisal Specialist Hospital and Research Center , Jeddah , Saudi Arabia
| | - Mrouge Mohamed Sobaihi
- Consultant Pediatric Endocrinology, King Faisal Specialist Hospital and Research Center , Jeddah , Saudi Arabia
| | - Ali Hassan Algiraigri
- Consultant Pediatric Oncology, King Faisal Specialist Hospital and Research Center , Jeddah , Saudi Arabia.,King Abdulaziz university hospital , Jeddah , Saudi Arabia
| | - Farh Roujouleh
- Resident General Pediatrics, King Faisal Specialist Hospital and Research Center , Jeddah , Saudi Arabia
| | - Fatima Ghurab
- Resident General Pediatrics, King Faisal Specialist Hospital and Research Center , Jeddah , Saudi Arabia
| | - Jean-Pierre Chanoine
- Clinical Professor and Head, Endocrinology and Diabetes Unit, British Columbia Children's Hospital , Vancouver Canada
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27
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Ueda Y, Yasoda A, Hirota K, Yamauchi I, Yamashita T, Kanai Y, Sakane Y, Fujii T, Inagaki N. Exogenous C-type natriuretic peptide therapy for impaired skeletal growth in a murine model of glucocorticoid treatment. Sci Rep 2019; 9:8547. [PMID: 31189976 PMCID: PMC6561908 DOI: 10.1038/s41598-019-44975-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 05/29/2019] [Indexed: 12/13/2022] Open
Abstract
Growth retardation is an important side effect of glucocorticoid (GC)-based drugs, which are widely used in various preparations to treat many pediatric diseases. We investigated the therapeutic effect of exogenous CNP-53, a stable molecular form of intrinsic CNP, on a mouse model of GC-induced growth retardation. We found that CNP-53 successfully restored GC-induced growth retardation when both dexamethasone (DEX) and CNP-53 were injected from 4 to 8 weeks old. Notably, CNP-53 was not effective during the first week. From 4 to 5 weeks old, neither CNP-53 in advance of DEX, nor high-dose CNP-53 improved the effect of CNP. Conversely, when CNP-53 was started at 5 weeks old, final body length at 8 weeks old was comparable to that when CNP-53 was started at 4 weeks old. As for the mechanism of resistance to the CNP effect, DEX did not impair the production of cGMP induced by CNP. CNP reduced Erk phosphorylation even under treatment with DEX, while CNP did not changed that of p38 or GSK3β. Collectively, the effect of CNP-53 on GC-induced growth retardation is dependent on age in a mouse model, suggesting adequate and deliberate use of CNP would be effective for GC-induced growth retardation in clinical settings.
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Affiliation(s)
- Yohei Ueda
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan
| | - Akihiro Yasoda
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan. .,Clinical Research Center, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan.
| | - Keisho Hirota
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan
| | - Ichiro Yamauchi
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan
| | - Takafumi Yamashita
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan
| | - Yugo Kanai
- Department of Diabetes and Endocrinology, Osaka Red Cross Hospital, 5-30 Fudegasaki-cho, Tennoji-ku, 543-8555, Osaka, Japan
| | - Yoriko Sakane
- Preemptive Medicine and Lifestyle Related Disease Research Center, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan
| | - Toshihito Fujii
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, 606-8507, Kyoto, Japan
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28
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Miller BS, Spencer SP, Geffner ME, Gourgari E, Lahoti A, Kamboj MK, Stanley TL, Uli NK, Wicklow BA, Sarafoglou K. Emergency management of adrenal insufficiency in children: advocating for treatment options in outpatient and field settings. J Investig Med 2019; 68:16-25. [PMID: 30819831 PMCID: PMC6996103 DOI: 10.1136/jim-2019-000999] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2019] [Indexed: 01/01/2023]
Abstract
Adrenal insufficiency (AI) remains a significant cause of morbidity and mortality in children with 1 in 200 episodes of adrenal crisis resulting in death. The goal of this working group of the Pediatric Endocrine Society Drug and Therapeutics Committee was to raise awareness on the importance of early recognition of AI, to advocate for the availability of hydrocortisone sodium succinate (HSS) on emergency medical service (EMS) ambulances or allow EMS personnel to administer patient's HSS home supply to avoid delay in administration of life-saving stress dosing, and to provide guidance on the emergency management of children in adrenal crisis. Currently, hydrocortisone, or an equivalent synthetic glucocorticoid, is not available on most ambulances for emergency stress dose administration by EMS personnel to a child in adrenal crisis. At the same time, many States have regulations preventing the use of patient's home HSS supply to be used to treat acute adrenal crisis. In children with known AI, parents and care providers must be made familiar with the administration of maintenance and stress dose glucocorticoid therapy to prevent adrenal crises. Patients with known AI and their families should be provided an Adrenal Insufficiency Action Plan, including stress hydrocortisone dose (both oral and intramuscular/intravenous) to be provided immediately to EMS providers and triage personnel in urgent care and emergency departments. Advocacy efforts to increase the availability of stress dose HSS during EMS transport care and add HSS to weight-based dosing tapes are highly encouraged.
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Affiliation(s)
- Bradley S Miller
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Sandra P Spencer
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mitchell E Geffner
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Evgenia Gourgari
- Department of Pediatrics, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Amit Lahoti
- Department of Pediatrics, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Manmohan K Kamboj
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Takara L Stanley
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Naveen K Uli
- Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Brandy A Wicklow
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kyriakie Sarafoglou
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
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29
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Ahmet A, Mokashi A, Goldbloom EB, Huot C, Jurencak R, Krishnamoorthy P, Rowan-Legg A, Kim H, Pancer L, Kovesi T. Adrenal suppression from glucocorticoids: preventing an iatrogenic cause of morbidity and mortality in children. BMJ Paediatr Open 2019; 3:e000569. [PMID: 31750407 PMCID: PMC6830460 DOI: 10.1136/bmjpo-2019-000569] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/26/2019] [Accepted: 09/28/2019] [Indexed: 12/18/2022] Open
Abstract
Adrenal suppression (AS) is an important side effect of glucocorticoids (GCs) including inhaled corticosteroids (ICS). AS can often be asymptomatic or associated with non-specific symptoms until a physiological stress such as an illness precipitates an adrenal crisis. Morbidity and death associated with adrenal crisis is preventable but continues to be reported in children. There is a lack of consensus about the management of children at risk of AS. However, healthcare professionals need to develop an awareness and approach to keep these children safe. In this article, current knowledge of the risk factors, diagnosis and management of AS are reviewed while drawing attention to knowledge gaps and areas of controversy. Possible strategies to reduce the morbidity associated with this iatrogenic condition are provided for healthcare professionals.
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Affiliation(s)
- Alexandra Ahmet
- Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Arati Mokashi
- Pediatrics, Division of Endocrinology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Ellen B Goldbloom
- Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Celine Huot
- Pediatrics, Division of Endocrinology, University of Montreal, Montreal, Quebec, Canada.,Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Roman Jurencak
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Division of Rheumatology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Preetha Krishnamoorthy
- Pediatrics, Division of Endocrinology, Montreal Childrens Hospital, Montreal, Quebec, Canada.,Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Anne Rowan-Legg
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Harold Kim
- Department of Medicine, Division of Clinical Immunology and Allergy, St. Joseph's Hospital, London, Ontario, Canada
| | - Larry Pancer
- Pediatrics, Markham Stouffville Hospital, Markham, Ontario, Canada
| | - Tom Kovesi
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Division of Respirology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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30
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Conklin LS, Damsker JM, Hoffman EP, Jusko WJ, Mavroudis PD, Schwartz BD, Mengle-Gaw LJ, Smith EC, Mah JK, Guglieri M, Nevo Y, Kuntz N, McDonald CM, Tulinius M, Ryan MM, Webster R, Castro D, Finkel RS, Smith AL, Morgenroth LP, Arrieta A, Shimony M, Jaros M, Shale P, McCall JM, Hathout Y, Nagaraju K, van den Anker J, Ward LM, Ahmet A, Cornish MR, Clemens PR. Phase IIa trial in Duchenne muscular dystrophy shows vamorolone is a first-in-class dissociative steroidal anti-inflammatory drug. Pharmacol Res 2018; 136:140-150. [PMID: 30219580 PMCID: PMC6218284 DOI: 10.1016/j.phrs.2018.09.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 12/24/2022]
Abstract
We report a first-in-patient study of vamorolone, a first-in-class dissociative steroidal anti-inflammatory drug, in Duchenne muscular dystrophy. This 2-week, open-label Phase IIa multiple ascending dose study (0.25, 0.75, 2.0, and 6.0 mg/kg/day) enrolled 48 boys with Duchenne muscular dystrophy (4 to <7 years), with outcomes including clinical safety, pharmacokinetics and pharmacodynamic biomarkers. The study design included pharmacodynamic biomarkers in three contexts of use: 1. Secondary outcomes for pharmacodynamic safety (insulin resistance, adrenal suppression, bone turnover); 2. Exploratory outcomes for drug mechanism of action; 3. Exploratory outcomes for expanded pharmacodynamic safety. Vamorolone was safe and well-tolerated through the highest dose tested (6.0 mg/kg/day) and pharmacokinetics of vamorolone were similar to prednisolone. Using pharmacodynamic biomarkers, the study demonstrated improved safety of vamorolone versus glucocorticoids as shown by reduction of insulin resistance, beneficial changes in bone turnover (loss of increased bone resorption and decreased bone formation only at the highest dose level), and a reduction in adrenal suppression. Exploratory biomarkers of pharmacodynamic efficacy showed an anti-inflammatory mechanism of action and a beneficial effect on plasma membrane stability, as demonstrated by a dose-responsive decrease in serum creatine kinase activity. With an array of pre-selected biomarkers in multiple contexts of use, we demonstrate the development of the first dissociative steroid that preserves anti-inflammatory efficacy and decreases steroid-associated safety concerns. Ongoing extension studies offer the potential to bridge exploratory efficacy biomarkers to clinical outcomes.
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Affiliation(s)
- Laurie S. Conklin
- ReveraGen Biopharma, LLC, Rockville, MD, USA,Children’s National Health System, George Washington University, Washington, DC, USA
| | | | - Eric P. Hoffman
- ReveraGen Biopharma, LLC, Rockville, MD, USA,Binghamton University- SUNY, Binghamton, NY, USA
| | | | | | | | | | | | - Jean K. Mah
- University of Calgary, Alberta Children’s Hospital, Calgary, Alberta, Canada
| | | | - Yoram Nevo
- Schneider Children’s Medical Center of Israel, Tel Aviv University, Tel Aviv, Israel
| | - Nancy Kuntz
- Ann & Robert H. Lurie Children’s Hospital Chicago, IL, USA
| | | | - Mar Tulinius
- Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Monique M. Ryan
- Royal Children’s Hospital, University of Melbourne, Melbourne, Australia
| | | | - Diana Castro
- University of Texas Southwestern, Dallas, TX, USA
| | | | | | | | | | | | | | | | | | | | - Kanneboyina Nagaraju
- ReveraGen Biopharma, LLC, Rockville, MD, USA,Binghamton University- SUNY, Binghamton, NY, USA
| | - John van den Anker
- ReveraGen Biopharma, LLC, Rockville, MD, USA,Children’s National Health System, George Washington University, Washington, DC, USA
| | - Leanne M. Ward
- Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | | | | | - Paula R. Clemens
- University of Pittsburgh and Department of Veterans Affairs Medical Center, Pittsburgh, PA, USA
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