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Beuschlein F, Else T, Bancos I, Hahner S, Hamidi O, van Hulsteijn L, Husebye ES, Karavitaki N, Prete A, Vaidya A, Yedinak C, Dekkers OM. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab 2024; 109:1657-1683. [PMID: 38724043 PMCID: PMC11180513 DOI: 10.1210/clinem/dgae250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Indexed: 06/18/2024]
Abstract
Glucocorticoids are widely prescribed as anti-inflammatory and immunosuppressive agents. This results in at least 1% of the population using chronic glucocorticoid therapy, being at risk for glucocorticoid-induced adrenal insufficiency. This risk is dependent on the dose, duration and potency of the glucocorticoid, route of administration, and individual susceptibility. Once glucocorticoid-induced adrenal insufficiency develops or is suspected, it necessitates careful education and management of affected patients. Tapering glucocorticoids can be challenging when symptoms of glucocorticoid withdrawal develop, which overlap with those of adrenal insufficiency. In general, tapering of glucocorticoids can be more rapidly within a supraphysiological range, followed by a slower taper when on physiological glucocorticoid dosing. The degree and persistence of HPA axis suppression after cessation of glucocorticoid therapy are dependent on overall exposure and recovery of adrenal function varies greatly amongst individuals. This first European Society of Endocrinology/Endocrine Society joint clinical practice guideline provides guidance on this clinically relevant condition to aid clinicians involved in the care of patients on chronic glucocorticoid therapy.
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Affiliation(s)
- Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University of Zürich (USZ) and University of Zürich (UZH), 8091 Zürich, Switzerland
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität, 81377 Munich, Germany
- The LOOP Zurich Medical Research Center, 8044 Zurich, Switzerland
| | - Tobias Else
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Joint appointment in Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Wuerzburg, Germany
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, TX 75390-8857, USA
| | - Leonie van Hulsteijn
- European Society of Endocrinology, Bristol BS32 4QW, UK
- Department of Clinical Epidemiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
- Department of Medicine, Haukeland University Hospital, N-5021 Bergen, Norway
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Christine Yedinak
- Department of Neurological Surgery, Oregon Health & Sciences University, Portland, OR 97239-3098, USA
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Endocrinology and Metabolism, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, 8200 Aarhus, Denmark
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Birtolo MF, Giannini E, Antonini S, Lavezzi E, Lasio G, Da Rin G, Mazziotti G, Lania AG. Prediction of adrenal insufficiency after pituitary surgery: a retrospective study using beckman access cortisol assay. Pituitary 2024; 27:160-168. [PMID: 38170374 DOI: 10.1007/s11102-023-01368-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Identifying patients requiring glucocorticoid replacement therapy after pituitary surgery is challenging as the tests commonly used for the diagnosis of secondary adrenal insufficiency (SAI) are not recommended in the immediate postoperative period. There are controversial data on the role of postoperative days' morning cortisol, with no specific data for each cortisol assay. The aim of this study is to investigate the reliability of 8.00 a.m. cortisol of the first and second postoperative days in predicting SAI. METHODS Data of patients underwent pituitary surgery in Humanitas Research Hospital in Italy, from March 2017 to August 2022, were retrospectively analyzed. Definitive diagnosis of SAI was made through ACTH test 1 µg six weeks after surgery. Cortisol was measured through Beckman Access Cortisol and the diagnosis of SAI was made if cortisol peak was below 14.8 µg/dL (408 nmol/L) at 30 or 60 min after stimulus. RESULTS Of the sixty-four patients enrolled, seven developed SAI. The ROC curves demonstrated that both first- and second-day postoperative 8.00 a.m. cortisol predict SAI (AUC 0.94 and 0.95, respectively). The optimal thresholds were 15.6 µg/dL (430.3 nmol/L; accuracy 89%) for the first day and 11.5 µg/dL (317.2 nmol/L, accuracy 81%) for the second day. Patients who developed SAI had larger tumors (p = 0.004) and lower fT4 (p = 0.038) before surgery. CONCLUSIONS Clinicians might rely on the first- and second- postoperative days 8.00 a.m. cortisol to identify patients to discharge with glucocorticoid replacement therapy waiting for the confirmation of SAI through the ACTH test.
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Affiliation(s)
- Maria Francesca Birtolo
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Emma Giannini
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
| | - Simone Antonini
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Elisabetta Lavezzi
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Giovanni Lasio
- Department of Neurosurgery, IRCCS Humanitas Clinical and Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Giorgio Da Rin
- Laboratory Medicine, IRCCS Humanitas Clinical and Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Gherardo Mazziotti
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy.
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy.
| | - Andrea G Lania
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
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3
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Lawrence NR, Arshad MF, Pofi R, Ashby S, Dawson J, Tomlinson JW, Newell-Price J, Ross RJ, Elder CJ, Debono M. Multivariable Model to Predict an ACTH Stimulation Test to Diagnose Adrenal Insufficiency Using Previous Test Results. J Endocr Soc 2023; 7:bvad127. [PMID: 37942292 PMCID: PMC10628819 DOI: 10.1210/jendso/bvad127] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Indexed: 11/10/2023] Open
Abstract
Context The adrenocorticotropin hormone stimulation test (AST) is used to diagnose adrenal insufficiency, and is often repeated in patients when monitoring recovery of the hypothalamo-pituitary-adrenal axis. Objective To develop and validate a prediction model that uses previous AST results with new baseline cortisol to predict the result of a new AST. Methods This was a retrospective, longitudinal cohort study in patients who had undergone at least 2 ASTs, using polynomial regression with backwards variable selection, at a Tertiary UK adult endocrinology center. Model was developed from 258 paired ASTs over 5 years in 175 adults (mean age 52.4 years, SD 16.4), then validated on data from 111 patients over 1 year (51.8, 17.5) from the same center, data collected after model development. Candidate prediction variables included previous test baseline adrenocorticotropin hormone (ACTH), previous test baseline and 30-minute cortisol, days between tests, and new baseline ACTH and cortisol used with calculated cortisol/ACTH ratios to assess 8 candidate predictors. The main outcome measure was a new test cortisol measured 30 minutes after Synacthen administration. Results Using 258 sequential ASTs from 175 patients for model development and 111 patient tests for model validation, previous baseline cortisol, previous 30-minute cortisol and new baseline cortisol were superior at predicting new 30-minute cortisol (R2 = 0.71 [0.49-0.93], area under the curve [AUC] = 0.97 [0.94-1.0]) than new baseline cortisol alone (R2 = 0.53 [0.22-0.84], AUC = 0.88 [0.81-0.95]). Conclusion Results of a previous AST can be objectively combined with new early-morning cortisol to predict the results of a new AST better than new early-morning cortisol alone. An online calculator is available at https://endocrinology.shinyapps.io/sheffield_sst_calculator/ for external validation.
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Affiliation(s)
- Neil Richard Lawrence
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
- Paediatric Endocrinology Department, Sheffield Children's NHS Foundation Trust, Sheffield S10 2TH, UK
| | - Muhammad Fahad Arshad
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
- Endocrinology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
| | - Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Sean Ashby
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
| | - Jeremy Dawson
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University Hospitals NHS Trust, Oxford OX3 9DU, UK
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford OX3 9DU, UK
| | - John Newell-Price
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
- Endocrinology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
| | - Richard J Ross
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
| | - Charlotte J Elder
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
- Paediatric Endocrinology Department, Sheffield Children's NHS Foundation Trust, Sheffield S10 2TH, UK
| | - Miguel Debono
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield S10 2TN, UK
- Endocrinology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
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Cozzolino A, Hasenmajer V, Newell-Price J, Isidori AM. COVID-19 pandemic and adrenals: deep insights and implications in patients with glucocorticoid disorders. Endocrine 2023; 82:1-14. [PMID: 37338722 PMCID: PMC10462567 DOI: 10.1007/s12020-023-03411-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/25/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Coronavirus disease-19 (COVID-19) has spread throughout the world. It was initially defined as a potentially severe syndrome affecting the respiratory tract, but it has since been shown to be a systemic disease with relevant extrapulmonary manifestations that increase mortality. The endocrine system has been found to be vulnerable to COVID-19 infection. The current review aims to evaluate the available data on the impact of COVID-19 infection and treatment, as well as COVID-19 vaccines, on adrenal gland function, particularly in patients with GC disorders. METHODS A thorough search of published peer-reviewed studies in PubMed was performed using proper keywords. RESULTS Adrenal viral tropism and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) replication in the adrenal glands have been demonstrated, and adrenal insufficiency (AI) is a rare, but potentially severe complication in COVID-19 disease, whose recognition can be difficult if only for the empirical treatments administered in the early stages. Glucocorticoid (GC) treatment have had a pivotal role in preventing clinical deterioration in patients with COVID-19, but long-term GC use may increase COVID-19-related mortality and the development of iatrogenic AI. Patients with GC disorders, especially AI and Cushing's syndrome, have been identified as being at high risk of COVID-19 infection and complications. Published evidence suggests that AI patient awareness and proper education may help adjust GC replacement therapy appropriately when necessary, thereby reducing COVID-19 severity. The COVID-19 pandemic has had an impact on AI management, particularly in terms of adherence to patients' care plans and self-perceived challenges. On the other hand, published evidence suggests that the clinical course of COVID-19 may be affected by the severity of hypercortisolism in patients with CS. Therefore, to ameliorate the risk profile in these patients, cortisol levels should be adequately controlled, along with careful monitoring of metabolic and cardiovascular comorbidities. To date, the COVID-19 vaccine remains the only available tool to face SARS-CoV-2, and it should not be treated differently in patients with AI and CS. CONCLUSION SARS-CoV-2 infection has been linked to adrenal damage and AI is a rare complication in COVID-19 disease, requiring prompt recognition. Educational efforts and patient awareness may reduce COVID-19 severity in patients with AI. Control of cortisol levels and monitoring of complications may improve the clinical course of COVID-19 in patients with CS.
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Affiliation(s)
- Alessia Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, IT, Rome, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, IT, Rome, Italy
| | - John Newell-Price
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, IT, Rome, Italy.
- Centre for Rare Diseases (ENDO-ERN accredited), Policlinico Umberto I, Rome, Italy.
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Abstract
PURPOSE OF REVIEW Adrenal insufficiency (AI) is the clinical manifestation of deficient production of glucocorticoids with occasionally deficiency also in mineralocorticoids and adrenal androgens and constitutes a fatal disorder if left untreated. The aim of this review is to summarize the new trends in diagnostic methods used for determining the presence of AI. RECENT FINDINGS Novel aetiologies of AI have emerged; severe acute respiratory syndrome coronavirus 2 infection was linked to increased frequency of primary AI (PAI). A new class of drugs, the immune checkpoint inhibitors (ICIs) widely used for the treatment of several malignancies, has been implicated mostly with secondary AI, but also with PAI. Salivary cortisol is considered a noninvasive and patient-friendly tool and has shown promising results in diagnosing AI, although the normal cut-off values remain an issue of debate depending on the technique used. Liquid chromatography-mass spectrometry (LC-MS/MS) is the most reliable technique although not widely available. SUMMARY Our research has shown that little progress has been made regarding our knowledge on AI. Coronavirus disease 2019 and ICIs use constitute new evidence on the pathogenesis of AI. The short synacthen test (SST) remains the 'gold-standard' method for confirmation of AI diagnosis, although salivary cortisol is a promising tool.
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Affiliation(s)
- Vasiliki Siampanopoulou
- Endocrinology Unit, First Department of Internal Medicine, Laiko General Hospital of Athens, National and Kapodistrian University of Athens, Athens
| | - Elisavet Tasouli
- First Department of Internal Medicine, Thriasio General Hospital of Elefsina, Elefsina, Greece
| | - Anna Angelousi
- Endocrinology Unit, First Department of Internal Medicine, Laiko General Hospital of Athens, National and Kapodistrian University of Athens, Athens
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Birtolo MF, Antonini S, Saladino A, Zampetti B, Lavezzi E, Chiodini I, Mazziotti G, Lania AGA, Cozzi R. ACTH Stimulation Test for the Diagnosis of Secondary Adrenal Insufficiency: Light and Shadow. Biomedicines 2023; 11:biomedicines11030904. [PMID: 36979883 PMCID: PMC10045406 DOI: 10.3390/biomedicines11030904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Secondary Adrenal Insufficiency (SAI) is a condition characterized by inappropriately low ACTH secretion due to a disease or injury to the hypothalamus or the pituitary. The evaluation when suspected is often challenging for the non-specific symptoms, the rarity of the disease, and the pitfalls associated with laboratory tests. A prompt and correct diagnosis of SAI is essential because although an adequate hormonal replacement therapy could be lifesaving, inappropriate life-long therapy with steroids can be harmful. The gold standard test for assessing the hypothalamus-pituitary-adrenal axis (HPA) is the insulin tolerance test (ITT), but due to safety issues is not widely used. Conversely, the ACTH stimulation test is a safer and well-tolerated tool for SAI diagnosis. However, data about its diagnostic accuracy show great variability due to both technical and interpretative aspects, such as dose, route of administration, the timing of the test, and assay used for cortisol measurements. Consequently, the clinical background of the patient and the pretest probability of HPA axis impairment become of paramount importance. We aimed to summarize the recent literature evidence in the conduction and interpretation of the ACTH stimulation test for the diagnosis of SAI to provide updated insights on its correct use in clinical practice.
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Affiliation(s)
- Maria Francesca Birtolo
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Simone Antonini
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Andrea Saladino
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Unit of Neurosurgery, 20133 Milan, Italy
| | - Benedetta Zampetti
- Endocrinology Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Elisabetta Lavezzi
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Iacopo Chiodini
- Endocrinology Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20122 Milan, Italy
| | - Gherardo Mazziotti
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Andrea G. A. Lania
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
- Correspondence:
| | - Renato Cozzi
- Endocrinology Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
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Park J, Titman A, Lancaster G, Selvarajah B, Collingwood C, Powell D, Das U, Dharmaraj P, Didi M, Senniappan S, Blair J. Baseline and peak cortisol response to the low dose short Synacthen test relates to indication for testing, age and sex. J Endocr Soc 2022; 6:bvac043. [DOI: 10.1210/jendso/bvac043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective
To review the outcomes of a simplified low dose Synacthen test (LDSST) performed in a tertiary endocrine service over seven years, and to examine for relationships between cortisol measurements and indication for testing, age and sex.
Design
Retrospective, observational study of LDSST performed in 2008 – 2014 (N=335) and 2016-2020 (N=160).
Methods
LDSST were performed by endocrine nurses. Synacthen 500ng/1.73m 2 administered as IV bolus, sampling at 0, 15, 25 and 35 minutes.
Results
Mean (± 1SD) baseline cortisol was 221 ± 120 nmol/L, peak 510 ± 166nmol/L and increment 210 ± 116 nmol/L. 336 (70%) of patients had a normal response (baseline cortisol >100nmol/L, peak >450nmol/L), 78 (16%) a suboptimal response (peak cortisol 350-450nmol/L) and were prescribed hydrocortisone to during periods of stress only, 67 (14%) an abnormal response (baseline <100nmol/L or peak <350nmol/L) and were prescribed daily hydrocortisone. Basal, peak and incremental increases in cortisol were higher in females (p=0.03, p<0.001, p=0.03 respectively). Abnormal results occurred most frequently in patients treated previously with pharmacological doses of glucocorticoids or structural brain abnormalities (p<0.0001).
Discussion
There are concerns that the specificity of the LDSST is poor. The low prevalence and strong association of abnormal results with indication for testing, suggests that over diagnosis occurred infrequently in this clinical setting.
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Affiliation(s)
- Julie Park
- Department of Endocrinology, Alder Hey Children’s NHS Foundation Trust
| | - Andrew Titman
- Department of Mathematics and Statistics, Lancaster University
| | - Gillian Lancaster
- School of Primary, Social and Community Care & Keele Clinical Trials Unit, Keele University
| | | | | | - Darren Powell
- Department of Biochemistry, Alder Hey Children’s NHS Foundation Trust
| | - Urmi Das
- Department of Endocrinology, Alder Hey Children’s NHS Foundation Trust
| | - Poonam Dharmaraj
- Department of Endocrinology, Alder Hey Children’s NHS Foundation Trust
| | - Mohammed Didi
- Department of Endocrinology, Alder Hey Children’s NHS Foundation Trust
| | | | - Joanne Blair
- Department of Endocrinology, Alder Hey Children’s NHS Foundation Trust
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Bothou C, Beuschlein F, Nowak A. Endocrine disorders in patients with Fabry disease: insights from a reference centre prospective study. Endocrine 2022; 75:728-739. [PMID: 34751898 PMCID: PMC8888367 DOI: 10.1007/s12020-021-02918-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/18/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT Fabry Disease (FD) is a rare X-linked storage disease characterised by a-galactosidase A deficiency and diffuse organ accumulation of glycosphingolipids. Enzyme replacement and chaperone therapies are only partially effective. It remains unclear if FD-related endocrine disorders contribute to the observed morbidity. OBJECTIVE To investigate the function of the endocrine system in patients with FD. DESIGN We conducted an observational prospective study from 2017 to 2020. SETTING AND PATIENTS We included 77 patients with genetically confirmed FD (27 men, 20/27 Classic, 7/26 Late Onset phenotype, 50 women, 41/50 and 9/50 respectively), who are systematically followed by our reference centre. RESULTS 36/77 (46.8%) patients had VitD deficiency (25(0H)VitD <20 μg/L) despite the fact that 19/36 (52.8%) were substituted with cholecalciferol. Only 21/77 (27.3%) patients had normal VitD levels without VitD substitution. 11/77 (14.3%) had significant hypophosphatemia (p < 0.80 mmol/L). Three new cases (3.9%) of subclinical, two (2.6%) of overt and six (7.8%) of known hypothyroidism were identified. Of note, men had significantly higher renin levels than women [61.4 (26.1-219.6) vs.25.4 (10.9-48.0) mU/L, p = 0.003]. There were no major abnormalities in adrenal, growth and sex-hormone axes. Patients of Classic phenotype had significantly higher High-Density Lipoprotein Cholesterol (HDL-C) levels (p = 0.002) and in men those levels were positively correlated with globotriaosylsphingosin (Lyso-Gb3) values. 10/77 (13%) of the patients were underweight. CONCLUSIONS VitD supplementation should be considered for all patients with FD. Thyroid screening should be routinely performed. Malnutrition should be prevented or treated, particularly in Classic phenotype patients. Overall, our data suggest that FD specialists should actively seek and diagnose endocrine disorders in their patients.
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Affiliation(s)
- Christina Bothou
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zürich, Switzerland
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zürich, Switzerland
| | - Albina Nowak
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zürich, Switzerland.
- Department of Internal Medicine, Psychiatry University Hospital Zurich, Zürich, Switzerland.
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9
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Ceccato F, Selmin E, Antonelli G, Barbot M, Daniele A, Boscaro M, Plebani M, Scaroni C. Low-dose short synacthen test with salivary cortisol in patients with suspected central adrenal insufficiency. Endocr Connect 2021; 10:1189-1199. [PMID: 34424852 PMCID: PMC8494418 DOI: 10.1530/ec-21-0404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/23/2021] [Indexed: 12/26/2022]
Abstract
CONTEXT The low-dose short synacthen test (LDSST) is recommended for patients with suspected central adrenal insufficiency (AI) if their basal serum cortisol (F) levels are not indicative of an intact hypothalamic-pituitary-adrenal (HPA) axis. OBJECTIVE To evaluate diagnostic threshold for salivary F before and 30 min after administering 1 μg of synacthen, performed before 09:30 h. DESIGN A cross-sectional study from 2014 to 2020. SETTING A tertiary referral university hospital. PATIENTS In this study, 174 patients with suspected AI, 37 with central AI and 137 adrenal sufficient (AS), were included. MAIN OUTCOME MEASURE The diagnostic accuracy (sensitivity (SE), specificity (SP)) of serum and salivary F levels measured, respectively, by chemiluminescence immunoassay and liquid chromatography-tandem mass spectrometry. RESULTS Low basal serum or salivary F levels could predict AI. For the LDSST, the best ROC-calculated threshold for serum F to differentiate AI from AS was 427 nmol/L (SE 79%, SP 89%), serum F > 500 nmol/L reached SP 100%. A salivary F peak > 12.1 nmol/L after administering synacthen reached SE 95% and SP 84% for diagnosing central AI, indicating a conclusive reduction in the likelihood of AI. This ROC-calculated threshold for salivary F was similar to the 2.5th percentile of patients with a normal HPA axis, so it was considered sufficient to exclude AI. Considering AS those patients with salivary F > 12.1 nmol/L after LDSST, we could avoid unnecessary glucocorticoid treatment: 99/150 subjects (66%) had an inadequate serum F peak after synacthen, but salivary F was >12.1 nmol/L in 79 cases, who could, therefore, be considered AS. CONCLUSIONS Salivary F levels > 12.1 nmol/L after synacthen administration can indicate an intact HPA axis in patients with an incomplete serum F response, avoiding the need to start glucocorticoid replacement treatment.
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Affiliation(s)
- Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Neuroscience DNS, University of Padova, Padova, Italy
- Correspondence should be addressed to F Ceccato:
| | - Elisa Selmin
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Giorgia Antonelli
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Laboratory Medicine, University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Neuroscience DNS, University of Padova, Padova, Italy
| | - Andrea Daniele
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Marco Boscaro
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Mario Plebani
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Laboratory Medicine, University-Hospital of Padova, Padova, Italy
| | - Carla Scaroni
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
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10
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Clarke SA, Phylactou M, Patel B, Mills EG, Muzi B, Izzi-Engbeaya C, Choudhury S, Khoo B, Meeran K, Comninos AN, Abbara A, Tan T, Dhillo WS. Normal Adrenal and Thyroid Function in Patients Who Survive COVID-19 Infection. J Clin Endocrinol Metab 2021; 106:2208-2220. [PMID: 34008009 PMCID: PMC8194556 DOI: 10.1210/clinem/dgab349] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Indexed: 12/15/2022]
Abstract
CONTEXT The COVID-19 pandemic continues to exert an immense burden on global health services. Moreover, up to 63% of patients experience persistent symptoms, including fatigue, after acute illness. Endocrine systems are vulnerable to the effects of COVID-19 as many glands express the ACE2 receptor, used by the SARS-CoV-2 virion for cellular access. However, the effects of COVID-19 on adrenal and thyroid gland function after acute COVID-19 remain unknown. OBJECTIVE Our objectives were to evaluate adrenal and thyroid gland function in COVID-19 survivors. METHODS A prospective, observational study was undertaken at the Clinical Research Facility, Imperial College NHS Healthcare Trust, including 70 patients ≥18 years of age, at least 3 months after diagnosis of COVID-19. Participants attended a research study visit (8:00-9:30 am), during which a short Synacthen test (250 µg IV bolus) and thyroid function assessments were performed. RESULTS All patients had a peak cortisol ≥450 nmol/L after Synacthen, consistent with adequate adrenal reserve. Basal and peak serum cortisol did not differ according to disease severity or history of dexamethasone treatment during COVID-19. There was no difference in baseline or peak cortisol after Synacthen or in thyroid function tests, or thyroid status, in patients with fatigue (n = 44) compared to those without (n = 26). CONCLUSION Adrenal and thyroid function ≥3 months after presentation with COVID-19 was preserved. While a significant proportion of patients experienced persistent fatigue, their symptoms were not accounted for by alterations in adrenal or thyroid function. These findings have important implications for the clinical care of patients after COVID-19.
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Affiliation(s)
- Sophie A Clarke
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 0NN, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, W6 8RF, UK
| | - Maria Phylactou
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 0NN, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, W6 8RF, UK
| | - Bijal Patel
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 0NN, UK
| | - Edouard G Mills
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 0NN, UK
| | - Beatrice Muzi
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 0NN, UK
| | - Chioma Izzi-Engbeaya
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 0NN, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, W6 8RF, UK
| | - Sirazum Choudhury
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 0NN, UK
- Department of Clinical Biochemistry, Imperial College Healthcare NHS Trust, London, W6 8RF, UK
| | - Bernard Khoo
- Department of Endocrinology, Division of Medicine, Faculty of Medical Sciences, Royal Free Campus, University College London, London, NW3 2QG, UK
| | - Karim Meeran
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 0NN, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, W6 8RF, UK
| | - Alexander N Comninos
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 0NN, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, W6 8RF, UK
| | - Ali Abbara
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 0NN, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, W6 8RF, UK
| | - Tricia Tan
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 0NN, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, W6 8RF, UK
| | - Waljit S Dhillo
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 0NN, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, W6 8RF, UK
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11
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Kanthagnany SK, Lane LC, Wood C, Sachdev P, Drake AJ, Cheetham T. Fifteen-minute consultation: An approach to the child receiving glucocorticoids. Arch Dis Child Educ Pract Ed 2021; 106:130-135. [PMID: 32769084 DOI: 10.1136/archdischild-2019-317812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 05/04/2020] [Accepted: 06/30/2020] [Indexed: 11/03/2022]
Abstract
Glucocorticoids (GC) are used in paediatric practice for a broad range of conditions and all paediatricians will prescribe GC, in some form, during their career. A wide variety of GC formulations, doses and administration routes are used for periods of time ranging from days to years. Exposure to exogenous GC can result in hypothalamic-pituitary-adrenal axis suppression-otherwise known as adrenal suppression (AS). Patients with AS may be well most of the time but if GC therapy is reduced or stopped or if additional endogenous GC cannot be generated during illness, then an absolute or relative lack of GC can result in severe illness or death. Here, we highlight the relevance of AS to all paediatricians by providing an overview of the background and discussing the presentation and approaches to the management of this clinical entity.
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Affiliation(s)
| | - Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Claire Wood
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Pooja Sachdev
- Paediatrics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Amanda Jane Drake
- University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Timothy Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK .,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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12
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Glucocorticoid Withdrawal-An Overview on When and How to Diagnose Adrenal Insufficiency in Clinical Practice. Diagnostics (Basel) 2021; 11:diagnostics11040728. [PMID: 33923971 PMCID: PMC8072923 DOI: 10.3390/diagnostics11040728] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 11/16/2022] Open
Abstract
Glucocorticoids (GCs) are widely used due to their anti-inflammatory and immunosuppressive effects. As many as 1-3% of the population are currently on GC treatment. Prolonged therapy with GCs is associated with an increased risk of GC-induced adrenal insufficiency (AI). AI is a rare and often underdiagnosed clinical condition characterized by deficient GC production by the adrenal cortex. AI can be life-threatening; therefore, it is essential to know how to diagnose and treat this disorder. Not only oral but also inhalation, topical, nasal, intra-articular and intravenous administration of GCs may lead to adrenal suppression. Moreover, recent studies have proven that short-term (<4 weeks), as well as low-dose (<5 mg prednisone equivalent per day) GC treatment can also suppress the hypothalamic-pituitary-adrenal axis. Chronic therapy with GCs is the most common cause of AI. GC-induced AI remains challenging for clinicians in everyday patient care. Properly conducted GC withdrawal is crucial in preventing GC-induced AI; however, adrenal suppression may occur despite following recommended GC tapering regimens. A suspicion of GC-induced AI requires careful diagnostic workup and prompt introduction of a GC replacement treatment. The present review provides a summary of current knowledge on the management of GC-induced AI, including diagnostic methods, treatment schedules, and GC withdrawal regimens in adults.
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13
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A Predictive Risk Score to Diagnose Adrenal Insufficiency in Outpatients: A 7 Year Retrospective Cohort Study. MEDICINES 2021; 8:medicines8030013. [PMID: 33801854 PMCID: PMC7998205 DOI: 10.3390/medicines8030013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 11/29/2022]
Abstract
Background: The diagnosis of adrenal insufficiency (AI) requires dynamic tests which may not be available in some institutions. This study aimed to develop a predictive risk score to help diagnose AI in outpatients with indeterminate serum cortisol levels. Methods: Five hundred and seven patients with intermediate serum cortisol levels (3–17.9 µg/dL) who had undergone ACTH (adrenocorticotropin) stimulation tests were included in the study. A predictive risk score was created using significant predictive factors identified by multivariable analysis using Poisson regression clustered by ACTH dose. Results: The seven predictive factors used in the development of a predictive model with their assigned scores are as follows: chronic kidney disease (9.0), Cushingoid appearance in exogenous steroid use (12.0), nausea and/or vomiting (6.0), fatigue (2.0), basal cortisol <9 µg/dL (12.5), cholesterol <150 mg/dL (2.5) and sodium <135 mEq/L (1.0). Predictive risk scores range from 0–50.0. A high risk level (scores of 19.5–50.0) indicates a higher possibility of having AI (positive likelihood ratio (LR+) = 11.75), while a low risk level (scores of <19.0) indicates a lower chance of having AI (LR+ = 0.09). The predictive performance of the scoring system was 0.82 based on the area under the curve. Conclusions: This predictive risk score can help to determine the probability of AI and can be used as a guide to determine which patients need treatment for AI and which require dynamic tests to confirm AI.
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14
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Kumar R, Carr P, Wassif W. Diagnostic performance of morning serum cortisol as an alternative to short synacthen test for the assessment of adrenal reserve; a retrospective study. Postgrad Med J 2020; 98:113-118. [PMID: 33122342 DOI: 10.1136/postgradmedj-2020-138514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/30/2020] [Accepted: 10/11/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The short synacthen test (SST) is widely used across the UK to assess adrenal reserve. The main objective of our study was to determine the morning serum cortisol level that will predict adrenal insufficiency (AI) thus reducing our reliance on SST. DESIGN This was a single centre retrospective study of 393 SST tests measuring 0 and 60 min cortisol levels after administration of 250 μg of synacthen (synthetic ACTH). PATIENTS AND METHODS All the SST tests for patients suspected of primary or secondary AI between April 2016 and October 2018 were included in this study. We used serum to determine circulating cortisol by a newer generation competitive electrochemiluminescence immunoassay (ECLIA) (Roche Diagnostics). A post-ACTH cortisol response of ≥420 nmol/L at 60 min was considered adequate to rule out AI. The data were analysed to ascertain the relationship between 0 min and 60 min serum cortisol. RESULTS A total of 393 SST results were included in this study. Overall, a total of 332 (84.5%) subjects achieved sufficient serum cortisol level at 60 min, while 61 subjects (15.5%) showed insufficient response. Using the logistic regression, we determined that a morning basal serum cortisol level of ≥354 nmol/L was able to predict normal adrenal function with 100% sensitivity. We were unable to find a lower cut-off value below which SST will not be required. By using this proposed cut-off point, approximately 37% of the SSTs tests could be avoided. CONCLUSIONS Basal morning serum cortisol can be safely used as a first step in the evaluation of patients with suspected AI. This will enhance the number of patients being screened for this condition.
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Affiliation(s)
- Rajeev Kumar
- Diabetes and Endocrinology, Bedford Hospital NHS Trust, Bedford, UK
| | - Peter Carr
- Statistical Analyst, The Alan Turing Institute, London, UK
| | - Ws Wassif
- Clinical Biochemistry, Bedford Hospital NHS Trust, Bedford, UK
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15
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Elder CJ, Vilela R, Johnson TN, Taylor RN, Kemp EH, Keevil BG, Cross AS, Ross RJ, Wright NP. Pharmacodynamic studies of nasal tetracosactide with salivary glucocorticoids for a noninvasive Short Synacthen Test. J Clin Endocrinol Metab 2020; 105:5850507. [PMID: 32593173 DOI: 10.1210/clinem/dgaa323] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/27/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT The Short Synacthen Test (SST) is the gold standard for diagnosing adrenal insufficiency. It requires invasive administration of Synacthen, venous sampling, and is resource-intensive. OBJECTIVE To develop a nasally administered SST, with salivary glucocorticoids measurement, to assess the adrenal response. DESIGN We conducted 5 studies: 4 open-label, sequence-randomized, crossover, pharmacodynamic studies testing 6 doses/formulations and a repeatability study. Additionally, pharmacokinetic analysis was undertaken using our chosen formulation, 500 µg tetracosactide with mucoadhesive chitosan, Nasacthin003, in our pediatric study. SETTING Adult and children's clinical research facilities. PARTICIPANTS A total of 36 healthy adult males and 24 healthy children. INTERVENTION We administered all 6 nasal formulations using an European regulator endorsed atomization device. The IV comparators were 250 µg or 1 µg SST. MAIN OUTCOME MEASURES We analyzed paired blood and saliva samples for plasma cortisol and salivary cortisol and cortisone. RESULTS The addition of chitosan to tetracosactide and dose escalation increased peak cortisol response (P = 0.01 and 0.001, respectively). The bioavailability of Nasacthin003 was 14.3%. There was no significant difference in plasma cortisol at 60 minutes between 500 µg Nasacthin003 and 250 µg IV Synacthen (P = 0.17). The repeatability coefficient at 60 minutes was 105 nmol/L for IV Synacthen and salivary cortisol and cortisone was 10.3 and 21.1 nmol/L, respectively. The glucocorticoid response in children was indistinguishable from that of adults. CONCLUSIONS Nasal administration of Nasacthin003 generates equivalent plasma cortisol values to the 250-µg IV SST and, with measurement at 60 minutes of salivary cortisol or cortisone, provides a noninvasive test for adrenal insufficiency.
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Affiliation(s)
- Charlotte J Elder
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, United Kingdom
- Department of Endocrinology, Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Ruben Vilela
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, United Kingdom
| | | | - Rosie N Taylor
- Statistical Services Unit, The University of Sheffield, Sheffield, United Kingdom
| | - E Helen Kemp
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, United Kingdom
| | - Brian G Keevil
- Department of Clinical Biology, Manchester University NHS Trust, Manchester, United Kingdom
| | - Alexandra S Cross
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, United Kingdom
| | - Richard J Ross
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, United Kingdom
| | - Neil P Wright
- Department of Endocrinology, Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
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16
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Hindmarsh PC, Honour JW. Letter to the Editor: "Evaluating the Low-Dose ACTH Stimulation Test in Children: Ideal Times for Cortisol Measurement". J Clin Endocrinol Metab 2020; 105:5698173. [PMID: 31912152 DOI: 10.1210/clinem/dgaa009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 01/06/2020] [Indexed: 02/13/2023]
Affiliation(s)
| | - John W Honour
- Institute for Women's Health, University College, London, London, UK
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17
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Poggi M, Samperi I, Mattia L, Di Rocco A, Iorio C, Monti S, Pugliese G, Toscano V. New Insights and Methods in the Approach to Thalassemia Major: The Lesson From the Case of Adrenal Insufficiency. Front Mol Biosci 2020; 6:162. [PMID: 32064267 PMCID: PMC7000370 DOI: 10.3389/fmolb.2019.00162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/23/2019] [Indexed: 11/25/2022] Open
Abstract
Background: Thalassemia Major (TM) is a complex pathology that needs a highly skilled approach. Endocrine comorbidities are nowadays the most important complications, including hypogonadism, hypothyroidism, diabetes mellitus, and bone diseases. Recent works stated that there could be a relevant prevalence of adrenal insufficiency (AI) present in TM, and this fact may become crucial, especially in case of major stressful events. Aim: Test the reliability of the standard test to diagnose AI in a group of TM and correlate it with clinical, hematological, and radiological data. Methods: We evaluated endocrine damages and the efficacy of iron chelation therapy in 102 patients affected by TM. AI was assessed by tetracosactide (Synacthen) 1 mcg iv (low-dose test, LDT) stimulation test. Patients with a subnormal response (peak cortisol < 500 nmol/L) were followed up to 5 years to check the symptoms and signs of AI. Results: We found AI in 13.7% of the population studied. We did not find any correlation between AI and all data evaluated. Only female gender seems to be a protective factor. A follow up of the patients affected by AI showed no signs of adrenal crisis, in spite of no replacement therapy. Conclusions: Our study shows a relevant prevalence of AI in TM, especially in males. The absence of an adrenal crisis, in spite of no replacement therapy, during the long-term follow up, seems to underline that current methods to evaluate AI, in TM, should consider a different and specific diagnostic test or different cut off for diagnosis.
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Affiliation(s)
- Maurizio Poggi
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Rome, Italy.,Endocrine-Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Irene Samperi
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Rome, Italy.,Endocrine-Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Lorenza Mattia
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Rome, Italy.,Endocrine-Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Arianna Di Rocco
- Department of Public Health and Infectious Disease, "Sapienza" University of Rome, Rome, Italy
| | - Cristina Iorio
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Rome, Italy.,Endocrine-Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Salvatore Monti
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Rome, Italy.,Endocrine-Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Rome, Italy.,Endocrine-Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Vincenzo Toscano
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Rome, Italy.,Endocrine-Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy
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18
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Kumar R, Carr P, Moore K, Rajput Z, Ward L, Wassif WS. Do we need 30 min cortisol measurement in the short synacthen test: a retrospective study. Postgrad Med J 2019; 96:467-472. [PMID: 31810992 DOI: 10.1136/postgradmedj-2019-137125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/31/2019] [Accepted: 11/10/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The short synacthen test (SST) is widely used across the UK to assess adrenal reserve but there remains no consensus on the timing of cortisol sampling to help diagnose adrenal insufficiency. The main objective of our study was to see if both 30 and 60 min sample are required following administration of synacthen to investigate suspected adrenal insufficiency (AI). DESIGN This was a single-centre retrospective study of 393 SSTs measuring 0, 30 and 60 min cortisol levels after administration of 250 µg of synacthen. PATIENTS AND METHODS All the SSTs for patients suspected of primary or secondary AI between April 2016 and October 2018 were included in this study. The tests were performed as per our hospital protocol. A post-adrenocorticotropic hormone (ACTH) cortisol response of 420 nmol/L at any time point was considered adequate to rule out AI. The data were analysed to ascertain the proportion of patients who achieved this level at 30 and/or 60 min. RESULTS A total of 393 SST results were included in this study. Patients were divided into two groups depending on whether (group A) or not (group B) they were on steroids. Overall, a total of 313 (79.6%) subjects achieved cortisol level of ≥420 nmol/L at 30 and 60 min while 19 (4.8%) had late response (ie, insufficient 30 min cortisol levels, rising to ≥420 nmol/L at 60 min). Another 61 subjects (15.5%) showed insufficient response at both 30 and 60 min (ie, failed to achieved level of ≥420 nmol/L). Importantly, there was no patient in either group who had adequate response at 30 min and then failed at 60 min. Patients in group A were more likely to have inadequate response at both 30 and 60 min while patients in group B were more likely to have normal response at both time points. CONCLUSIONS Our results suggest that about 5% of people undergoing SST may be inappropriately diagnosed as having AI (and subjected to long-term unnecessary steroid treatment) if the 60 min sample is not maintained. We suggest that 30 min sample does not add any additional diagnostic utility and can be omitted thus simplifying SST even further and saving on cost and resources. We propose that single measurement after 60 min of administration of synthetic ACTH is a sufficient screening test for AI.
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Affiliation(s)
- Rajeev Kumar
- Diabetes and Endocrinology, Bedford Hospital NHS Trust, Bedford, UK
| | - Peter Carr
- Statistical Analyst, The Open University, Milton Keynes, UK
| | - Kimberley Moore
- Clinical Biochemistry, Bedford Hospital NHS Trust, Bedford, UK
| | - Zeeshan Rajput
- Department of Acute Medicine, Bedford Hospital NHS Trust, Bedford, UK
| | - Louise Ward
- Clinical Biochemistry, Bedford Hospital NHS Trust, Bedford, UK
| | - W S Wassif
- Clinical Biochemistry, Bedford Hospital NHS Trust, Bedford, UK
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19
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Dineen R, Mohamed A, Gunness A, Rakovac A, Cullen E, Barnwell N, Neary C, Behan LA, Boran G, Gibney J, Sherlock M. Outcomes of the short Synacthen test: what is the role of the 60 min sample in clinical practice? Postgrad Med J 2019; 96:67-72. [DOI: 10.1136/postgradmedj-2019-136669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/09/2019] [Accepted: 09/02/2019] [Indexed: 11/03/2022]
Abstract
In recent years, the short Synacthen test (SS) has become the most widely used test to assess adrenal reserve. Despite its frequent use, there are still several areas related to the short Synacthen test (SST), which have no consensus including the optimum sampling times, that is, whether a 60 min post-Synacthen administration cortisol is necessary or not.MethodologyWe performed a retrospective data analysis of 492 SSTs performed on adult patients in a tertiary referral teaching hospital in Ireland. The SSTs were performed in the inpatient and outpatient setting and included patients across all medical disciplines and not exclusively to the endocrinology department.Results313 patients had 0, 30 and 60 min samples available for analysis. A total of 270/313 (82%) were deemed to pass the test, that is, cortisol ≥500 nmol/L at both 30 and 60 min. Of the 313 patients, 19 (6%) patients had an indeterminate response, cortisol <500 nmol/L at 30 min, but rising to ≥500 nmol/L on the 60 min sample. Of these 19 patients, only 9/19 patients had a serum cortisol level at 30 min <450 nmol/L, requiring clinical treatment with glucocorticoid replacement. All 24/313 (8%) patients who had insufficient responses at 60 min were also insufficient at 30 min sampling. No individuals passed (≥500 nmol/L) at 30 min and then failed (<500 nmol/L) at 60 min.ConclusionUsing the 30 min cortisol sample post-Synacthen administration alone identifies clinically relevant adrenal insufficiency in the majority of cases. A small subset of patients have a suboptimal response at 30 min but have a 60 min cortisol concentration above the threshold for a pass. Data regarding the long-term outcomes and management of such patients are lacking and require further study.
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20
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Ceccato F, Scaroni C. Central adrenal insufficiency: open issues regarding diagnosis and glucocorticoid treatment. ACTA ACUST UNITED AC 2019; 57:1125-1135. [DOI: 10.1515/cclm-2018-0824] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/13/2018] [Indexed: 12/15/2022]
Abstract
Abstract
Background
Central adrenal insufficiency (CAI) is characterized by impaired adrenocorticotropin (ACTH) secretion because of a disease or injury to the hypothalamus or the pituitary, leading to a reduced cortisol production. CAI suspicion arises more frequently in patients with pituitary tumors, cranial irradiation/surgery/injury/infections, as well as after exogenous glucocorticoid withdrawal. Nevertheless, a late diagnosis is not uncommon because CAI may present with nonspecific signs or symptoms, as fatigue or hyponatremia.
Content
The PubMed database was searched (years 1980–2018), using “central adrenal insufficiency” and “ACTH deficiency” as keywords. Subsequently, reference sections of the retrieved articles were searched.
Summary
Dynamic tests are needed when morning basal cortisol levels are not sufficient to exclude or to confirm CAI. Short Synacthen Test (SST) is the most used, and Endocrine Society’s guidelines recommend a cortisol peak >500 nmol/L to exclude CAI. Despite thresholds, understanding the pretest probability of ACTH deficiency (the clinical background of the patient) is essential because the diagnostic accuracy of SST in case of a negative result is suboptimal. Glucocorticoid replacement therapy, able to replicate cortisol circadian rhythm, is required in patients with CAI; fludrocortisone treatment is not necessary. Short-acting glucocorticoid drugs (hydrocortisone or cortisone acetate) are the most used; lower doses than previously used are nowadays recommended to reduce cortisol-related comorbidities. Promising results have been obtained with modified-release hydrocortisone, especially regarding glucose metabolism in patients with primary adrenal insufficiency.
Outlook
An accurate clinical diagnosis and a careful individualized therapy are mandatory in patients with CAI.
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21
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Karangizi AHK, Al-Shaghana M, Logan S, Criseno S, Webster R, Boelaert K, Hewins P, Harper L. Glucocorticoid induced adrenal insufficiency is common in steroid treated glomerular diseases - proposed strategy for screening and management. BMC Nephrol 2019; 20:154. [PMID: 31060510 PMCID: PMC6503364 DOI: 10.1186/s12882-019-1354-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 04/24/2019] [Indexed: 11/20/2022] Open
Abstract
Background Glucocorticoids (GCs) are frequently used to treat glomerular diseases but are associated with multiple adverse effects including hypothalamic-pituitary-adrenal axis inhibition that can lead to adrenal insufficiency (AI) on withdrawal. There is no agreed GC tapering strategy to minimise this risk. Methods This is a single centre retrospective study, between 2013 to 2016, of patients with glomerular disease on GC therapy for more than 3 months screened for GC induced AI with short synacthen stimulation tests (SSTs) done prior to complete GC withdrawal. We investigated the prevalence of AI, predictors, choice of screening tool and recovery. Results Biochemical evidence of GC induced AI was found in 57 (46.3%) patients. Total duration of GC did not differ between those with and without AI (p = 0.711). Patients with GC induced AI had a significantly lower pre-synacthen baseline cortisol as compared to patients without AI. A cut off pre-synacthen baseline cortisol of ≥223.5 nmol/l had a specificity of 100% for identifying individuals without biochemical AI. Patients with GC induced AI took a mean of 8.7 ± 4.6 months (mean ± SD) to recover. Patients with persistent AI had a significantly lower index post-synacthen cortisol measurement. Conclusions We demonstrate that biochemically proven GC induced AI is common in patients with glomerular diseases, is not predicted by daily dose or duration and takes a considerable time to recover. The study supports the use of morning basal cortisol testing as an appropriate means to avoid the need for SSTs in all patients and should be performed in all patients prior to consideration of GC withdrawal after 3 months duration.
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Affiliation(s)
- Alvin H K Karangizi
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, B15 2TH, UK
| | - May Al-Shaghana
- Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, B15 2TH, UK
| | - Sarah Logan
- Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, B15 2TH, UK
| | - Sherwin Criseno
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, B15 2TH, UK
| | - Rachel Webster
- Department of Biochemistry, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, B15 2TH, UK
| | - Kristien Boelaert
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, B15 2TH, UK.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Peter Hewins
- Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, B15 2TH, UK
| | - Lorraine Harper
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK. .,Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, B15 2TH, UK.
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Sklar CA, Antal Z, Chemaitilly W, Cohen LE, Follin C, Meacham LR, Murad MH. Hypothalamic-Pituitary and Growth Disorders in Survivors of Childhood Cancer: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:2761-2784. [PMID: 29982476 DOI: 10.1210/jc.2018-01175] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To formulate clinical practice guidelines for the endocrine treatment of hypothalamic-pituitary and growth disorders in survivors of childhood cancer. PARTICIPANTS An Endocrine Society-appointed guideline writing committee of six medical experts and a methodologist. CONCLUSIONS Due to remarkable improvements in childhood cancer treatment and supportive care during the past several decades, 5-year survival rates for childhood cancer currently are >80%. However, by virtue of their disease and its treatments, childhood cancer survivors are at increased risk for a wide range of serious health conditions, including disorders of the endocrine system. Recent data indicate that 40% to 50% of survivors will develop an endocrine disorder during their lifetime. Risk factors for endocrine complications include both host (e.g., age, sex) and treatment factors (e.g., radiation). Radiation exposure to key endocrine organs (e.g., hypothalamus, pituitary, thyroid, and gonads) places cancer survivors at the highest risk of developing an endocrine abnormality over time; these endocrinopathies can develop decades following cancer treatment, underscoring the importance of lifelong surveillance. The following guideline addresses the diagnosis and treatment of hypothalamic-pituitary and growth disorders commonly encountered in childhood cancer survivors.
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Affiliation(s)
| | - Zoltan Antal
- Memorial Sloan-Kettering Cancer Center, New York, New York
- Weill Cornell Medicine and New York Presbyterian Hospital, New York, New York
| | | | | | | | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota
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