Inhibition of Adrenal Steroidogenesis by Danazol in Vivo**Presented at the Thirty-Sixth Annual Meeting of The American Fertility Society, March 18 to 22, 1980, Houston, Tex

Danazol

A comprehensive profile of danazol describing the nomenclatures, formulae, elemental composition, appearance, uses and applications is presented. The profile contains the method which was utilized for the preparation of the drug substance and its respective scheme is outlined. The physical characteristics of the drug including the solubility, X-ray powder diffraction pattern, differential scanning calorimetry, thermal behavior and spectroscopic studies are described. The methods which were used for the analysis of the drug substance in bulk drug and/or in pharmaceutical formulations including the compendial, spectrophotometric, electrochemical and the chromatographic methods are reported. The stability, toxicity, pharmacokinetics, bioavailability, drug evaluation and monitoring, comparisons, pharmacology, in addition to several compiled reviews on the drug substance which were involved. Finally, two hundred and seventy-nine references are listed at the end of this profile.

Drug-induced endocrine blood pressure elevation

Patients with uncontrolled hypertension are at risk for cardiovascular complications. The majority of them suffers from unidentified forms of hypertension and a fraction has so-called secondary hypertension with an identifiable cause. The patient's medications, its use of certain herbal supplements and over-the-counter agents represent potential causal factors for secondary hypertension that are often overlooked. The current review focuses on drugs that are likely to elevate blood pressure by affecting the human endocrine system at the level of steroid synthesis or metabolism, mineralocorticoid receptor activity, or by affecting the catecholaminergic system. Drugs with known adverse effects but where benefits outweigh their risks, drug candidates and market withdrawals are reviewed. Finally, potential therapeutic strategies are discussed.

Inhibition of progesterone secretion with trilostane for mid-trimester termination of pregnancy: randomized controlled trials

BACKGROUND

Progesterone is central to the maintenance of pregnancy, and is thus the ideal target for fertility regulation. Two mechanisms by which progesterone can be targeted are: receptor blockade and reduction of progesterone production through enzyme inhibition. Mifepristone, a receptor blocker, is usually given as 'pretreatment' prior to prostaglandin administration in mid-trimester termination of pregnancy (TOP). Unfortunately, there are difficulties accessing mifepristone in developing countries, and TOP is therefore performed using prostaglandins alone, which results in unacceptably long induction-to-abortion intervals. Trilostane is a 3beta-hydroxysteroid dehydrogenase inhibitor which reduces progesterone production. In these mid-trimester studies it is evaluated as a method of pretreatment prior to misoprostol administration.

METHODS

Three consecutive randomized controlled trials comparing different trilostane regimens for pretreatment were performed. In study 1, trilostane was compared with placebo; in study 2, two doses of trilostane were compared (1080 mg and 720 mg); in study 3, the effect of adding danazol to trilostane as combination therapy was evaluated. The primary outcome in all the studies was the induction-to-abortion interval. Serum progesterone, estradiol and cortisol were measured serially during treatment.

RESULTS

In study 1, 48 women were randomized. The median induction-to-abortion interval was 9 h in the trilostane group and 18.5 h in the placebo group (P < 0.0001). Progesterone and estradiol production was significantly reduced in the women receiving trilostane, with maintenance of diurnal cortisol variation. Twenty-eight women were randomized in study 2, which demonstrated that there was no significant difference in the induction-to-abortion interval using 1080 mg and 720 mg trilostane when compared with the higher doses used in study 1. Study 3, in which 40 women were included, failed to show any additional benefit using combination therapy with danazol and trilostane.

CONCLUSIONS

Trilostane is an effective pretreatment agent in mid-trimester TOP.

The influence of hormones and pharmaceutical agents on DHEA and DHEA-S concentrations: a review of clinical studies

Low endogenous levels of dehydroepiandrosterone (DHEA) and/or its sulfoconjugated derivative DHEA-S have been associated with diseases such as lupus, cancer, and diabetes. Circulating concentrations of DHEA and DHEA-S resulting from endogenous production or hormone supplementation may also be relevant in psychiatric illness. Drugs may significantly increase or decrease circulating concentrations of these adrenal androgens by various mechanisms. Some agents, such as dexamethasone, affect the HPA axis by inhibiting ACTH and therefore decrease DHEA and DHEA-S concentrations. Central nervous system agents, including carbamazepine and phenytoin, induce the P450 enzymes that metabolize DHEA and DHEA-S and therefore decrease circulating concentrations of these hormones. Danazol alters the ratio between DHEA and DHEA-S by inhibiting sulfatase. As research moves forward to better understand the relationships of these adrenal androgens with health and disease, it is essential that studies be designed to control for the influence of administered pharmaceuticals on DHEA and DHEA-S.

Evidence for estrogen synthesis in adenomyotic tissues

OBJECTIVE

To investigate steroidogenesis in eutopic and ectopic endometrial tissues in adenomyosis.

STUDY DESIGN

Aromatase and estrone sulfatase activities were determined by anion-exchange resin column chromatography, thin-layer chromatography, and cocrystallization. The effects of danazol on the activity of these enzymes were also examined. Moreover, localization of aromatase in eutopic and ectopic endometrial tissues was immunohistochemically examined with antihuman placental aromatase cytochrome P-450 antibody.

RESULTS

Aromatase and estrone sulfatase activities were detected in ectopic endometrium. The activity of these enzymes was significantly suppressed by danazol. In addition, aromatase was immunohistochemically detected in glandular cells of eutopic and ectopic endometrial tissues.

CONCLUSIONS

The results suggest that estrogen is synthesized in the eutopic and ectopic endometrial tissues of women with uterine adenomyosis and that it may affect the growth of adenomyosis. Danazol suppressed synthesis of estrogen in vitro.

The effects of fetal exposure to danazol

OBJECTIVE

To assess the consequences of exposure to danazol in utero. Additionally, by assessing the risk, to facilitate the counselling of pregnant women inadvertently exposed to danazol in early pregnancy.

DESIGN

Retrospective review of reported case histories.

SUBJECTS

129 women exposed to danazol during pregnancy were identified from individual case reports, data from the Australian Drug Reactions Advisory Committee and the United States Food and Drug Administration and from the reports of danazol exposure made directly to the manufacturers.

MAIN OUTCOME MEASURES

Teratogenic effects of fetal exposure to danazol in relation to dosage and duration of exposure.

RESULTS

Of the 129 reported pregnancies, 12 miscarried and 23 were aborted. Of the 94 completed pregnancies, 37 resulted in the birth of normal males, 34 in non-virilized females and 23 in virilized females. Virilization occurred in a proportion of female fetuses with a pattern of cliteromegaly, fused labia and urogenital sinus formation. Surgery to the genital tract was usually, but not always, required in childhood. The abnormality has not been reported where danazol therapy had been discontinued before the 8th week of pregnancy. Although more common in the higher dosages, virilization was reported in one case with a 200 mg daily dosage.

CONCLUSIONS

Danazol should remain contraindicated in pregnancy and clinicians should give careful contraceptive advice to patients commencing or continuing danazol therapy. Nonetheless it is possible to be cautiously optimistic about the outcome of danazol-exposed pregnancies, particularly if treatment is discontinued before 8 completed weeks gestation.

Danazol suppresses the production of interleukin-1 beta and tumor necrosis factor by human monocytes

The effects of estradiol (E2), progesterone (P), and danazol on the production of interleukin-1 beta (IL-1 beta) and tumor necrosis factor (TNF) by OK-432 (a streptococcal preparation)-stimulated monocytes were examined. E2 and P at physiologic concentrations enhanced IL-1 beta and TNF production by monocytes from donors with lower control levels (without steroids added) of IL-1 beta and TNF. However, E2 and P at physiologic concentrations did not affect IL-1 beta and TNF production by monocytes from donors with higher control levels of IL-1 beta and TNF. Danazol inhibited IL-1 beta and TNF production by monocytes in a dose-dependent manner from not only donors with lower control levels of IL-1 beta and TNF but also donors with higher control levels of IL-1 beta and TNF. Danazol at a concentration of 10(-6) M significantly suppressed IL-1 beta and TNF production in the presence of E2 and/or P at concentrations giving peak responses of IL-1 beta production. These findings suggest possible new mechanisms of action for danazol in the treatment of endometriosis and infertility associated with immune abnormalities.

Comparison of the pharmacology of nafarelin and danazol

The pharmacologic profiles of danazol and nafarelin differ considerably from each other. Danazol interacts with multiple classes of proteins, whereas the gonadotropin-releasing hormone agonist nafarelin interacts only with the pituitary gonadotropin-releasing hormone receptor. Differences in the molecular, endocrine, and clinical pharmacologic properties of these agents may provide clues to their varying effects in the management of women with endometriosis.

Photodynamic therapy of rabbit endometrial transplants: a model for treatment of endometriosis

The potential of photodynamic therapy for endometriosis was evaluated by autotransplantation of endometrial tissue in 15 female virgin New Zealand white rabbits. After maturation, 14 animals were injected intravenously with 10 mg/kg of dihematoporphyrin ether (DHE) and, 24 hours later, transplants were exposed to 630 nm light at 100 to 210 mW/cm2. Sixteen transplants received 100 J/cm2, 10 transplants received 50 J/cm2; 13 untreated transplants served as controls. In the remaining animal that did not receive DHE, 3 transplants were irradiated with 100 J/cm2. Six days after treatment, transplants were harvested with the underlying musculature, and multiple sections were examined histopathologically. Complete endometrial epithelial destruction was seen in 13 of 16 transplants (81%) in the 100 J/cm2 group and in 6 of 10 transplants (60%) in the 50-J/cm2 group. Nearly complete endometrial epithelial destruction was seen in 2 other transplants in each group. No damage occurred in either the 3 transplants that received 100 J/cm2 without prior DHE or in the 13 transplants with DHE and no irradiation. The sensitivity of ectopic rabbit endometrial tissue encourages further evaluation of photodynamic therapy for the treatment of human endometrial disorders.

Ovarian suppression induced with Buserelin or danazol in the management of endometriosis: a randomized, comparative study

The effectiveness of Buserelin (Hoechst-Roussel Pharmaceuticals, Inc., Somerville, NJ) (0.2 mg subcutaneously [SC] or 1.2 mg intranasally [IN] per day) and danazol (800 mg per day) in inducing ovarian suppression for the management of endometriosis was compared in a prospective randomized study. During 6 months of treatment, peripheral follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol concentrations were suppressed to a similar degree in both groups. Symptomatic improvement and laparoscopically assessed regression of endometriotic lesions also were comparable. After treatment, 8 of 18 infertile women treated with Buserelin and 5 of 8 treated with danazol conceived. General and hypoestrogenic side effects were similar in both groups, while androgenic and anabolic were more frequent with danazol. High density lipoprotein (HDL)-cholesterol increased in the Buserelin and decreased in the danazol group. The study indicates that at the dose tested, buserelin and danazol induce a similar degree of ovarian suppression resulting in a comparable clinical improvement and regression of endometriotic lesions.

A randomized, prospective comparison of endocrine changes induced with intranasal leuprolide or danazol for treatment of endometriosis

A prospective, randomized trial compared hormonal changes induced with intranasal leuprolide 1.6 mg/day to danazol 800 mg/day for treatment of endometriosis. Both regimens induced anovulation and ovarian suppression in all subjects. Mean estradiol (E2) and progesterone (P) levels were suppressed with both regimens, but were lower with leuprolide. There was no difference in cumulative follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels, although at times during treatment mean levels of these hormones were lower with leuprolide. Higher P levels in the danazol group, most likely of adrenal origin, indicated a suppressive effect on adrenal steroidogenesis. Symptomatic improvement was significant in both groups. Laparoscopy after treatment also demonstrated a decrease in endometriosis scores in both groups. At 12 months after treatment, cumulative pregnancy and live birth rates were similar in both groups. Leuprolide offers an attractive alternative to danazol for the medical treatment of endometriosis.

Danazol inhibits steroidogenesis by the human ovary in vivo

Gonadotropins, estradiol (E2), and the steroid precursors of ovarian estrogen secretion were examined in women on danazol to clarify actions of the medication on hypothalamic-pituitary-ovarian function. Follicle-stimulating hormone was not altered acutely after a single maximal dose or chronically during therapy, whereas a slight but significant increase in luteinizing hormone was noted during the 6 months of treatment. During danazol treatment, there was a blunted response of E2 to injections of human menopausal gonadotropins. The progestin and androgen precursors of E2 were reduced, with the exception of 17-hydroxypregnenolone, which was significantly increased. This 17-hydroxylase enzyme block persisted in spite of dexamethasone suppression of adrenal function. Therefore, the reduced ovarian secretion of E2 in women receiving danazol is due in part to reductions of ovarian precursor steroids for E2 synthesis, consequent to a direct ovarian action of the medication.

A simple in vitro approach to the estimation of the biopotency of drugs affecting adrenal steroidogenesis

Dispersed guinea-pig adrenal cells can be maximally stimulated to secrete cortisol by adrenocorticotrophin (ACTH greater than 50 ng/l). Further, this stimulation appears to be specific to ACTH alone, with other naturally occurring chemicals (e.g. steroids, protein hormones) at supra-physiological concentrations being without effect on cortisol production. The effect of drugs of differing structure and therapeutic function (aminogluthethimide, metyrapone, trilostane, 17-ketotrilostane, danazol, epostane, megestrol acetate, stanozolol and etomidate) on ACTH-stimulated (50 ng/l) cortisol production has been tested in this system. All the drugs depressed steroid output in a similar dose-related fashion. The concentration of drug which inhibited cortisol output by 50% was (mumol/l, mean +/- SEM): etomidate 0.097 +/- 0.002: epostane 0.44 +/- 0.02: 17-ketotrilostane 0.55 +/- 0.04: trilostane 1.3 +/- 0.1: metyrapone 3.5 +/- 0.6: megestrol acetate, 11 +/- 2: danazol 22 +/- 2: aminogluthethimide 41 +/- 5: stanozolol 50 +/- 4. Thus, etomidate, an anaesthetic, is more potent than the established anti-steroidogenic drugs metyrapone, aminogluthethimide and trilostane. Further, direct anti-steroidogenic effects have been demonstrated for megestrol acetate and stanozolol for the first time. We conclude that this technique offers a promising new approach to the assessment of biological potency of drugs affecting endocrine tissues.

Danazol versus carbon dioxide laser plus postoperative danazol: treatment of infertility due to mild pelvic endometriosis

The mechanism of action by which mild pelvic endometriosis causes infertility is still unknown. Danazol has been proposed as the sole agent to treat this condition; however, the results for pregnancy rates do not give as much cause for enthusiasm at the present time as they did when this drug was introduced. To ascertain the role of laser via the laparoscopic approach, this retrospective study looks at the pregnancy success rate in two groups of patients. Group I was treated with danazol alone; group II was treated with danazol after laser surgery. Although the success rate is better in group II, the population sample in both groups is modest and does not allow one to draw meaningful statistical conclusions at the present time, but the use of carbon dioxide laser with the laparoscope plus postoperative danazol seems to be a better approach to this condition that affects the infertile female.

On the site of action of the anti-adrenal steroidogenic effect of etomidate and megestrol acetate

The sites of action of the anti-steroidogenic action of etomidate and megestrol acetate have been established with a novel in vitro approach based upon the inhibition of cortisol (Co) secretion by dispersed guinea-pig adrenal cells. The cells were challenged with the Co precursor steroids (all at 10(-5) mol/l) pregnenolone (Pe), 17-hydroxy-pregnenolone (17-Pe), progesterone (Po), 17-hydroxyprogesterone (17-Po), 21-deoxycortisol (21-DOC) and 11-deoxycortisol (11-DOC), or 1-24 adrenocorticotrophin (ACTH, 100 ng/l) in the presence or absence of either etomidate, megestrol acetate, metyrapone or trilostane (all at 5 X 10(-5) mol/l). In the absence of drug, the steroid precursors or ACTH provoked a cortisol secretion of greater than 14 times that secreted by cells incubated in their absence. ACTH-stimulated Co secretion was inhibited by greater than 85% by all the drugs employed. In the presence of trilostane and megestrol acetate, Co secretion provoked by the delta 4 3-keto steroids (Po, 17-Po, 21-DOC and 11-DOC) was similar to the controls. However, with the delta 5, 3 beta-hydroxy steroids, 17-Pe and Pe, Co secretion was inhibited by greater than 57% in the presence of these drugs. In contrast, etomidate and metyrapone inhibited Co secretion by greater than 60% when 11-deoxycortisol was employed, indicative of a block at 11 beta-hydroxylase, the final step in the cortisol biosynthetic pathway. Similar results were seen with Pe, 17-Pe, Po and 17-Po, all of which are converted to cortisol via a biosynthetic route which includes catalysis by 11 beta-hydroxylase.(ABSTRACT TRUNCATED AT 250 WORDS)

Endocrine effects of danazol in the treatment of endometriosis

The effects of danazol therapy on circulating gonadotrophins, oestradiol and sex hormone-binding globulin (SHBG) binding capacity have been studied in eight patients with endometriosis. There was a significant rise in luteinizing hormone (LH) in the first week of treatment with a fall in oestradiol levels. There was a marked fall in SHBG in the first week which continued up to 4 weeks. It is concluded that danazol is not 'anti-gonadotrophic' as frequently claimed and that its therapeutic actions, side effects and the endocrine changes could be explained by an effect on SHBG production. The rationale of its use in other conditions requires reconsideration.

Peripheral androgen levels in danazol-treated premenopausal women

Eighteen normally menstruating women with endometriosis were treated with 600 mg of danazol daily for 6 months. Blood samples were taken before and after 2, 4, 8, 12, and 16 weeks of treatment and were analyzed for plasma dehydroepiandrosterone sulfate (DHEA-S), dehydroepiandrosterone (DHEA), and testosterone (T) and for serum alanine aminotransferase (ALAT), albumin, creatinine, potassium, and sodium. The basal values of all parameters studied were well within normal reference limits. DHEA-S was significantly increased at 2, 4, and 8 weeks, and DHEA significantly decreased at 8 and 12 weeks of treatment. The ratio between DHEA and DHEA-S was significantly decreased at weeks 4, 8, 12, and 16. T was significantly decreased during the whole period of observation. ALAT was significantly increased at weeks 4, 8, 12, and 16. A slight but significant increase was observed for creatinine and potassium, while no changes were observed for albumin and sodium. Of the two major androgen sources, the adrenal cortex appears to be relatively unaffected; whereas the ovary may be affected to a minor degree. Therefore, it seems likely that the changes observed in DHEA and DHEA-S may be due to minor alterations in renal and hepatic turnover rather than an effect on adrenal steroidogenesis.

Danazol: endocrine pharmacology and therapeutic applications

The options for the medical management of endometriosis have been expanded by the introduction of the synthetic steroid, danazol. The results of large clinical studies suggest that danazol treatment produces significant improvement in the symptoms, signs, and laparoscopic findings of endometriosis. The original studies of the pharmacology of danazol concluded that danazol was a strong antigonadotrophin with mild androgenic effects and no other hormonal properties. Recent studies which emphasize the molecular pharmacology of danazol suggest that this steroid has direct effects on hypothalamic-pituitary function, multiple classes of steroid receptors, gonadal steroidogenesis, and endogenous steroid metabolism. These studies demonstrate that: (1) danazol prevents the midcycle surge of luteinizing hormone (LH) and follicle-stimulating hormone (FSH); (2) danazol does not significantly suppress basal LH or FSH in gonadally intact human beings; (3) in castrated animals danazol can prevent the compensatory increase in LH and FSH; (4) danazol binds to androgen, progesterone, and glucocorticoid receptors; (5) danazol does not bind to estrogen receptors; (6) danazol binds to sex hormone-binding globulin and corticosteroid-binding globulin; (7) danazol inhibits multiple enzymes of steroidogenesis; (8) danazol increases the metabolic clearance rate of progesterone; and (9) metabolites of danazol are hormonally active. Given the complex pharmacology of danazol it is inappropriate to continue to refer to danazol as a "selective antigonadotrophin."U