1
|
Bioletto F, Barale M, Parasiliti-Caprino M, Giannelli J, Campioni L, Cappiello V, Di Carlo MC, Ghigo E, Procopio M, Giordano R. Bone safety of dual-release hydrocortisone in patients with autoimmune primary adrenal insufficiency. Front Endocrinol (Lausanne) 2023; 14:1234237. [PMID: 37766685 PMCID: PMC10519793 DOI: 10.3389/fendo.2023.1234237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Background Conventional glucocorticoids (C-GC) replacement regimens have a detrimental effect on skeletal health in patients with adrenal insufficiency (AI), ultimately leading to an increased fracture risk. The novel dual-release hydrocortisone (DR-HC) formulations are characterized by a more favourable safety profile on various clinical endpoints. Data comparing the impact of C-GC and DR-HC on bone, however, are scarce. Methods Twenty-seven patients with autoimmune primary AI (PAI; 13 treated with C-GC and 14 treated with DR-HC) were evaluated to compare bone-related parameters between the two treatment groups. Results No significant differences between the two treatments groups were observed with respect to bone turnover markers. Patients treated with C-GC showed a lower bone mineral density (BMD) at lumbar spine (LS; 0.791 ± 0.195 vs. 0.942 ± 0.124 g/cm2, p=0.025) and at femoral neck (FN; 0.633 ± 0.114 vs. 0.716 ± 0.088 g/cm2, p=0.045). Moreover, they were characterized by a lower trabecular bone score (TBS; 1.236 ± 0.035 vs. 1.383 ± 0.030, p=0.004) and by a higher mean number of vertebral fractures per patient (0.75 vs. 0 fractures, p=0.002). TBS was the best predictor of fracture risk, with a pseudo-R2 of 0.593; moreover, at mediation analysis, it was able to fully explain the observed detrimental effect of C-GC, compared to DR-HC, on fracture risk. Conclusions These results suggest that DR-HC is associated with less bone-related complications compared to C-GC in patients with PAI. Moreover, TBS seems to play a pivotal role in the mediation of the relationship between glucocorticoid treatment regimens and fracture risk.
Collapse
Affiliation(s)
- Fabio Bioletto
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marco Barale
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Mirko Parasiliti-Caprino
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Jacopo Giannelli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Lorenzo Campioni
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Vincenzo Cappiello
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Maria Chiara Di Carlo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Massimo Procopio
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Roberta Giordano
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| |
Collapse
|
2
|
Bugălă NM, Carsote M, Stoica LE, Albulescu DM, Ţuculină MJ, Preda SA, Boicea AR, Alexandru DO. New Approach to Addison Disease: Oral Manifestations Due to Endocrine Dysfunction and Comorbidity Burden. Diagnostics (Basel) 2022; 12:diagnostics12092080. [PMID: 36140482 PMCID: PMC9497746 DOI: 10.3390/diagnostics12092080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/17/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
This review highlights oral anomalies with major clinical impact in Addison disease (AD), including dental health and dermatologic features, through a dual perspective: pigmentation issues and AD comorbidities with oral manifestations. Affecting 92% of AD patients, cutaneomucosal hyperpigmentation is synchronous with or precedes general manifestations by up to a decade, underlying melanocytic infiltration of the basal epidermal layer; melanophages in the superficial dermis; and, rarely, acanthosis, perivascular lymphocytic infiltrate, and hyperkeratosis. Intraoral pigmentation might be the only sign of AD; thus, early recognition is mandatory, and biopsy is helpful in selected cases. The buccal area is the most affected location; other sites are palatine arches, lips, gums, and tongue. Pigmented oral lesions are patchy or diffuse; mostly asymptomatic; and occasionally accompanied by pain, itchiness, and burn-like lesions. Pigmented lingual patches are isolated or multiple, located on dorsal and lateral areas; fungiform pigmented papillae are also reported in AD individuals. Dermoscopy examination is particularly indicated for fungal etiology; yet, it is not routinely performed. AD’s comorbidity burden includes the cluster of autoimmune polyglandular syndrome (APS) type 1 underlying AIRE gene malfunction. Chronic cutaneomucosal candidiasis (CMC), including oral CMC, represents the first sign of APS1 in 70–80% of cases, displaying autoantibodies against interleukin (IL)-17A, IL-17F ± IL-22, and probably a high mucosal concentration of interferon (IFN)-γ. CMC is prone to systemic candidiasis, representing a procarcinogenic status due to Th17 cell anomalies. In APS1, the first cause of mortality is infections (24%), followed by oral and esophageal cancers (15%). Autoimmune hypoparathyroidism (HyP) is the earliest endocrine element in APS1; a combination of CMC by the age of 5 years and dental enamel hypoplasia (the most frequent dental complication of pediatric HyP) by the age of 15 is an indication for HyP assessment. Children with HyP might experience short dental roots, enamel opacities, hypodontia, and eruption dysfunctions. Copresence of APS-related type 1 diabetes mellitus (DM) enhances the risk of CMC, as well as periodontal disease (PD). Anemia-related mucosal pallor is related to DM, hypothyroidism, hypogonadism, corresponding gastroenterological diseases (Crohn’s disease also presents oral ulceration (OU), mucogingivitis, and a 2–3 times higher risk of PD; Biermer anemia might cause hyperpigmentation by itself), and rheumatologic diseases (lupus induces OU, honeycomb plaques, keratotic plaques, angular cheilitis, buccal petechial lesions, and PD). In more than half of the patients, associated vitiligo involves depigmentation of oral mucosa at different levels (palatal, gingival, alveolar, buccal mucosa, and lips). Celiac disease may manifest xerostomia, dry lips, OU, sialadenitis, recurrent aphthous stomatitis and dental enamel defects in children, a higher prevalence of caries and dentin sensitivity, and gingival bleeding. Oral pigmented lesions might provide a useful index of suspicion for AD in apparently healthy individuals, and thus an adrenocorticotropic hormone (ACTH) stimulation is useful. The spectrum of autoimmune AD comorbidities massively complicates the overall picture of oral manifestations.
Collapse
Affiliation(s)
- Narcis Mihăiţă Bugălă
- Department of Medical Informatics and Biostatistics, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- C.I. Parhon National Institute of Endocrinology, Aviatorilor Ave. 34–38, Sector 1, 011683 Bucharest, Romania
- Correspondence: ; Tel.: +40-744851934
| | - Loredana Elena Stoica
- Department of Dermatology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Dana Maria Albulescu
- Department of Anatomy, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mihaela Jana Ţuculină
- Department of Odontology, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Smaranda Adelina Preda
- Department of Odontology, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Ancuta-Ramona Boicea
- Department of Occupational Medicine, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Dragoș Ovidiu Alexandru
- Department of Medical Informatics and Biostatistics, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| |
Collapse
|
3
|
Sabbadin C, Betterle C, Scaroni C, Ceccato F. Frequently Asked Questions in Patients With Adrenal Insufficiency in the Time of COVID-19. Front Endocrinol (Lausanne) 2021; 12:805647. [PMID: 35002978 PMCID: PMC8739913 DOI: 10.3389/fendo.2021.805647] [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: 10/30/2021] [Accepted: 12/10/2021] [Indexed: 12/15/2022] Open
Abstract
Adrenal insufficiency (AI) is a life-threatening disorder, with increased morbidity and mortality, especially in case of an acute illness that can increase the requirement of cortisol. A novel infectious disease, termed Coronavirus Disease 2019 (COVID-19), appeared in 2020. Therefore, AI patients are experiencing a novel challenge: the risk of infection. In our experience, a prompt contact to the Endocrine center (with a telemedicine consultation) and a full awareness of diseases (cortisol deficiency, COVID-19 and the self-management of an adrenal crisis) are important to motivate patients. Vaccine is an effective treatment to prevent hospitalization and aggressive course of COVID-19. Some patients manifest challenges due to inequitable access and vaccine hesitancy, resulting in a delay in the acceptance of vaccines despite the availability of vaccination services. Therefore, an effort of all physicians must be conducted in order to advise patients with AI. In this short review, we try to answer some frequently asked questions regarding the management of patients with AI.
Collapse
Affiliation(s)
- Chiara Sabbadin
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Corrado Betterle
- Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Filippo Ceccato
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Department of Neuroscience (DNS), University of Padova, Padova, Italy
| |
Collapse
|
4
|
Zhou Z, Zhang S, Hu F. Endocrine Disorder in Patients With Craniopharyngioma. Front Neurol 2021; 12:737743. [PMID: 34925209 PMCID: PMC8675636 DOI: 10.3389/fneur.2021.737743] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/13/2021] [Indexed: 12/26/2022] Open
Abstract
Craniopharyngioma is an intracranial congenital epithelial tumor growing along the pathway of the embryonic craniopharyngeal tube. The main clinical symptoms of patients with craniopharyngioma include high intracranial pressure, visual field defect, endocrine dysfunction, and hypothalamic dysfunction. At present, the preferred treatment remains the surgical treatment, but the recovery of endocrine and hypothalamic function following surgery is limited. In addition, endocrine disorders often emerge following surgery, which seriously reduces the quality of life of patients after operation. So far, research on craniopharyngioma focuses on ways to ameliorate endocrine dysfunction. This article reviews the latest research progress on pathogenesis, manifestation, significance, and treatment of endocrine disorders in patients with craniopharyngioma.
Collapse
Affiliation(s)
- Zihao Zhou
- Department of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Sheng Zhang
- Department of Neurosurgery, Xuzhou Medical University Affiliated Lianyungang Hospital, Xuzhou, China
| | - Fangqi Hu
- Department of Neurosurgery, Nanjing Medical University Affiliated Lianyungang Hospital, Nanjing, China
| |
Collapse
|
5
|
Isidori AM, Arnaldi G, Boscaro M, Falorni A, Giordano C, Giordano R, Pivonello R, Pozza C, Sbardella E, Simeoli C, Scaroni C, Lenzi A. Towards the tailoring of glucocorticoid replacement in adrenal insufficiency: the Italian Society of Endocrinology Expert Opinion. J Endocrinol Invest 2020; 43:683-696. [PMID: 31773582 DOI: 10.1007/s40618-019-01146-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/11/2019] [Indexed: 11/28/2022]
Abstract
CONTEXT Glucocorticoid (GC) replacement therapy in patients with adrenal insufficiency (AI) is life saving. After over 50 years of conventional GC treatment, novel formulations are now entering routine clinical practice. METHODS Given the spectrum of medications currently available and new insights into the understanding of AI, the authors reviewed relevant medical literature with emphasis on original studies, prospective observational data and randomized controlled trials performed in the past 35 years. The Expert Opinion of a panel of selected endocrinologists was sought to answer specific clinical questions. The objective was to provide an evidence-supported guide, for the use of GC in various settings from university hospitals to outpatient clinics, that offers specific advice tailored to the individual patient. RESULTS The Panel reviewed available GC replacement therapies, comprising short-acting, intermediate and long-acting oral formulations, subcutaneous formulations and the novel modified-release hydrocortisone. Advantages and disadvantages of these formulations were reviewed. CONCLUSIONS In the Panel's opinion, achieving the optimal GC timing and dosing is needed to improve the outcome of AI. No-single formulation offers the best option for every patients. Recent data suggest that more emphasis should be given to the timing of intake. Tailoring of GS should be attempted in all patients-by experts-on a case-by-case basis. The Panel identified specific subgroups of AI patients that could be help by this process. Long-term studies are needed to confirm the short-term benefits associated with the modified-release GCs. The impact of GC tailoring has yet to be proven in terms of hospitalization rate, morbidity and mortality.
Collapse
Affiliation(s)
- A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - G Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Azienda Ospedaliero-Universitaria, Università Politecnica delle Marche, Ancona, Italy
| | - M Boscaro
- UOC Endocrinologia, Dipartimento di Medicina DIMED, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - A Falorni
- Dipartimento di Medicina, Università di Perugia, Perugia, Italy
| | - C Giordano
- Section of Diabetology, Endocrinology and Metabolism, PROMISE, University of Palermo, Palermo, Italy
| | - R Giordano
- Department of Clinical and Biological Sciences, Division of Endocrinology, Diabetes and Metabolism-Department of Medical Sciences, University of Turin, Turin, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - C Pozza
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - C Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - C Scaroni
- UOC Endocrinologia, Dipartimento di Medicina DIMED, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
6
|
Kallali W, Gray E, Mehdi MZ, Lindsay R, Metherell LA, Buonocore F, Suntharalingham JP, Achermann JC, Donaldson M. Long-term outcome of partial P450 side-chain cleavage enzyme deficiency in three brothers: the importance of early diagnosis. Eur J Endocrinol 2020; 182:K15-K24. [PMID: 31917682 PMCID: PMC7087497 DOI: 10.1530/eje-19-0696] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/09/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE CYP11A1 mutations cause P450 side-chain cleavage (scc) deficiency, a rare form of congenital adrenal hyperplasia with a wide clinical spectrum. We detail the phenotype and evolution in a male sibship identified by HaloPlex targeted capture array. FAMILY STUDY The youngest of three brothers from a non-consanguineous Scottish family presented with hyperpigmentation at 3.7 years. Investigation showed grossly impaired glucocorticoid function with ACTH elevation, moderately impaired mineralocorticoid function, and normal external genitalia. The older brothers were found to be pigmented also, with glucocorticoid impairment but normal electrolytes. Linkage studies in 2002 showed that all three brothers had inherited the same critical regions of the maternal X chromosome suggesting an X-linked disorder, but analysis of NR0B1 (DAX-1, adrenal hypoplasia) and ABCD1 (adrenoleukodystrophy) were negative. In 2016, next-generation sequencing revealed compound heterozygosity for the rs6161 variant in CYP11A1 (c.940G>A, p.Glu314Lys), together with a severely disruptive frameshift mutation (c.790_802del, K264Lfs*5). The brothers were stable on hydrocortisone and fludrocortisone replacement, testicular volumes (15-20 mL), and serum testosterone levels (24.7, 33.3, and 27.2 nmol/L) were normal, but FSH (41.2 µ/L) was elevated in the proband. The latter had undergone left orchidectomy for suspected malignancy at the age of 25 years and was attending a fertility clinic for oligospermia. Initial histology was reported as showing nodular Leydig cell hyperplasia. However, histological review using CD56 staining confirmed testicular adrenal rest cell tumour (TART). CONCLUSION This kinship with partial P450scc deficiency demonstrates the importance of precise diagnosis in primary adrenal insufficiency to ensure appropriate counselling and management, particularly of TART.
Collapse
Affiliation(s)
- Wafa Kallali
- Children’s Hospital El Bechir Hamza of Tunis, Tunis, Tunisia
| | - Ewan Gray
- David Elder Medical Practice, Glasgow, UK
| | | | - Robert Lindsay
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Louise A Metherell
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Federica Buonocore
- Genetics & Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Jenifer P Suntharalingham
- Genetics & Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - John C Achermann
- Genetics & Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Malcolm Donaldson
- Child Health Section of University of Glasgow School of Medicine, Queen Elizabeth University Hospital, Glasgow, UK
- Correspondence should be addressed to M Donaldson;
| |
Collapse
|
7
|
Abstract
Primary adrenal insufficiency (PAI) occurs in 1/5000-1/7000 individuals in the general population. Autoimmune Addison's disease (AAD) is the major cause of PAI and is a major component of autoimmune polyendocrine syndrome type 1 (APS1) and type 2 (APS2). Presence of 21-hydroxylase autoantibodies (21OHAb) identifies subjects with ongoing clinical or pre-clinical adrenal autoimmunity. AAD requires life-long substitutive therapy with two-three daily doses of hydrocortisone (HC) (15-25 mg/day) or one daily dose of dual-release HC and with fludrocortisone (0.5-2.0 mg/day). The lowest possible HC dose must be identified according to clinical and biochemical parameters to minimize long-term complications that include osteoporosis and cardiovascular and metabolic alterations. Women with AAD have lower fertility and parity as compared to age-matched healthy controls. Patients must be educated to double-triple HC dose in the case of fever or infections and to switch to parenteral HC in the case of vomiting, diarrhoea or acute hypotension.
Collapse
Affiliation(s)
- Serena Saverino
- Section of Internal Medicine and Endocrine and Metabolic Sciences, Department of Medicine, University of Perugia, Perugia, Italy
| | - Alberto Falorni
- Section of Internal Medicine and Endocrine and Metabolic Sciences, Department of Medicine, University of Perugia, Perugia, Italy.
| |
Collapse
|
8
|
Alexandraki KI, Grossman AB. Management of Hypopituitarism. J Clin Med 2019; 8:jcm8122153. [PMID: 31817511 PMCID: PMC6947162 DOI: 10.3390/jcm8122153] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 12/14/2022] Open
Abstract
Hypopituitarism includes all clinical conditions that result in partial or complete failure of the anterior and posterior lobe of the pituitary gland’s ability to secrete hormones. The aim of management is usually to replace the target-hormone of hypothalamo-pituitary-endocrine gland axis with the exceptions of secondary hypogonadism when fertility is required, and growth hormone deficiency (GHD), and to safely minimise both symptoms and clinical signs. Adrenocorticotropic hormone deficiency replacement is best performed with the immediate-release oral glucocorticoid hydrocortisone (HC) in 2–3 divided doses. However, novel once-daily modified-release HC targets a more physiological exposure of glucocorticoids. GHD is treated currently with daily subcutaneous GH, but current research is focusing on the development of once-weekly administration of recombinant GH. Hypogonadism is targeted with testosterone replacement in men and on estrogen replacement therapy in women; when fertility is wanted, replacement targets secondary or tertiary levels of hormonal settings. Thyroid-stimulating hormone replacement therapy follows the rules of primary thyroid gland failure with L-thyroxine replacement. Central diabetes insipidus is nowadays replaced by desmopressin. Certain clinical scenarios may have to be promptly managed to avoid short-term or long-term sequelae such as pregnancy in patients with hypopituitarism, pituitary apoplexy, adrenal crisis, and pituitary metastases.
Collapse
Affiliation(s)
- Krystallenia I. Alexandraki
- Endocrine Unit, 1st Department of Propaedeutic Medicine, School of Medicine, National and Kapodistrian University of Athens, 115 27 Athens, Greece;
| | - Ashley B. Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford OX3 7LE, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London EC1M 6BQ, UK
- Correspondence:
| |
Collapse
|
9
|
Betterle C, Presotto F, Furmaniak J. Epidemiology, pathogenesis, and diagnosis of Addison's disease in adults. J Endocrinol Invest 2019; 42:1407-1433. [PMID: 31321757 DOI: 10.1007/s40618-019-01079-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/25/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Addison's disease (AD) is a rare disorder and among adult population in developed countries is most commonly caused by autoimmunity. In contrast, in children genetic causes are responsible for AD in the majority of patients. PURPOSE This review describes epidemiology, pathogenesis, genetics, natural history, clinical manifestations, immunological markers and diagnostic strategies in patients with AD. Standard care treatments including the management of patients during pregnancy and adrenal crises consistent with the recent consensus statement of the European Consortium and the Endocrine Society Clinical Practice Guideline are described. In addition, emerging therapies designed to improve the quality of life and new strategies to modify the natural history of autoimmune AD are discussed. CONCLUSIONS Progress in optimizing replacement therapy for patients with AD has allowed the patients to lead a normal life. However, continuous education of patients and health care professionals of ever-present danger of adrenal crisis is essential to save lives of patients with AD.
Collapse
Affiliation(s)
- C Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padova, Via Ospedale Civile 105, 35128, Padua, Italy
| | - F Presotto
- Endocrine Unit, Department of Medicine (DIMED), University of Padova, Via Ospedale Civile 105, 35128, Padua, Italy.
- Unit of Internal Medicine, Ospedale dell'Angelo, via Paccagnella 11, 30174, Mestre-Venice, Italy.
| | | |
Collapse
|
10
|
Colombo C, De Leo S, Di Stefano M, Vannucchi G, Persani L, Fugazzola L. Primary Adrenal Insufficiency During Lenvatinib or Vandetanib and Improvement of Fatigue After Cortisone Acetate Therapy. J Clin Endocrinol Metab 2019; 104:779-784. [PMID: 30383218 PMCID: PMC6402317 DOI: 10.1210/jc.2018-01836] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/25/2018] [Indexed: 01/25/2023]
Abstract
CONTEXT Two tyrosine kinase inhibitors (TKIs), lenvatinib and vandetanib, are often used to treat advanced radioiodine-refractory differentiated thyroid cancer (RAI-R DTC) and medullary thyroid cancer (MTC), respectively. Fatigue is a common adverse event during treatment with these and other TKIs and a common cause of drug discontinuation or dosage reduction. CASES DESCRIPTION We evaluated the basal and stimulated adrenal function in 12 patients with advanced RAI-R DTC and MTC treated with lenvatinib or vandetanib, respectively. Ten patients complaining of fatigue showed a progressive ACTH increase with normal cortisol levels. Moreover, six of 10 patients had a blunted cortisol response after ACTH stimulation, thus confirming the diagnosis of primary adrenal insufficiency (PAI). The causal relationship between TKIs and PAI onset was also demonstrated by the repeated testing of adrenal function before and during treatment. Patients with PAI received cortisone acetate replacement therapy, with a substantial and prompt improvement in the degree of fatigue, as assessed by the Common Terminology Criteria for Adverse Events version 4.03, thus supporting the major impact of impaired adrenal function in the genesis of this adverse event. CONCLUSIONS We show that the occurrence of PAI may be a common cause of fatigue during lenvatinib and vandetanib treatment, and we therefore recommend testing adrenal function for a prompt start of replacement therapy to avoid treatment discontinuation, dosage reduction, and potentially severe PAI complications.
Collapse
Affiliation(s)
- Carla Colombo
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Simone De Leo
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Marta Di Stefano
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Guia Vannucchi
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Luca Persani
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Laura Fugazzola
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Correspondence and Reprint Requests: Laura Fugazzola, MD, Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Piazzale Brescia, 20-20149 Milan, Italy. E-mail:
| |
Collapse
|
11
|
Salah DB, Charfi N, Elleuch M, Kacem FH, Rekik N, Mnif M, Mnif F, Abid M. [Cardiovascular and metabolic impact of glucocorticoid substitution therapy in patients with Addison's disease]. Pan Afr Med J 2019; 30:251. [PMID: 30627312 PMCID: PMC6307925 DOI: 10.11604/pamj.2018.30.251.12546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/11/2018] [Indexed: 12/01/2022] Open
Abstract
Les études récentes menées chez des patients atteints de maladie d'Addison (MA) ont permis de révéler que cette pathologie, même traitée, reste grevée d'une morbi-mortalité non négligeable. L'objectif de notre étude était de déterminer les effets délétères de la substitution glucocorticoïde au long cours principalement sur le plan métabolique et cardiovasculaire. Il s'agit d'une étude rétrospective qui a inclu 28 patients ayant une MA traitée, évoluant depuis plus que 15 ans. L'âge moyen était de 58,53 ans avec une prédominance féminine à 65%. La durée moyenne de suivi était de 17,87 ans. La dose d'hydrocortisone était initialement à 32,5mg/j (20,52 mg/m2) et à 27,9mg/j (16,41mg/m2) au moment de l'étude. La prévalence du syndrome métabolique (SM) au cours de la MA était de 35,71% après une durée de traitement supérieur à 15 ans. On note au terme du suivi que 28,57% des patients étaient obèses. Vingt-cinq (25)% des patients avaient développé une HTA et un diabète de type 2. La prévalence de la dyslipidémie était passé de 3,57% à 42,85%. Un seul patient avait présenté un infarctus de myocarde à 25 ans de suivi. Les facteurs favorisant la survenue du SM dans notre étude étaient l'ancienneté de la maladie et la perte du poids à la découverte de la maladie. L'ajustement du traitement substitutif au cours de la maladie d'Addison reste un enjeu au vu de la morbi-mortalité liée au surdosage. Un suivi régulier, et une approche thérapeutique personnalisée sont nécessaires pour améliorer le pronostic de ses patients.
Collapse
Affiliation(s)
- Dhoha Ben Salah
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Nadia Charfi
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Mouna Elleuch
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Faten Hadj Kacem
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Nabila Rekik
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Mouna Mnif
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Fatma Mnif
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Mohamed Abid
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| |
Collapse
|
12
|
Abstract
Primary adrenal insufficiency (PAI) is a life-threatening disorder of adrenal cortex which is characterized by deficient biosynthesis of glucocorticoids, with or without deficiency in mineralocorticoids and adrenal androgens. Typical manifestations of primary adrenal insufficiency include hyperpigmentation, hypotension, hypoglycaemia, hyponatremia with or without hyperkalemia that are generally preceded by nonspecific symptoms at the onset. Recessively inherited monogenic disorders constitute the largest group of primary adrenal insufficiency in children. The diagnostic process of primary adrenal insufficiency includes demonstration of low cortisol concentrations along with high plasma ACTH and identifying the cause of the disorder. Specific molecular diagnosis is achieved in more than 80% of children with PAI by detailed clinical and biochemical characterization integrated with advanced molecular tools. Hormone replacement therapy determined on the type and the severity of deficient adrenocortical hormones is the mainstay of treatment. Optimized methods of steroid hormone delivery, improved monitoring of hormone replacement along with intensive education of patients and families on the rules during intercurrent illness and stress will significantly reduce the morbidity and mortality associated with primary adrenal insufficiency.
Collapse
Affiliation(s)
- Tarik Kirkgoz
- Marmara University School of Medicine, Department of Paediatric Endocrinology and Diabetes, Istanbul, Turkey.
| | - Tulay Guran
- Marmara University School of Medicine, Department of Paediatric Endocrinology and Diabetes, Istanbul, Turkey.
| |
Collapse
|
13
|
Camozzi V, Betterle C, Frigo AC, Zaccariotto V, Zaninotto M, De Caneva E, Lucato P, Gomiero W, Garelli S, Sabbadin C, Salvà M, Costa MD, Boscaro M, Luisetto G. Vertebral fractures assessed with dual-energy X-ray absorptiometry in patients with Addison's disease on glucocorticoid and mineralocorticoid replacement therapy. Endocrine 2018; 59:319-329. [PMID: 28795340 DOI: 10.1007/s12020-017-1380-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 07/21/2017] [Indexed: 12/30/2022]
Abstract
PURPOSE to assess bone damage and metabolic abnormalities in patients with Addison's disease given replacement doses of glucocorticoids and mineralocorticoids. METHODS A total of 87 patients and 81 age-matched and sex-matched healthy controls were studied. The following parameters were measured: urinary cortisol, serum calcium, phosphorus, creatinine, 24-h urinary calcium excretion, bone alkaline phosphatase, parathyroid hormone, serum CrossLaps, 25 hydroxyvitamin D, and 1,25 dihydroxyvitamin D. Clear vertebral images were obtained with dual-energy X-ray absorptiometry in 61 Addison's disease patients and 47 controls and assessed using Genant's classification. RESULTS Nineteen Addison's disease patients (31.1%) had at least one morphometric vertebral fracture, as opposed to six controls (12.8%, odds ratio 3.09, 95% confidence interval 1.12-8.52). There were no significant differences in bone mineral density parameters at any site between patients and controls. In Addison's disease patients, there was a positive correlation between urinary cortisol and urinary calcium excretion. Patients with fractures had a longer history of disease than those without fractures. Patients taking fludrocortisone had a higher bone mineral density than untreated patients at all sites except the lumbar spine. CONCLUSIONS Addison's disease patients have more fragile bones irrespective of any decrease in bone mineral density. Supra-physiological doses of glucocorticoids and longer-standing disease (with a consequently higher glucocorticoid intake) might be the main causes behind patients' increased bone fragility. Associated mineralocorticoid treatment seems to have a protective effect on bone mineral density.
Collapse
Affiliation(s)
- Valentina Camozzi
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Corrado Betterle
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy.
| | - Anna Chiara Frigo
- Department of Cardiac, Thoracic and Vascular Sciences, Biostatistics, Epidemiology and Public Health Unit, University of Padua, Via Loredan 18, Padua, 35131, Italy
| | - Veronica Zaccariotto
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University of Padua, Via Giustiniani 2, Padua, 35128, Italy
| | - Erica De Caneva
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Paola Lucato
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Walter Gomiero
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Silvia Garelli
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Chiara Sabbadin
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Monica Salvà
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Miriam Dalla Costa
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Marco Boscaro
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| | - Giovanni Luisetto
- Department of Medicine, Endocrinology Division, University of Padua, Via Ospedale 105, Padua, 35128, Italy
| |
Collapse
|
14
|
Graziadio C, Hasenmajer V, Venneri MA, Gianfrilli D, Isidori AM, Sbardella E. Glycometabolic Alterations in Secondary Adrenal Insufficiency: Does Replacement Therapy Play a Role? Front Endocrinol (Lausanne) 2018; 9:434. [PMID: 30123187 PMCID: PMC6085438 DOI: 10.3389/fendo.2018.00434] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 07/13/2018] [Indexed: 02/01/2023] Open
Abstract
Secondary adrenal insufficiency (SAI) is a potentially life-threatening endocrine disorder due to an impairment of corticotropin (ACTH) secretion from any process affecting the hypothalamus or pituitary gland. ACTH deficit can be isolated or associated with other pituitary failures (hypopituitarism). An increased mortality due to cardiovascular, metabolic, and infectious diseases has been described in both primary and secondary adrenal insufficiency. However, few studies have provided compelling evidences on the underlying mechanism in SAI, because of the heterogeneity of the condition. Recently, some studies suggested that inappropriate glucocorticoid (GCs) replacement therapy, as for dose and/or timing of administration, may play a role. Hypertension, insulin resistance, weight gain, visceral obesity, increased body mass index, metabolic syndrome, impaired glucose tolerance, diabetes mellitus, dyslipidemia have all been associated with GC excess. These conditions are particularly significant when SAI coexists with other pituitary alterations, such as growth hormone deficiency, hypogonadism, and residual tumor. Novel regimen schemes and GC preparations have been introduced to improve compliance and better mimick endogenous cortisol rhythm. The controlled trials on the improved replacement therapies, albeit in the short-term, show some beneficial effects on cardiovascular risk, glucose metabolism, and quality of life. This review examines the current evidence from the available clinical trials investigating the association between different glucocorticoid replacement therapies (type, dose, frequency, and timing of treatment) and glycometabolic alterations in SAI.
Collapse
|
15
|
Adi-Dako O, Ofori-Kwakye K, Boakye-Gyasi ME, Oppong Bekoe S, Okyem S. In Vitro Evaluation of Cocoa Pod Husk Pectin as a Carrier for Chronodelivery of Hydrocortisone Intended for Adrenal Insufficiency. JOURNAL OF DRUG DELIVERY 2017; 2017:8284025. [PMID: 29435369 PMCID: PMC5757137 DOI: 10.1155/2017/8284025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/22/2017] [Accepted: 11/27/2017] [Indexed: 02/06/2023]
Abstract
This study evaluated the in vitro potential of cocoa pod husk (CPH) pectin as a carrier for chronodelivery of hydrocortisone intended for adrenal insufficiency. FTIR studies found no drug-CPH pectin interactions, and chemometric analysis showed that pure hydrocortisone bears closer similarity to hydrocortisone in hot water soluble pectin (HWSP) than hydrocortisone in citric acid soluble pectin (CASP). CPH pectin-based hydrocortisone matrix tablets (~300 mg) were prepared by direct compression and wet granulation techniques, and the tablet cores were film-coated with a 15% HPMC formulation for timed release, followed by a 12.5% Eudragit® S100 formulation for acid resistance. In vitro drug release studies of the uncoated and coated matrix tablets in simulated gastrointestinal conditions showed that wet granulation tablets exhibit greater retardation of drug release in aqueous medium than directly compressed tablets. CASP showed greater suppression of drug release in aqueous medium than HWSP. Wet granulation HWSP-based matrix tablets coated to a final coat weight gain of ~25% w/w were optimized for chronodelivery of hydrocortisone in the colon. The optimized tablets exhibited a lag phase of ~6 h followed by accelerated drug release in the colonic region and have potential to control night time cortisol levels in patients with adrenal insufficiency.
Collapse
Affiliation(s)
- Ofosua Adi-Dako
- Department of Pharmaceutics, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
- School of Pharmacy, University of Ghana, Legon, Ghana
| | - Kwabena Ofori-Kwakye
- Department of Pharmaceutics, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | - Mariam El Boakye-Gyasi
- Department of Pharmaceutics, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | - Samuel Oppong Bekoe
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | - Samuel Okyem
- Central Laboratory, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| |
Collapse
|
16
|
Mazziotti G, Formenti AM, Frara S, Roca E, Mortini P, Berruti A, Giustina A. MANAGEMENT OF ENDOCRINE DISEASE: Risk of overtreatment in patients with adrenal insufficiency: current and emerging aspects. Eur J Endocrinol 2017; 177:R231-R248. [PMID: 28583942 DOI: 10.1530/eje-17-0154] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/31/2017] [Accepted: 06/05/2017] [Indexed: 01/17/2023]
Abstract
The effects of long-term replacement therapy of adrenal insufficiency (AI) are still a matter of controversy. In fact, the established glucocorticoid replacement regimens do not completely reproduce the endogenous hormonal production and the monitoring of AI treatment may be a challenge for the lack of reliable clinical and biochemical markers. Consequently, several AI patients are frequently exposed to relative glucocorticoid excess potentially leading to develop chronic complications, such as diabetes mellitus, dyslipidemia, hypertension and fragility fractures with consequent impaired QoL and increased mortality risk. This review deals with the pathophysiological and clinical aspects concerning the over-replacement therapy of primary and secondary AI.
Collapse
Affiliation(s)
- G Mazziotti
- Endocrinology Unit, ASST, Carlo Poma, Mantua, Italy
| | - A M Formenti
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - S Frara
- Chair of Endocrinology, San Raffaele Vita-Salute University, Milan, Italy
| | - E Roca
- Chair of Medical Oncology, University of Brescia, Brescia, Italy
| | - P Mortini
- Chair of Neurosurgery, San Raffaele Vita-Salute University, Milan, Italy
| | - A Berruti
- Chair of Medical Oncology, University of Brescia, Brescia, Italy
| | - A Giustina
- Chair of Endocrinology, San Raffaele Vita-Salute University, Milan, Italy
| |
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW This review focuses on the pathophysiological and clinical aspects of diabetes mellitus occurring in patients with Cushing disease (CD). RECENT FINDINGS Insulin resistance and impairment in insulin secretion are both involved in the pathogenesis of glucocorticoid-induced diabetes. Correction of glucocorticoid excess does not always resolve abnormalities of glucose homeostasis, and correction of hyperglycaemia is specifically required. In fact, insulin resistance may persist even after correction of glucocorticoid excess and diabetes needs to be treated for long term. On the other hand, emerging drugs used in the treatment of CD, such as the novel somatostatin analog pasireotide, may have direct effects on glucose homeostasis regardless of control of cortisol excess. Diabetes mellitus is a frequent and early complication of CD with important diagnostic, prognostic and therapeutic implications. Specifically, diagnosis of CD in patients with diabetes may be difficult due to potential misinterpretation of markers of cortisol hypersecretion. Moreover, diabetes mellitus is often difficult to be controlled in CD requiring a careful and dedicated therapeutic approach. Finally, the coexistence of diabetes may influence the therapeutic decision making in CD, since drugs used in this setting may variably influence glucose homeostasis regardless of control of hypercortisolism.
Collapse
Affiliation(s)
- G Mazziotti
- Endocrinology Unit, ASST Carlo Poma, Mantova, Italy
| | - A M Formenti
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - S Frara
- Vita-Salute University San Raffaele Milan, Milan, Italy
| | - F Maffezzoni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - M Doga
- Vita-Salute University San Raffaele Milan, Milan, Italy
| | - A Giustina
- Vita-Salute University San Raffaele Milan, Milan, Italy.
| |
Collapse
|
18
|
Chihaoui M, Chaker F, Yazidi M, Grira W, Ben Amor Z, Rejeb O, Slimane H. Ramadan fasting in patients with adrenal insufficiency. Endocrine 2017; 55:289-295. [PMID: 27878773 DOI: 10.1007/s12020-016-1186-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 11/16/2016] [Indexed: 10/20/2022]
Abstract
AIM The risks of fasting during Ramadan in patients with adrenal insufficiency are unknown. The aims of this study were to evaluate these risks in such patients, to determine the risk factors and finally to set some recommendations. METHODS It is a cross-sectional study about 180 patients with known and treated adrenal insufficiency. The patients responded to a 14-item questionnaire concerning their knowledge about the disease and fasting during the last month of Ramadan. RESULTS There were 132 women and 48 men. The mean age was 47.6 ± 15.0 years (14-79). One hundred and thirty eight patients (76.7 %) were advised by their physician not to fast. Ninety-one patients (50.5 %) tried to fast. Complications occurred in 61 cases (67.0 %): asthenia in 88.5 % of cases, intense thirst in 32.8 %, symptoms of dehydration in 49.2 % and symptoms of hypoglycaemia in 18 %. One patient was hospitalized. Fifty-five patients (60.4 %) were able to fast for the whole month. Age, gender, duration of the disease, its primary origin, associated hypothyroidism, diabetes mellitus, hypertension or diabetes insipidus and daily dose of hydrocortisone did not significantly differ between fasters and non-fasters, full-month-fasters and partial-month-fasters, and fasters with complications and fasters without complications. The frequency of adequate knowledge about the disease was significantly higher in full-month-fasters vs. partial-month-fasters, and in fasters without complications vs. those with complications. CONCLUSION In patients with adrenal insufficiency, fasting can cause complications especially if the level of knowledge about the disease is low.
Collapse
Affiliation(s)
- Mélika Chihaoui
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia.
| | - Fatma Chaker
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Wafa Grira
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Zohra Ben Amor
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Ons Rejeb
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| | - Hedia Slimane
- Department of Endocrinology, University of Tunis El Manar, Faculty of Medicine of Tunis, La Rabta Hospital, Tunis, Tunisia
| |
Collapse
|
19
|
Jublanc C, Bruckert E. L’insuffisance surrénalienne chez l’adulte. Rev Med Interne 2016; 37:820-826. [DOI: 10.1016/j.revmed.2016.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 02/23/2016] [Indexed: 12/17/2022]
|
20
|
Falorni A, Bini V, Betterle C, Brozzetti A, Castaño L, Fichna M, Kämpe O, Mellgren G, Peterson P, Chen S, Rönnelid J, Seissler J, Tiberti C, Uibo R, Yu L, Lernmark Å, Husebye E. Determination of 21-hydroxylase autoantibodies: inter-laboratory concordance in the Euradrenal International Serum Exchange Program. Clin Chem Lab Med 2016; 53:1761-70. [PMID: 25811668 DOI: 10.1515/cclm-2014-1106] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/11/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND 21-Hydroxylase autoantibodies (21OHAb) are markers of an adrenal autoimmune process that identifies individuals with autoimmune Addison's disease (AAD). Quality and inter-laboratory agreement of various 21OHAb tests are incompletely known. The objective of the study was to determine inter-laboratory concordance for 21OHAb determinations. METHODS Sixty-nine sera from 51 patients with AAD and 51 sera from 51 healthy subjects were blindly coded by a randomization center and distributed to 14 laboratories that determined 21OHAb, either by an "in-house" assay (n=9) using in vitro-translated (35)S-21OH or luciferase-labeled 21OH or a commercial kit with (125)I-21OH (n=5). Main outcome measures were diagnostic accuracy of each participating laboratory and inter-laboratory agreement of 21OHAb assays. RESULTS Intra-assay coefficient of variation ranged from 2.6% to 5.3% for laboratories using the commercial kit and from 5.1% to 23% for laboratories using "in-house" assays. Diagnostic accuracy, expressed as area under ROC curve (AUC), varied from 0.625 to 0.947 with the commercial kit and from 0.562 to 0.978 with "in-house" methods. Cohen's κ of inter-rater agreement was 0.603 among all 14 laboratories, 0.691 among "in-house" laboratories, and 0.502 among commercial kit users. Optimized cutoff levels, calculated on the basis of AUCs, increased the diagnostic accuracy of every laboratory (AUC >0.9 for 11/14 laboratories) and increased the Cohen's κ of inter-rater agreement. Discrepancies in quantitation of 21OHAb levels among different laboratories increased with increasing autoantibody levels. CONCLUSIONS The quality of 21OHAb analytical procedures is mainly influenced by selection of cutoff value and correct handling of assay materials. A standardization program is needed to identify common standard sera and common measuring units.
Collapse
|
21
|
Fichna M, Żurawek M, Gryczyńska M, Sowińska A, Nowak J, Ruchała M. Polymorphic variants of the HSD11B1 gene may be involved in adverse metabolic effects of glucocorticoid replacement therapy in Addison's disease. Eur J Intern Med 2016; 31:99-104. [PMID: 27083553 DOI: 10.1016/j.ejim.2016.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 03/06/2016] [Accepted: 03/28/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Marta Fichna
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 49 Przybyszewskiego, 60-355 Poznan, Poland; Institute of Human Genetics, Polish Academy of Sciences, 32 Strzeszynska, 60-479 Poznan, Poland; Department of Clinical Immunology, Poznan University of Medical Sciences, 5d Rokietnicka, 60-805 Poznan, Poland.
| | - Magdalena Żurawek
- Institute of Human Genetics, Polish Academy of Sciences, 32 Strzeszynska, 60-479 Poznan, Poland
| | - Maria Gryczyńska
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 49 Przybyszewskiego, 60-355 Poznan, Poland
| | - Anna Sowińska
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 79 Dabrowskiego, 60-529 Poznan, Poland
| | - Jerzy Nowak
- Institute of Human Genetics, Polish Academy of Sciences, 32 Strzeszynska, 60-479 Poznan, Poland
| | - Marek Ruchała
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 49 Przybyszewskiego, 60-355 Poznan, Poland
| |
Collapse
|
22
|
Bhattacharya S, Das A, Maiti A. A 28-year-old man with syncope, hypotension, and lethargy. Eur J Intern Med 2016; 30:e1-e2. [PMID: 26577224 DOI: 10.1016/j.ejim.2015.11.005] [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: 09/14/2015] [Accepted: 11/01/2015] [Indexed: 11/30/2022]
Affiliation(s)
| | - Avash Das
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Abhishek Maiti
- Department of Internal Medicine, University of Texas Health Science Centre at Houston, Houston, TX, USA.
| |
Collapse
|
23
|
Giordano R, Guaraldi F, Marinazzo E, Fumarola F, Rampino A, Berardelli R, Karamouzis I, Lucchiari M, Manetta T, Mengozzi G, Arvat E, Ghigo E. Improvement of anthropometric and metabolic parameters, and quality of life following treatment with dual-release hydrocortisone in patients with Addison's disease. Endocrine 2016; 51:360-8. [PMID: 26184416 DOI: 10.1007/s12020-015-0681-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 07/01/2015] [Indexed: 01/06/2023]
Abstract
In patients with Addison's disease (AD), a dual-release preparation of hydrocortisone (Plenadren, PLEN) has been demonstrated to maintain cortisol levels in a more physiological range than conventional glucocorticoid therapy, and to exert positive effects. This study aimed to assess variations of anthropometric, metabolic, and hormonal parameters in patients with AD after switching from conventional hydrocortisone (HC) treatment to PLEN. In nineteen AD patients (15 F and 4 M, age 27-65 years) treated with HC 20 mg/day thrice daily, body weight, BMI, waist circumference, fasting glucose, HbA1c, serum lipids, plasma renin activity, electrolytes, and blood pressure were evaluated at baseline, and 1, 3, 6, and 12 months after switching from HC to PLEN. At baseline, and after 1 and 12 months of PLEN, blood ACTH and cortisol (at 0800 h at fasting, and 30, 60, 90, 120, and 240 min after drug ingestion), and health-related quality of life (HRQoL), using 30-AddiQoL questionnaire, were evaluated. During PLEN, waist and serum lipid progressively decreased. After 12 months of PLEN, a significant difference was observed in waist circumference (P = 0.007), HbA1c (P = 0.002), total and LDL-cholesterol levels (P < 0.05). ACTH levels at 240 min and the area under the curve (AUC) were lower (P < 0.05) during PLEN than HC, while cortisol peaks and AUC were similar. 30-AddiQoL total score also improved (P = 0.04) during PLEN. In AD patients, PLEN reduces central adiposity, and improves glucose and metabolism parameters and HRQoL.
Collapse
Affiliation(s)
- Roberta Giordano
- Department of Clinical and Biological Sciences, University of Turin, 10126, Turin, Italy.
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
| | - Federica Guaraldi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Elisa Marinazzo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Federica Fumarola
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Alessia Rampino
- Department of Clinical and Biological Sciences, University of Turin, 10126, Turin, Italy
| | - Rita Berardelli
- Division of Oncological Endocrinology, Department of Medical Sciences, University of Turin, 10126, Turin, Italy
| | - Ioannis Karamouzis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - Manuela Lucchiari
- Clinical Biochemistry Laboratory, "Città della Salute e della Scienza di Torino" University Hospital, 10126, Turin, Italy
| | - Tilde Manetta
- Clinical Biochemistry Laboratory, "Città della Salute e della Scienza di Torino" University Hospital, 10126, Turin, Italy
| | - Giulio Mengozzi
- Clinical Biochemistry Laboratory, "Città della Salute e della Scienza di Torino" University Hospital, 10126, Turin, Italy
| | - Emanuela Arvat
- Division of Oncological Endocrinology, Department of Medical Sciences, University of Turin, 10126, Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| |
Collapse
|
24
|
Gasco V, Berton A, Caprino MP, Karamouzis I, Maccario M, Ghigo E, Grottoli S. Acylated ghrelin as provocative test for the diagnosis of ACTH deficiency in patients with hypothalamus-pituitary disease. Endocrine 2015; 50:474-82. [PMID: 25487034 DOI: 10.1007/s12020-014-0494-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 11/25/2014] [Indexed: 01/03/2023]
Abstract
The insulin tolerance test (ITT) is the gold standard to evaluate adrenocorticotropic hormone (ACTH) insufficiency. However, alternative tests have been proposed such as metyrapone, glucagon, and ACTH stimulation test. We determined the diagnostic reliability of testing with ghrelin, the natural GH secretagogue that is a potent stimulus exploring the integrity of hypothalamic-pituitary-adrenal axis. We studied the ACTH and cortisol response to acylated ghrelin in 49 patients with history of pituitary disease. The best cortisol and ACTH cut offs to ghrelin test, defined as those with the best sensitivity (SE) and specificity (SP), were identified using the ROC analysis. We also compared accuracy of ghrelin test with that of a simple and cheap test like basal cortisol and ACTH levels. The best cortisol and ACTH cut offs to ghrelin test were ≤11.6 µg/dl (SE 86.4%, SP 77.8%) and ≤32.5 pg/ml (SE 72.7%, SP 51.9%), respectively; the best basal cortisol and ACTH cut offs were ≤10.7 µg/dl (SE 90.9%, SP 70.4%) and ≤25.0 pg/ml (SE 85%, SP 37%), respectively. The diagnostic accuracy was 81.6, 60.9, 79.6, and 57.4%, respectively. A comparison between ROC AUC showed a great diagnostic power for cortisol, both stimulated and basal, versus ACTH, both stimulated and basal, but no difference between stimulated and basal cortisol evaluation. Our data show that testing with acylated ghrelin is not a useful diagnostic tool for the diagnosis of central hypocortisolism; particularly ghrelin test adds no more information that basal cortisol evaluation in the diagnosis of ACTH deficiency in patients with hypothalamus-pituitary disease.
Collapse
Affiliation(s)
- Valentina Gasco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy
| | - Alessandro Berton
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy
| | - Mirko Parasiliti Caprino
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy
| | - Ioannis Karamouzis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy
| | - Mauro Maccario
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy
| | - Silvia Grottoli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Città della Salute e della Scienza - Osp. San Giovanni Battista, C.so Dogliotti 14, 10126, Turin, Italy.
| |
Collapse
|
25
|
Brozzetti A, Alimohammadi M, Morelli S, Minarelli V, Hallgren Å, Giordano R, De Bellis A, Perniola R, Kämpe O, Falorni A. Autoantibody response against NALP5/MATER in primary ovarian insufficiency and in autoimmune Addison's disease. J Clin Endocrinol Metab 2015; 100:1941-8. [PMID: 25734249 DOI: 10.1210/jc.2014-3571] [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: 02/10/2023]
Abstract
CONTEXT NACHT leucine-rich-repeat protein 5 (NALP5)/maternal antigen that embryo requires (MATER) is an autoantigen in hypoparathyroidism associated with autoimmune polyendocrine syndrome type 1 (APS1) but is also expressed in the ovary. Mater is an autoantigen in experimental autoimmune oophoritis. OBJECTIVES The objectives of the study were to determine the frequency of NALP5/MATER autoantibodies (NALP5/MATER-Ab) in women with premature ovarian insufficiency (POI) and in patients with autoimmune Addison's disease (AAD) and to evaluate whether inhibin chains are a target for autoantibodies in POI. METHODS Autoantibodies against NALP5/MATER and inhibin chains-α and -βA were determined by radiobinding assays in 172 patients with AAD without clinical signs of gonadal insufficiency, 41 women with both AAD and autoimmune POI [steroidogenic cell autoimmune POI (SCA-POI)], 119 women with idiopathic POI, 19 patients with APS1, and 211 healthy control subjects. RESULTS NALP5/MATER-Ab were detected in 11 of 19 (58%) sera from APS1 patients, 12 of 172 (7%) AAD sera, 5 of 41 (12%) SCA-POI sera, 0 of 119 idiopathic POI sera and 1 of 211 healthy control sera (P < .001). None of 160 POI sera, including 41 sera from women with SCA-POI and 119 women with idiopathic POI, and none of 211 healthy control sera were positive for inhibin chain-α/βA autoantibodies. CONCLUSIONS NALP5/MATER-Ab are associated with hypoparathyroidism in APS1 but are present also in patients with AAD and in women with SCA-POI without hypoparathyroidism. Inhibin chains do not appear to be likely candidate targets of autoantibodies in human POI.
Collapse
Affiliation(s)
- Annalisa Brozzetti
- Department of Internal Medicine (A.B., S.M., V.M., A.F.), University of Perugia, 06126 Perugia, Italy; Department of Medical Sciences (M.A., O.K.), Science for Life Laboratory, Uppsala University, 750 03 Uppsala, Sweden; Centre of Molecular Medicine (M.A., A.H., O.K.), Department of Medicine (Solna), Karolinska Institutet, 171 76 Stockholm, Sweden; Division of Endocrinology, Diabetology, and Metabolism (R.G.), Department of Medical Sciences, University of Turin, 10126 Turin, Italy; Department of Cardio-Thoracic and Respiratory Science (A.D.B.), Endocrinology Unit, Second University of Naples, 80132 Naples, Italy; and Department of Pediatrics-Neonatal Intensive Care (R.P.), V. Fazzi Regional Hospital, 73100 Lecce, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Fichna M, Fichna P, Gryczyńska M, Czarnywojtek A, Żurawek M, Ruchała M. Steroid replacement in primary adrenal failure does not appear to affect circulating adipokines. Endocrine 2015; 48:677-85. [PMID: 25129652 PMCID: PMC4351438 DOI: 10.1007/s12020-014-0388-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 08/06/2014] [Indexed: 01/17/2023]
Abstract
Despite continuous efforts for an optimal steroid replacement, recent observations suggest increased cardiometabolic risk and related mortality in primary adrenal insufficiency (PAI). Adipokines are peptides from the adipose tissue, markers of cardiometabolic dysfunction. This study was aimed to evaluate serum levels of adipokines: leptin, adiponectin, and resistin in PAI during conventional steroid substitution. The analysis comprised 63 patients (mean age 42.7 ± 14.1 years) and 63 healthy controls. Serum adipokines, lipid profile, and plasma glucose were assessed in both cohorts. ACTH, serum insulin, HOMA-IR, DHEA-S, cortisol and 24 h urinary free cortisol were determined in PAI. Body mass composition was analyzed by Dual-Energy X-ray Absorptiometry. Mean BMI in the control group was 24.1 ± 3.9 kg/m(2) and 23.7 ± 3.9 kg/m(2) in the PAI cohort. Serum leptin and adiponectin levels were similar in both groups, whereas resistin appeared significantly lower among affected subjects (p = 0.0002). Its levels were weakly correlated with HOMA-IR (p = 0.048). Leptin was independently correlated with fasting insulin, HOMA-IR, BMI, and body fat (p < 0.001). At the multiple regression analysis only weight (p = 0.017), total and HDL cholesterol (p < 0.001) appeared significant predictors of adiponectin level. No adipokine correlations with serum cortisol or daily hydrocortisone dose were found. Patients receiving DHEA substitution displayed lower leptin and adiponectin levels (p < 0.05). In conclusion, our study did not provide evidence of an adverse adipokine profile in patients with PAI under conventional glucocorticoid replacement. Serum adipokines in treated PAI follow similar correlations to those reported in healthy subjects. Further prospective studies are warranted to verify and explain plausible excess of cardiovascular mortality in PAI.
Collapse
Affiliation(s)
- Marta Fichna
- Institute of Human Genetics, Polish Academy of Sciences, 32 Strzeszynska, 60-479, Poznan, Poland,
| | | | | | | | | | | |
Collapse
|
27
|
An observational study on adrenal insufficiency in a French tertiary centre: Real life versus theory. ANNALES D'ENDOCRINOLOGIE 2015; 76:1-8. [DOI: 10.1016/j.ando.2014.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 11/04/2014] [Accepted: 11/10/2014] [Indexed: 11/19/2022]
|
28
|
Johannsson G, Falorni A, Skrtic S, Lennernäs H, Quinkler M, Monson JP, Stewart PM. Adrenal insufficiency: review of clinical outcomes with current glucocorticoid replacement therapy. Clin Endocrinol (Oxf) 2015; 82:2-11. [PMID: 25187037 DOI: 10.1111/cen.12603] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 06/25/2014] [Accepted: 08/27/2014] [Indexed: 11/28/2022]
Abstract
Glucocorticoid replacement therapy in patients with adrenal insufficiency (AI), whether primary (Addison's disease) or secondary (due to hypopituitarism), has been established for some 50 years. The current standard treatment regimen involves twice- or thrice-daily dosing with a glucocorticoid, most commonly oral hydrocortisone. Based on previous small-scale studies and clinical perception, life expectancy with conventional glucocorticoid replacement therapy has been considered normal, with a low incidence of adverse events. Data from the past 10-15 years, however, have shown that morbidity remains high and life expectancy is reduced. The increased morbidity and decreased life expectancy appear to be due to both increased exposure to cortisol and insufficient cortisol coverage during infections and other stress-related events. This is thought to reflect a failure of treatment to replicate the natural circadian rhythm of cortisol release, together with a failure to identify and deliver individualized cortisol exposure and to manage patients adequately when increased doses are required. The resulting over- or under-treatment may result in Cushing-like symptoms or adrenal crisis, respectively. This review summarizes the morbidity and mortality seen in patients receiving the current standard of care for AI and suggests areas for improvement in glucocorticoid replacement therapy.
Collapse
Affiliation(s)
- Gudmundur Johannsson
- Department of Endocrinology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | | | | | | |
Collapse
|
29
|
Noppe G, van Rossum EFC, Vliegenthart J, Koper JW, van den Akker ELT. Elevated hair cortisol concentrations in children with adrenal insufficiency on hydrocortisone replacement therapy. Clin Endocrinol (Oxf) 2014; 81:820-5. [PMID: 25039686 DOI: 10.1111/cen.12551] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 04/20/2014] [Accepted: 07/07/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Glucocorticoid replacement therapy in patients with adrenal insufficiency needs to be tailored to the individual patient based on body composition and clinical signs and symptoms as no objective method for assessment of treatment adequacy is available. Current treatment regimens are often not satisfactory, which is shown by the adverse metabolic profile and doubled mortality rates in treated adrenal insufficiency patients. Measurement of cortisol concentrations in hair reflect the long-term systemic cortisol exposure and may be of use in refinement of hydrocortisone treatment. OBJECTIVE We aimed to study whether long-term cortisol (hydrocortisone) levels, as measured in scalp hair, are similar in children with adrenal insufficiency and healthy children. MATERIAL AND METHODS We set up a case control study, measuring anthropometric characteristics and hair cortisol concentrations (HCC) in 54 hydrocortisone substituted children with adrenal insufficiency (AI patients) in the age of 4-18 years and 54 healthy children matched for gender and age. RESULTS Mean HCC were significantly higher in AI patients compared with healthy controls (mean 13·3 vs 8·2 pg/mg, P = 0·02). AI patients also had a higher BMI (P < 0·001) and waist circumference (WC) (P = 0·02). HCC was significantly associated with BMI (P = 0·002) and WC (P = 0·002). HCC explained 13% of the difference in BMI and 29% of the difference in WC between AI patients and controls. CONCLUSION Hydrocortisone-treated AI patients have increased HCC and adverse anthropometric characteristics compared with healthy controls. HCC measurement may be of value in identifying overtreatment and thereby improve hydrocortisone replacement therapy.
Collapse
Affiliation(s)
- G Noppe
- Division of Endocrinology, Department of Paediatrics, Sophia Children's Hospital, Erasmus MC, Rotterdam, The Netherlands; Division of Endocrinology, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | | | | | | |
Collapse
|
30
|
Falhammar H, Nyström HF, Thorén M. Quality of life, social situation, and sexual satisfaction, in adult males with congenital adrenal hyperplasia. Endocrine 2014; 47:299-307. [PMID: 24408051 DOI: 10.1007/s12020-013-0161-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 12/28/2013] [Indexed: 11/28/2022]
Abstract
To determine quality of life (QoL) in adult males with congenital adrenal hyperplasia (CAH). CAH males with 21-hydroxylase deficiency (n = 30), 19-67 years old, were compared with controls (n = 32). QoL was assessed using questionnaires on general living conditions and sexual issues, and the psychological well-being index (PGWB) form. Fewer CAH males than controls were students (3 vs. 25 %, P = 0.028) and more had blue-collar work (57 vs. 33 %, P = 0.023). Patients were less interested in sports (47 vs. 72 %, P = 0.034) and art/literature/film (10 vs. 47 %, P = 0.004). PGWB total score was 82.7 ± 13.7 versus 87.0 ± 11.1 (P = NS), but hydrocortisone/cortisone acetate treated scored lower than controls and prednisolone treated. Glucocorticoid over-treated had lower QoL than those with poor control (PGWB total score 77.1 ± 13.5 vs. 92.4 ± 11.1, P = 0.026) and controls (P = 0.025). Total PGWB score was positively correlated with adrenal androgens and steroid precursors. Subscale scores indicated that patients with late diagnosis were more depressive (12.1 ± 2.8 vs. 13.9 ± 1.4, P = 0.011) and had a lower self-control (11.3 ± 3.6 vs. 13.1 ± 1.0, P = 0.019) compared with controls. Sexual satisfaction was similar in spite of more patients being sexually inactive (27 vs. 6 %, P = 0.040). Adult CAH males differed from controls with respect to type of occupation and spare time interests but had similar QoL despite being less sexually active. Optimizing glucocorticoid therapy might further improve QoL. Some disadvantages found in patients diagnosed late will hopefully not be seen in patients diagnosed by neonatal screening, but this has yet to be studied.
Collapse
Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, D02:04, Karolinska University Hospital, 171 76, Stockholm, Sweden,
| | | | | |
Collapse
|
31
|
Abstract
Adrenal insufficiency is the clinical manifestation of deficient production or action of glucocorticoids, with or without deficiency also in mineralocorticoids and adrenal androgens. It is a life-threatening disorder that can result from primary adrenal failure or secondary adrenal disease due to impairment of the hypothalamic-pituitary axis. Prompt diagnosis and management are essential. The clinical manifestations of primary adrenal insufficiency result from deficiency of all adrenocortical hormones, but they can also include signs of other concurrent autoimmune conditions. In secondary or tertiary adrenal insufficiency, the clinical picture results from glucocorticoid deficiency only, but manifestations of the primary pathological disorder can also be present. The diagnostic investigation, although well established, can be challenging, especially in patients with secondary or tertiary adrenal insufficiency. We summarise knowledge at this time on the epidemiology, causal mechanisms, pathophysiology, clinical manifestations, diagnosis, and management of this disorder.
Collapse
Affiliation(s)
- Evangelia Charmandari
- Division of Endocrinology, Metabolism, and Diabetes, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece; Division of Endocrinology and Metabolism, Clinical Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.
| | - Nicolas C Nicolaides
- Division of Endocrinology, Metabolism, and Diabetes, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece; Division of Endocrinology and Metabolism, Clinical Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - George P Chrousos
- Division of Endocrinology, Metabolism, and Diabetes, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece; Division of Endocrinology and Metabolism, Clinical Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| |
Collapse
|
32
|
Giordano R, Guaraldi F, Berardelli R, Karamouzis I, D'Angelo V, Zichi C, Grottoli S, Ghigo E, Arvat E. Dual-release Hydrocortisone in Addison's Disease - A Review of the Literature. EUROPEAN ENDOCRINOLOGY 2014; 10:75-78. [PMID: 29872468 DOI: 10.17925/ee.2014.10.01.75] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 08/09/2013] [Indexed: 02/02/2023]
Abstract
In patients with adrenal insufficiency, glucocorticoids (GCs) are insufficiently secreted and GC replacement is essential for health and, indeed, life. Despite GC-replacement therapy, patients with adrenal insufficiency have a greater cardiovascular risk than the general population, and suffer from impaired health-related quality of life. Although the aim of the replacement GC therapy is to reproduce as much as possible the physiological pattern of cortisol secretion by the normal adrenal gland, the pharmacokinetics of available oral immediate-release hydrocortisone or cortisone make it impossible to fully mimic the cortisol rhythm. Therefore, there is an unmet clinical need for the development of novel pharmaceutical preparations of hydrocortisone, in order to guarantee a more physiological serum cortisol concentration time-profile, and to improve the long-term outcome in patients under GC substitution therapy.
Collapse
Affiliation(s)
| | - Federica Guaraldi
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences
| | - Rita Berardelli
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences
| | - Ioannis Karamouzis
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences
| | - Valentina D'Angelo
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences
| | - Clizia Zichi
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences
| | - Silvia Grottoli
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences
| | - Ezio Ghigo
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences
| | - Emanuela Arvat
- Division of Oncological Endocrinology, Department of Medical Sciences, University of Turin, Turin, Italy
| |
Collapse
|
33
|
Abstract
An increasing body of evidence suggests that immune-mediated processes affect female reproductive success at multiple levels. Crosstalk between endocrine and immune systems regulates a large number of biological processes that affect target tissues, and this crosstalk involves gene expression, cytokine and/or lymphokine release and hormone action. In addition, endocrine-immune interactions have a major role in the implantation process of the fetal (paternally derived) semi-allograft, which requires a reprogramming process of the maternal immune system from rejection to temporary tolerance for the length of gestation. Usually, the female immune system is supportive of all of these processes and, therefore, facilitates reproductive success. Abnormalities of the female immune system, including autoimmunity, potentially interfere at multiple levels. The relevance of the immune system to female infertility is increasingly recognized by investigators, but clinically is often not adequately considered and is, therefore, underestimated. This Review summarizes the effect of individual autoimmune endocrine diseases on female fertility, and points towards selected developments expected in the near future.
Collapse
Affiliation(s)
- Aritro Sen
- The Center for Human Reproduction (CHR), 21 East 69th Street, New York, NY 10021, USA
| | - Vitaly A Kushnir
- The Center for Human Reproduction (CHR), 21 East 69th Street, New York, NY 10021, USA
| | - David H Barad
- The Center for Human Reproduction (CHR), 21 East 69th Street, New York, NY 10021, USA
| | - Norbert Gleicher
- The Center for Human Reproduction (CHR), 21 East 69th Street, New York, NY 10021, USA
| |
Collapse
|
34
|
Yuen KCJ, Chong LE, Koch CA. Adrenal insufficiency in pregnancy: challenging issues in diagnosis and management. Endocrine 2013; 44:283-92. [PMID: 23377701 DOI: 10.1007/s12020-013-9893-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 01/21/2013] [Indexed: 10/27/2022]
Abstract
Adrenal insufficiency (AI) in pregnancy is relatively rare, but it is associated with significant maternal and fetal morbidity and mortality if untreated during gestation or in the puerperium. Hence, timely diagnosis and decisive treatment by the clinician are critical. However, due to pregnancy-induced metabolic and endocrine changes and the resemblance of symptomatology of AI to those of pregnancy, the diagnosis is often difficult to recognize and challenging to confirm. Normal pregnancy is a state of glucocorticoid excess particularly in the latter stages, and normative values for serum cortisol levels are not well-established. Furthermore, testing the hypothalamic-pituitary-adrenal axis using validated stimulation tests during pregnancy are lacking. Therefore, it is the aim of the present review to discuss and to summarize the current knowledge, focussing on the challenges in recognizing AI in pregnancy and interpreting the diagnostic tests, and to propose a clinical approach for optimizing the management of AI in women diagnosed before or during pregnancy.
Collapse
Affiliation(s)
- Kevin C J Yuen
- Division of Endocrinology, Diabetes and Clinical Nutrition, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mailcode L607, Portland, OR, 97239-3098, USA,
| | | | | |
Collapse
|
35
|
Intra-articular methylprednisolone acetate injection at the knee joint and the hypothalamic–pituitary–adrenal axis: a randomized controlled study. Clin Rheumatol 2013; 33:99-103. [DOI: 10.1007/s10067-013-2374-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 08/11/2013] [Accepted: 08/13/2013] [Indexed: 10/26/2022]
|
36
|
Papierska L, Rabijewski M. Delay in diagnosis of adrenal insufficiency is a frequent cause of adrenal crisis. Int J Endocrinol 2013; 2013:482370. [PMID: 23864857 PMCID: PMC3707239 DOI: 10.1155/2013/482370] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 06/10/2013] [Indexed: 11/17/2022] Open
Abstract
Delay of diagnosis of primary adrenal insufficiency (PAI) leads to adrenal crisis which is potentially lethal complication. The objective of our work was an assessment whether the establishment of diagnosis of adrenocortical insufficiency in Poland is so much delayed as assessed in the past. We have analysed data from 60 patients with diagnosis of PAI established in our department during the past 12 years and who are still under our care. We found that the time to diagnosis of primary adrenal insufficiency in Poland exceeds 3 months in every patient and 6 months in patients admitted with symptoms of adrenal crisis. Forty-four percent of patients were diagnosed only just after the hospitalisation due to crisis, despite the evident signs and symptoms of PAI. Lack of appetite and loss of body weight occurred in all patients and for that reason a diagnosis of chronic gastric and duodenal ulcer disease was the most often incorrect diagnosis. After the proper diagnosis and treatment, in the course of 1-11 years of observation, there was only 6 imminent adrenal crises in 5 patients. Our results indicated that training of primary care physicians in the field of recognising and treatment of adrenal insufficiency is still essential.
Collapse
Affiliation(s)
- Lucyna Papierska
- Clinic of Endocrinology, The Centre of Postgraduate Medical Education, Warsaw, Poland
- *Lucyna Papierska:
| | - Michał Rabijewski
- Clinic of Endocrinology, The Centre of Postgraduate Medical Education, Warsaw, Poland
- Department of Internal Diseases, Diabetology and Endocrinology, Medical University of Warsaw, Poland
| |
Collapse
|