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Bäcklund N, Lundstedt S, Tornevi A, Wihlbäck AC, Olsson T, Dahlqvist P, Brattsand G. Salivary Cortisol and Cortisone Can Circumvent Confounding Effects of Oral Contraceptives in the Short Synacthen Test. J Clin Endocrinol Metab 2024; 109:1899-1906. [PMID: 38173358 PMCID: PMC11180507 DOI: 10.1210/clinem/dgad763] [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: 09/06/2023] [Revised: 12/06/2023] [Accepted: 12/27/2023] [Indexed: 01/05/2024]
Abstract
CONTEXT Adrenal insufficiency (AI) is usually diagnosed by low plasma cortisol levels following a short Synacthen test (SST). Most plasma cortisol is bound to corticosteroid-binding globulin, which is increased by estrogen in combined estrogen-progestin oral contraceptives (COCs). Women with AI using COCs are therefore at risk of having an apparently normal plasma cortisol level during SST, which would not adequately reflect AI. OBJECTIVE This work aimed to test whether salivary cortisol or cortisone during SST is more robust against the COC effect and to calculate the lower reference limits (LRLs) for these to be used as tentative diagnostic cutoffs to exclude AI. METHODS Forty-one healthy women on COCs and 46 healthy women without exogenous estrogens underwent an SST with collection of plasma and salivary samples at 0, 30, and 60 minutes after Synacthen injection. The groups were compared using regression analysis with age as covariate and the LRLs were calculated parametrically. RESULTS SST-stimulated plasma cortisol levels were significantly higher in the COC group vs controls, while mean salivary cortisol and cortisone levels were slightly lower in the COC group. Importantly, COC use did not significantly alter LRLs for salivary cortisol or cortisone. The smallest LRL difference between groups was seen for salivary cortisone. CONCLUSION Salivary cortisol and especially salivary cortisone are considerably less affected by COC use than plasma cortisol during SST. Due to similar LRLs, a common cutoff for salivary cortisol and cortisone during SST can be used to exclude AI in premenopausal women irrespective of COC use.
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Affiliation(s)
- Nils Bäcklund
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Staffan Lundstedt
- Department of Medical Biosciences, Division of Clinical Chemistry, Umeå University, 901 87 Umeå, Sweden
| | - Andreas Tornevi
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Anna-Carin Wihlbäck
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87 Umeå, Sweden
| | - Tommy Olsson
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Göran Brattsand
- Department of Medical Biosciences, Division of Clinical Chemistry, Umeå University, 901 87 Umeå, Sweden
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2
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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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3
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Page‐Wilson G, Oak B, Silber A, Okeyo JC, Ortiz N, O'Hara M, Moloney S, Geer EB. Holistic burden of illness in patients with endogenous Cushing's syndrome: A systematic literature review. Endocrinol Diabetes Metab 2024; 7:e464. [PMID: 38124436 PMCID: PMC10782070 DOI: 10.1002/edm2.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE The objective of this systematic literature review (SLR) was to summarize the latest studies evaluating the burden of illness in endogenous Cushing's syndrome (CS), including the impact of CS on overall and domain-specific health-related quality of life (HRQoL) and the economic burden of CS to provide a holistic understanding of disease and treatment burden. METHODS An SLR was conducted in PubMed, MEDLINE and Embase using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist to identify peer-reviewed manuscripts and conference abstracts published in English from 2015 to December 4, 2020. RESULTS Forty-five publications were eligible for inclusion; data were extracted from 37 primary studies while 8 SLRs were included for reference only. Thirty-one studies reported HRQoL using validated patient reported outcome (PRO) measures in pre- or post-surgery, radiotherapy and pharmacotherapy patients. Overall, this SLR found that patients with CS have worse outcomes relative to healthy populations across specific dimensions, such as depression, despite an improvement in HRQoL post-treatment. These findings reveal that CS symptoms are not fully resolved by the existing care paradigm. Few studies report on the economic burden of CS and currently available data indicate a high direct healthcare system cost burden. CONCLUSIONS Patients with CS experience a significant, complex and multifactorial HRQoL burden. Symptom-specific burden studies are sparse in the literature and the understanding of long-term CS symptomatic burden and economic burden is limited. This review intends to provide an updated reference for clinicians, payers and other stakeholders on the burden of CS as reported in published literature and to encourage further research in this area.
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Affiliation(s)
- Gabrielle Page‐Wilson
- Division of EndocrinologyColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | | | | | - Janetricks C. Okeyo
- Formerly at Strongbridge Biopharma plc, a wholly owned subsidiary of Xeris Biopharma Holdings, Inc.TrevosePennsylvaniaUSA
| | - Nancy Ortiz
- Formerly at Strongbridge Biopharma plc, a wholly owned subsidiary of Xeris Biopharma Holdings, Inc.TrevosePennsylvaniaUSA
| | | | - Stephen Moloney
- Formerly at Strongbridge Biopharma plc, a wholly owned subsidiary of Xeris Biopharma Holdings, Inc.TrevosePennsylvaniaUSA
| | - Eliza B. Geer
- Multidisciplinary Pituitary and Skull Base Tumor CenterMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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Karoonkatima M, Narongroeknawin P, Chaiamnuay S, Asavatanabodee P, Pakchotanon R. Glucocorticoid Withdrawal Symptoms and Quality of Life in Patients with Systemic Lupus Erythematosus. Int J Rheumatol 2023; 2023:5750791. [PMID: 38023806 PMCID: PMC10656199 DOI: 10.1155/2023/5750791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/26/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Methods SLE patients whose prednisolone had been previously withdrawn or taken <5 mg/day were enrolled. Serum morning cortisol levels were collected after 72-hour GCS discontinuation, and low-dose ACTH stimulation test (LDST) was performed. Patient report outcomes (PROs) included SLE-specific quality of life questionnaire (SLEQoL), functional assessment of chronic illness therapy (FACIT), patient health questionnaire (PHQ-9), and Pittsburgh's sleep quality index (PSQI). Results Serum morning cortisol of 100 SLE patients was tested. Most patients were female (88%). Seventy-four patients showed remission. The mean ± SD of prednisolone was 0.73 ± 1.08 mg/day. Total SLEQoL and FACIT (mean ± SD) of all patients were 67.05 ± 26.15 and 13.7 ± 8.87, respectively. Eighteen percent of patients had moderate-severe depressive symptoms, and 49% were poor sleepers. Adrenal function was determined by LDST in only 39 patients; 5 patients (12.8%) were adrenal insufficiency (AI), and 34 patients were normal adrenal function. Compared to normal adrenal function patients, SLE patients with AI had higher proportion of moderate-severe depressive symptom (PHQ - 9 > 9), but not statistically significant (40% vs. 20.6%, p = 0.34). PROs were comparable between groups. Independent factors associated with SLEQoL were FACIT (adjusted β 1.31, 95% CI 0.76, 1.86, p < 0.001), PHQ-9 (adjusted β 5.21, 95% CI 4.32, 6.09, p < 0.001), and PSQI (adjusted β 4.23, 95% CI 3.01, 5.45, p < 0.001), but not with AI (adjusted β -5.2, 95% CI -33.26, 22.93, 0.71, p = 0.71). Conclusion SLE patients with previous GCS exposure could experience AI and withdrawal symptoms such as sleep disturbance and depression during discontinuation of low-dose GCS. Fatigue, depression, and poor sleeper were significantly associated with poor SLEQoL.
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Affiliation(s)
- Matee Karoonkatima
- Rheumatic Disease Unit, Department of Internal Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Pongthorn Narongroeknawin
- Rheumatic Disease Unit, Department of Internal Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Sumapa Chaiamnuay
- Rheumatic Disease Unit, Department of Internal Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Paijit Asavatanabodee
- Rheumatic Disease Unit, Department of Internal Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Rattapol Pakchotanon
- Rheumatic Disease Unit, Department of Internal Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
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5
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Page-Wilson G, Oak B, Silber A, Okeyo J, Ortiz N, O'Hara M, Moloney S, Geer EB. Evaluating the burden of endogenous Cushing's syndrome using a web-based questionnaire and validated patient-reported outcome measures. Pituitary 2023; 26:364-374. [PMID: 37074630 PMCID: PMC10113723 DOI: 10.1007/s11102-023-01314-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION Endogenous Cushing's syndrome (CS) is a rare endocrine condition caused by chronic oversecretion of cortisol, resulting in a diverse constellation of symptoms. This study examined the ongoing burden of illness (BOI), from the first appearance of symptoms through treatment, which is currently not well evaluated. METHODS A quantitative, cross-sectional, web-enabled survey including 5 validated patient reported outcomes (PRO) measures was conducted in patients with CS who had been diagnosed ≥ 6 months prior and who had received ≥ 1 treatment for their endogenous CS at the time of the survey. RESULTS Fifty-five patients participated in this study; 85% were women. The mean age was 43.4 ± 12.3 years (± standard deviation, SD). On average, respondents reported a 10-year gap between the first occurrence of symptoms and diagnosis; 80% underwent surgical treatment for CS. Respondents experienced symptoms on 16 days in a typical month, and their health-related quality of life was moderately impacted based on the CushingQoL score. Weight gain, muscle fatigue, and weakness were the most common symptoms and 69% percent of patients reported moderate or severe fatigue using the Brief Fatigue Inventory. Following treatment, the occurrence of most symptoms declined over time, although anxiety and pain did not significantly decrease. Overall, 38% of participants reported an annual average of 25 missed workdays due to CS symptoms. CONCLUSIONS These results demonstrate a BOI in CS despite ongoing treatment and illustrate the need for interventions to address persistent symptoms, particularly weight gain, pain, and anxiety.
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Affiliation(s)
| | | | | | - Janetricks Okeyo
- Formerly at Strongbridge Biopharma plc, a wholly owned subsidiary of Xeris Biopharma Holdings, Inc, Trevose, USA
| | - Nancy Ortiz
- Formerly at Strongbridge Biopharma plc, a wholly owned subsidiary of Xeris Biopharma Holdings, Inc, Trevose, USA
| | | | - Stephen Moloney
- Formerly at Strongbridge Biopharma plc, a wholly owned subsidiary of Xeris Biopharma Holdings, Inc, Trevose, USA
| | - Eliza B Geer
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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6
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Li D. Quality of Life in Patients with Adrenal Insufficiency. Endocrinol Metab Clin North Am 2022; 51:741-753. [PMID: 36244690 DOI: 10.1016/j.ecl.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients with adrenal insufficiency, despite standard glucocorticoid replacement therapy, continue to experience and report impaired self-perceived health status and quality of life. In this review, we will describe quality of life in this patient population, and summarize the determinants of quality of life, based on previous survey-based studies and clinical trials. In addition, some new emerging data during the still ongoing coronavirus disease pandemic are also reviewed in the present article.
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Affiliation(s)
- Dingfeng Li
- Department of Endocrinology, Endocrine and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, F20, Cleveland, OH 44195, USA.
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7
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Yeoh P, Czuber‐Dochan W, Aylwin S, Sturt J. Lived experience of people with adrenocortical carcinoma and associated adrenal insufficiency. Endocrinol Diabetes Metab 2022; 5:e341. [PMID: 35670031 PMCID: PMC9258998 DOI: 10.1002/edm2.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/14/2022] [Accepted: 04/18/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Adrenocortical carcinoma (ACC) is a rare cancer with an annual incidence of 0.7–2 cases per million population and 5‐year survival of 31.2%. Adrenal insufficiency (AI) is a common and life shortening complication of ACC, and little is understood about how it impacts on patients' experience. Objective To understand patients' lived experience of the condition, its treatment, care process, impact of AI on ACC wellbeing, self‐care needs and support. Methods Systematic review of MEDLINE, EMBASES, CINAHL, PsycINFO and Open Grey for studies published until February 2021. All research designs were included. The findings underwent a thematic analysis and narrative synthesis. Studies quality was assessed using mixed method assessment tools. Results A total of 2837 citations were identified; 15 titles with cohort, cross‐sectional, case series and case report study designs met the inclusion criteria involving 479 participants with adrenal insufficiency secondary to adrenocortical carcinoma (AI/ACC). Quantitative research identified impacts of disease and treatment on survivorship, the burden of living with AI/ACC, toxicity of therapies, supporting self‐care and AI management. These impact factors included adjuvant therapies involved and their toxicities, caregivers/family supports, healthcare and structure support in place, specialist skill and knowledge provided by healthcare professional on ACC management. No qualitative patient experiences evidence was identified. Conclusion ACC appears to have high impact on patients' wellbeing including the challenges with self‐care and managing AI. Evidence is needed to understand patient experience from a qualitative perspective.
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Affiliation(s)
- Phillip Yeoh
- Florence Nightingale Faculty of Nursing Midwifery & Palliative Care. King's College London London UK
- Department of Endocrinology & Diabetes The London Clinic London UK
| | - Wladyslawa Czuber‐Dochan
- Florence Nightingale Faculty of Nursing Midwifery & Palliative Care. King's College London London UK
| | - Simon Aylwin
- Department of Endocrinology King's College Hospital London UK
| | - Jackie Sturt
- Florence Nightingale Faculty of Nursing Midwifery & Palliative Care. King's College London London UK
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8
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Abstract
Addison's disease typically results from the autoimmune destruction of the adrenal cortex and requires lifelong replacement with glucocorticoids and mineralocorticoids. Main symptoms are non-specific and, therefore, often overlooked or misleading. Patients are frequently not diagnosed until experiencing a life-threatening adrenal crisis. This article highlights the essential clinical characteristics, diagnostic aspects and principles of management of adrenal insufficiency.
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9
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Transsphenoidal pituitary adenoma resection: do early post-operative cortisol levels predict permanent long-term hypocortisolism? Neurosurg Rev 2021; 45:1353-1362. [PMID: 34545507 PMCID: PMC8976765 DOI: 10.1007/s10143-021-01643-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 11/08/2022]
Abstract
Transsphenoidal surgery provides a minimal invasive treatment for pituitary adenoma. Our aim is to evaluate the endocrinological outcomes after adenoma resection focusing on the corticotroph function, and to identify prognostic factors for an impaired hypothalamic–pituitary–adrenal-axis function (HPA) and the reliability of postoperative early morning serum cortisol measurements. We performed a retrospective analysis of all patients treated for pituitary adenoma from April 2006 to January 2019 in our neurosurgical department. Pituitary function was assessed pre- and postoperatively as well as at 6 weeks to 12 weeks and at 1-year follow-up. Two hundred eleven patients were included. Nine percent of the patients recovered from a preoperative adrenal insufficiency, 10.4% developed a new need for hormone substitution, and a long-term deficiency of the hypothalamic–pituitary–adrenal-axis was observed in 30.9%. Cortisol measurements 5 days after surgery had a lower area under the curve (AUC) than cortisol levels detected after 6 to 12 weeks (AUC 0.740 vs. AUC 0.808) in predicting an intact corticotrope function. The cut-off value determined for cortisol measured after 6 weeks was 6.95 µg/dl (sensitivity of 94%, specificity of 68%). Postoperative early morning cortisol levels seem to be less sensitive and specific in predicting long-term corticotroph function than measurements after 6 weeks and 1 year, emphasizing the importance of endocrine follow-up testing.
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10
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Abstract
Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that target two key signalling pathways related to T cell activation and exhaustion, by binding to and inhibiting cytotoxic T lymphocyte antigen 4 (CTLA4) or PD1 and its ligand PDL1. ICIs, such as nivolumab, pembrolizumab and ipilimumab, are approved for the treatment of numerous and diverse cancer types, in various combination regimens, and are now an established cornerstone of cancer therapeutics. Toxicities induced by ICIs are autoimmune in nature and are referred to as immune-related adverse events (irAEs); these events can affect any organ system in an unpredictable fashion. Importantly, irAEs can manifest as endocrinopathies involving the thyroid (hypothyroidism or thyrotoxicosis), pituitary (hypophysitis), adrenal glands (adrenal insufficiency) and pancreas (diabetes mellitus). These events are a frequent source of acute and persistent morbidity in patients treated with ICIs and can even be fatal. Over the past few years, there has been a growing understanding of the underlying pathogenesis of irAEs that has led to the development of more effective management strategies. Herein, we review the current understanding of the pathobiology, clinical manifestations and treatment approaches to endocrine toxicities arising from ICIs.
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Affiliation(s)
- Jordan J Wright
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
| | - Alvin C Powers
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN, USA
- VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA.
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11
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Zamponi V, Lardo P, Maggio R, Simonini C, Mazzilli R, Faggiano A, Pugliese G, Stigliano A. Female Sexual Dysfunction in Primary Adrenal Insufficiency. J Clin Med 2021; 10:jcm10132767. [PMID: 34202462 PMCID: PMC8268403 DOI: 10.3390/jcm10132767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose. No data are currently available on female sexual dysfunction (FSD) in primary adrenal insufficiency (PAI) and the possible impact of replacement therapy. The aim of this study was to evaluate the prevalence of FSD and sexual distress (SD), and to evaluate the possible impact of replacement therapy on sexuality in women with PAI. Methods. Female Sexual Function Index-6 (FSFI-6) and Sexual Distress Scale (SDS) questionnaires were administered to 22 women with PAI and 23 healthy women matched for age as controls. Results. The prevalence of sexual symptoms measured by FSFI-6 (total score < 19) was significantly higher in women with PAI (15/22; 68.2%) compared to the controls (2/23; 8.7%; p = 0.001). Regarding the questionnaire items, significantly different scores were found for desire (p < 0.001), arousal (p = 0.0006), lubrication (p = 0.046) and overall sexual satisfaction (p < 0.0001) in women with PAI compared to the controls. The rate of FSD (FSFI < 19 with SDS >15) was 60% in patients with PAI. A significant inverse correlation was found between FSFI-6 total scores and SD (r = −0.65; p = 0.0011), while a significant direct correlation was found between FSFI-6 total scores and serum cortisol levels (r = 0.55; p = 0.035). Conclusions. A higher prevalence of FSD was found in women affected by PAI compared to healthy women. Desire seems to be the most impaired aspect of sexual function. Moreover, sexual dysfunction in this population seems to be related to sexual distress and cortisol levels.
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12
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Sævik ÅB, Wolff AB, Björnsdottir S, Simunkova K, Hynne MS, Dolan DWP, Bratland E, Knappskog PM, Methlie P, Carlsen S, Isaksson M, Bensing S, Kämpe O, Husebye ES, Løvås K, Øksnes M. Potential Transcriptional Biomarkers to Guide Glucocorticoid Replacement in Autoimmune Addison's Disease. J Endocr Soc 2021; 5:bvaa202. [PMID: 33553982 PMCID: PMC7853175 DOI: 10.1210/jendso/bvaa202] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Indexed: 12/11/2022] Open
Abstract
Background No reliable biomarkers exist to guide glucocorticoid (GC) replacement treatment in autoimmune Addison's disease (AAD), leading to overtreatment with alarming and persistent side effects or undertreatment, which could be fatal. Objective To explore changes in gene expression following different GC replacement doses as a means of identifying candidate transcriptional biomarkers to guide GC replacement in AAD. Methods Step 1: Global microarray expression analysis on RNA from whole blood before and after intravenous infusion of 100 mg hydrocortisone (HC) in 10 patients with AAD. In 3 of the most highly upregulated genes, we performed real-time PCR (rt-PCR) to compare gene expression levels before and 3, 4, and 6 hours after the HC infusion. Step 2: Rt-PCR to compare expression levels of 93 GC-regulated genes in normal versus very low morning cortisol levels in 27 patients with AAD. Results Step 1: Two hours after infusion of 100 mg HC, there was a marked increase in FKBP5, MMP9, and DSIPI expression levels. MMP9 and DSIPI expression levels correlated with serum cortisol. Step 2: Expression levels of CEBPB, DDIT4, FKBP5, DSIPI, and VDR were increased and levels of ADARB1, ARIDB5, and POU2F1 decreased in normal versus very low morning cortisol. Normal serum cortisol levels positively correlated with DSIPI, DDIT4, and FKBP5 expression. Conclusions We introduce gene expression as a novel approach to guide GC replacement in AAD. We suggest that gene expression of DSIPI, DDIT4, and FKBP5 are particularly promising candidate biomarkers of GC replacement, followed by MMP9, CEBPB, VDR, ADARB1, ARID5B, and POU2F1.
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Affiliation(s)
- Åse Bjorvatn Sævik
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Anette B Wolff
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Sigridur Björnsdottir
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Eirik Bratland
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Per M Knappskog
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Paal Methlie
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Siri Carlsen
- Department of Endocrinology, Stavanger University Hospital, Stavanger, Norway
| | - Magnus Isaksson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Olle Kämpe
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Kristian Løvås
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Marianne Øksnes
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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13
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Abstract
Measurement of Health-Related Quality of Life (HRQoL) is emerging as an important clinical endpoint which complements diagnostic workup and contributes to place patients at the centre of the decision-making process through the recognition of their needs, concerns, goals and expectations. Chronic excessive cortisol exposure in Cushing's syndrome (CS) causes severe physical and psychological morbidity which invariably affects HRQoL during the active phase of the disease and even after successful treatment. This sustained deterioration of patient's wellbeing is partly related to the persistence of several features associated with prior cortisol excess, including affective disorders, cognitive dysfunctions and negative illness perception. The aim of this review is to summarize the most recent evidence on HRQoL in CS, including the main determinants of its impairment and the results of some educational programs specifically addressed to improve patient's coping abilities. The preliminary results of an unpublished survey on patient's unmet needs will also be presented.
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Affiliation(s)
| | - Iris Crespo
- Department of Basic Sciences, School of Medicine and Health Sciences, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Susan M Webb
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, 08025 Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), 08025 Barcelona, Spain
| | - Elena Valassi
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, 08025 Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), 08025 Barcelona, Spain; School of Medicine, Universitat Internacional de Catalunya (UIC), Barcelona, Spain.
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14
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Didriksen NM, Sævik ÅB, Sortland LS, Øksnes M, Husebye ES. Sex-Specific Limitations in Physical Health in Primary Adrenal Insufficiency. Front Endocrinol (Lausanne) 2021; 12:718660. [PMID: 34733237 PMCID: PMC8558514 DOI: 10.3389/fendo.2021.718660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/29/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients with primary adrenal insufficiency (PAI) suffer reduced quality of life (QoL), but comparisons with large-scale normative data are scarce. The clinical characteristics associated with reduced QoL are largely unknown. METHODS Cross-sectional data on clinical characteristics and QoL scores from 494 patients were included. QoL was measured using RAND-36 (generic) and AddiQoL (-30 and -8, disease-specific). RAND-36 is reported as subdomain scores as well as physical (PCS) and metal (MCS) summary scores and compared with normative data. RESULTS Perception of physical role was consistently decreased across age groups in patients with PAI compared with normative data [75 (0-100) vs. 100 (50-100), p<0.001]. Men with PAI reported significantly lower scores for social functioning [88 (75-100) vs. 100 (75-100), p<0.001], as well as for vitality and physical role. In women, the greatest impairment was seen in physical role [50 (0-100) vs. 100 (50-100), p<0.001], followed by social functioning, vitality, physical function, general health, mental health, and emotional role. Overall, better QoL was associated with male sex (AddiQoL-30: 89 ± 13 vs. 82 ± 13, p<0.002), younger age (e.g. 20-29 vs. 80-89 years: PCS 59 [50-62] vs. 46 [37-53], p<0.001), autoimmune etiology [PCS: 53 (45-59) vs.. 45 (38-54), p<0.001], and absence of autoimmune comorbidity [PCS: 54 (45-59) vs. 50 (43-58), p<0.001]. There were no significant differences in QoL scores between different doses or dosing regimens of glucocorticoid or mineralocorticoid replacement. CONCLUSION QoL is reduced in patients with PAI, especially perception of physical role in women and social functioning in men. Among patients with PAI, female sex, higher age, non-autoimmune etiology, and autoimmune comorbidity was associated with lower QoL-scores.
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Affiliation(s)
| | - Åse Bjorvatn Sævik
- Department of Clinical Science, University of Bergen, Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Linn Solveig Sortland
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Marianne Øksnes
- Department of Clinical Science, University of Bergen, Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Eystein Sverre Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- *Correspondence: Eystein Sverre Husebye,
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15
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Bensing S, Giordano R, Falorni A. Fertility and pregnancy in women with primary adrenal insufficiency. Endocrine 2020; 70:211-217. [PMID: 32472424 DOI: 10.1007/s12020-020-02343-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/06/2020] [Indexed: 12/17/2022]
Abstract
Primary adrenal insufficiency (PAI) occurs in ~1/5000-1/7000 individuals and is in most cases caused by autoimmune Addison's disease (AAD). Around 10-20% of women with AAD develop premature ovarian insufficiency (POI) before the age of 40 years. 21-Hydroxylase autoantibodies (21OHAb) are the best single immune marker to classify AAD among PAI patients and autoimmune POI in hypergonadotropic hypogonadic women. In AAD, detection of steroid-cell autoantibodies (StCA) predicts future development of POI. AAD-related autoimmune POI is characterized by a selective destruction of theca cells with preservation of primary follicles and granulosa cells of secondary and tertiary follicles. Women with AAD show reduced fertility and parity. Patients with well-managed disease are generally expected to have uneventful pregnancies with favorable outcome, but increased risk of maternal and neonatal complications has been reported. Hence, AAD pregnant women must be carefully monitored by skilled staff which is familiar with the disorder and specific attention must be given to the substitutive therapy.
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Affiliation(s)
- Sophie Bensing
- Department of Endocrinology, Inflammation & Infection Theme, Karolinska University Hospital, 171 77 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Roberta Giordano
- Department of Clinical and Biological Sciences and Division of Endocrinology, Diabetes and Metabolism-Department of Medical Sciences, University of Turin, 10123, Turin, Italy
| | - Alberto Falorni
- Section of Internal Medicine and Endocrinological and Metabolic Sciences, Department of Medicine, University of Perugia, 06129, Perugia, Italy.
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16
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Perysinakis I, Aggeli C, Kaltsas G, Zografos GN. Adrenal-sparing surgery: current concepts on a theme from the past. Hormones (Athens) 2020; 19:317-327. [PMID: 32388629 DOI: 10.1007/s42000-020-00202-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/07/2020] [Indexed: 12/14/2022]
Abstract
Adrenal insufficiency represents a debilitating condition which mandates lifelong steroid replacement and which is associated with significant long-term morbidity, due to either inadequate or excessive replacement. The concept of preserving healthy cortical tissue by means of partial adrenalectomy has evolved as a means of avoiding the detrimental consequences of adrenal insufficiency. The advent of advanced technology in adrenal surgery has greatly facilitated the performance of partial adrenalectomy, enabling utilization of this method in an increasing number of endocrine diseases. Hereditary pheochromocytoma, Conn's syndrome, Cushing's syndrome, and non-functional adrenal masses represent the current indications for partial adrenalectomy, although the specific circumstances under which adrenal-sparing surgery should be proposed are still debatable. Partial adrenalectomy can be achieved by all types of minimally invasive surgery. In the absence of randomized, prospective, controlled studies designed to compare laparoscopic, retroperitoneoscopic, and robot-assisted partial adrenalectomy, none of these techniques has as yet been proven to be the gold standard for adrenal-sparing surgery. Apart from indications for surgery, results of surgery, and different types of partial adrenalectomy, controversial topics addressed in this review article include technical aspects such as the volume of residual adrenal tissue needed, ligation of adrenal vein, and means of tumor identification. Discussion of these controversial topics represents an attempt to define the role of partial adrenalectomy in modern adrenal surgery.
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Affiliation(s)
- Iraklis Perysinakis
- Third Surgical Department of Surgery, General Hospital "G. Gennimatas", Athens, Greece.
| | - Ch Aggeli
- Third Surgical Department of Surgery, General Hospital "G. Gennimatas", Athens, Greece
| | - Gr Kaltsas
- First Department of Propaedeutic Internal Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - G N Zografos
- Third Surgical Department of Surgery, General Hospital "G. Gennimatas", Athens, Greece
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17
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Oftedal BE, Wolff ASB. New era of therapy for endocrine autoimmune disorders. Scand J Immunol 2020; 92:e12961. [PMID: 32853446 DOI: 10.1111/sji.12961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/10/2020] [Accepted: 08/19/2020] [Indexed: 12/24/2022]
Abstract
The new era of immune and reconstitution therapy of autoimmune disorders is ongoing. However, endocrine autoimmune diseases comprise a group of elaborating pathologies where the development of new treatment strategies remains slow. Substitution of the missing hormones is still standard practice, taking care of the devastating symptoms but not the cause of disease. As our knowledge of the genetic contribution to the aetiology of endocrine disorders increases and early diagnostic tools are available, it is now possible to identify persons at risk before they acquire full-blown disease. This review summarizes current knowledge and treatment of endocrine autoimmune disorders, focusing on type 1 diabetes, Addison's disease, autoimmune thyroid diseases and primary ovarian insufficiency. We explore which new therapies might be used in the different stages of the disease, focus on legalized therapy and elaborate on the ongoing clinical studies for these diseases and the research front, before hypothesizing on the way ahead.
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Affiliation(s)
- Bergithe E Oftedal
- Department of Clinical Science, University of Bergen, Bergen, Norway.,KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
| | - Anette S B Wolff
- Department of Clinical Science, University of Bergen, Bergen, Norway.,KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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18
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Zhu J, Eichler F, Biffi A, Duncan CN, Williams DA, Majzoub JA. The Changing Face of Adrenoleukodystrophy. Endocr Rev 2020; 41:bnaa013. [PMID: 32364223 PMCID: PMC7286618 DOI: 10.1210/endrev/bnaa013] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/27/2020] [Indexed: 12/30/2022]
Abstract
Adrenoleukodystrophy (ALD) is a rare X-linked disorder of peroxisomal oxidation due to mutations in ABCD1. It is a progressive condition with a variable clinical spectrum that includes primary adrenal insufficiency, myelopathy, and cerebral ALD. Adrenal insufficiency affects over 80% of ALD patients. Cerebral ALD affects one-third of boys under the age of 12 and progresses to total disability and death without treatment. Hematopoietic stem cell transplantation (HSCT) remains the only disease-modifying therapy if completed in the early stages of cerebral ALD, but it does not affect the course of adrenal insufficiency. It has significant associated morbidity and mortality. A recent gene therapy clinical trial for ALD reported short-term MRI and neurological outcomes comparable to historical patients treated with HSCT without the associated adverse side effects. In addition, over a dozen states have started newborn screening (NBS) for ALD, with the number of states expecting to double in 2020. Genetic testing of NBS-positive neonates has identified novel variants of unknown significance, providing further opportunity for genetic characterization but also uncertainty in the monitoring and therapy of subclinical and/or mild adrenal insufficiency or cerebral involvement. As more individuals with ALD are identified at birth, it remains uncertain if availability of matched donors, transplant (and, potentially, gene therapy) centers, and specialists may affect the timely treatment of these individuals. As these promising gene therapy trials and NBS transform the clinical management and outcomes of ALD, there will be an increasing need for the endocrine management of presymptomatic and subclinical adrenal insufficiency. (Endocrine Reviews 41: 1 - 17, 2020).
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Affiliation(s)
- Jia Zhu
- Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts
| | - Florian Eichler
- Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Alessandra Biffi
- Harvard Medical School, Boston, Massachusetts
- Dana-Farber and Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts
- Harvard Stem-Cell Institute, Cambridge, Massachusetts
- San Raffaele Telethon Institute for Gene Therapy, San Raffaele Scientific Institute, Milan, Italy
| | - Christine N Duncan
- Harvard Medical School, Boston, Massachusetts
- Dana-Farber and Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts
| | - David A Williams
- Harvard Medical School, Boston, Massachusetts
- Dana-Farber and Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts
- Harvard Stem-Cell Institute, Cambridge, Massachusetts
| | - Joseph A Majzoub
- Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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19
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Dineen R, Martin-Grace J, Thompson CJ, Sherlock M. The management of glucocorticoid deficiency: Current and future perspectives. Clin Chim Acta 2020; 505:148-159. [DOI: 10.1016/j.cca.2020.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 01/10/2023]
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20
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Steenaard RV, Kremers MNT, Michon LA, Zijlstra M, Haak HR. Patient and Partner Perspectives on Health-Related Quality of Life in Adrenocortical Carcinoma. J Endocr Soc 2020; 4:bvaa040. [PMID: 32342024 PMCID: PMC7174051 DOI: 10.1210/jendso/bvaa040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/30/2020] [Indexed: 11/25/2022] Open
Abstract
Little is known about the impact of adrenocortical carcinoma (ACC) on health-related quality of life (HRQoL), and no disease-specific questionnaire exists. This qualitative study aimed to identify relevant domains of HRQoL for patients with ACC. In 2 focus group interviews, we discussed concerns regarding living with ACC and its treatments. The first group consisted of 6 patients on mitotane therapy and their partners or relatives, the second group of 4 patients after surgery alone and their partners. Inductive qualitative content analysis was used to analyze the interviews. We identified 4 domains related to HRQoL in patients with ACC, namely physical complaints, mental consequences, social consequences, and functional limitations. For example, physical complaints included symptoms of the disease and side effects of mitotane therapy; mental consequences included feeling insecure and living from scan to scan; and functional limitations included daily activities and mobility. We further found that patients' experiences with the health care system and health care professionals and partner perspectives influence HRQoL. In conclusion, ACC has a large impact on HRQoL in 4 domains. These results can be used to improve communication about HRQoL issues. We will use our findings to generate a disease-specific questionnaire to measure HRQoL in patients with ACC.
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Affiliation(s)
- Rebecca V Steenaard
- Department of Internal Medicine, Máxima MC, Eindhoven/Veldhoven, the Netherlands
- Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, the Netherlands
| | - Marjolein N T Kremers
- Department of Internal Medicine, Máxima MC, Eindhoven/Veldhoven, the Netherlands
- Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, the Netherlands
| | - Laura A Michon
- Department of Internal Medicine, Máxima MC, Eindhoven/Veldhoven, the Netherlands
| | - Myrte Zijlstra
- Department of Internal Medicine, St. Jans Gasthuis, Weert, the Netherlands
- Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
- Netherlands Association for Palliative Care (PZNL), Utrecht, the Netherlands
| | - Harm R Haak
- Department of Internal Medicine, Máxima MC, Eindhoven/Veldhoven, the Netherlands
- Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, the Netherlands
- Department of Internal Medicine, Division of General Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
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21
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Fasano A, Leonard MM, Mitchell DM, Eng G. Case 1-2020: An 11-Year-Old Boy with Vomiting and Weight Loss. N Engl J Med 2020; 382:180-189. [PMID: 31914246 PMCID: PMC8176458 DOI: 10.1056/nejmcpc1913469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Alessio Fasano
- From the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Harvard Medical School - both in Boston
| | - Maureen M Leonard
- From the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Harvard Medical School - both in Boston
| | - Deborah M Mitchell
- From the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Harvard Medical School - both in Boston
| | - George Eng
- From the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Massachusetts General Hospital, and the Departments of Pediatrics (A.F., M.M.L., D.M.M.) and Pathology (G.E.), Harvard Medical School - both in Boston
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22
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Abstract
Primary adrenal insufficiency (PAI) occurs in 1/5000-1/7000 individuals in the general population. Autoimmune Addison's disease (AAD) is the major cause of PAI and is a major component of autoimmune polyendocrine syndrome type 1 (APS1) and type 2 (APS2). Presence of 21-hydroxylase autoantibodies (21OHAb) identifies subjects with ongoing clinical or pre-clinical adrenal autoimmunity. AAD requires life-long substitutive therapy with two-three daily doses of hydrocortisone (HC) (15-25 mg/day) or one daily dose of dual-release HC and with fludrocortisone (0.5-2.0 mg/day). The lowest possible HC dose must be identified according to clinical and biochemical parameters to minimize long-term complications that include osteoporosis and cardiovascular and metabolic alterations. Women with AAD have lower fertility and parity as compared to age-matched healthy controls. Patients must be educated to double-triple HC dose in the case of fever or infections and to switch to parenteral HC in the case of vomiting, diarrhoea or acute hypotension.
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Affiliation(s)
- Serena Saverino
- Section of Internal Medicine and Endocrine and Metabolic Sciences, Department of Medicine, University of Perugia, Perugia, Italy
| | - Alberto Falorni
- Section of Internal Medicine and Endocrine and Metabolic Sciences, Department of Medicine, University of Perugia, Perugia, Italy.
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23
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Thompson LH, Nordenström E, Almquist M, Bergenfelz A. Health-related quality of life in patients undergoing adrenalectomy: report from a Swedish National Audit. Langenbecks Arch Surg 2019; 404:807-814. [PMID: 31773244 PMCID: PMC6908554 DOI: 10.1007/s00423-019-01844-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 11/13/2019] [Indexed: 01/06/2023]
Abstract
Purpose The aim of the study was to examine subjective health-related quality of life (HRQoL) in patients undergoing adrenalectomy. Methods The study included patients scheduled for adrenalectomy 2014–2017 after giving informed consent. The SF-36 questionnaire was administrated before operation and 1 year postoperatively. Results were compared with published normative values in Sweden. Results Some 50 patients were included. SF-36 scores for the whole cohort improved significantly after adrenalectomy in all dimensions except for bodily pain. Compared with the general Swedish population, the patients reported a significantly reduced HRQoL before and after adrenalectomy in all domains except for bodily pain postoperatively. Patients with benign functional tumours had lower HRQoL in physical domains before adrenalectomy than patients with benign non-functional tumours; Physical Component Summary (PCS), median 33.1 (range 17.1–62.9) vs. 44.2 (20.0–66.5), p = 0.018. Postoperatively, HRQoL was similar in the two groups of patients. Patients with benign functional tumours reported significantly improved HRQoL in all dimensions after adrenalectomy: PCS 33.1 (17.1–62.9) preoperatively vs. 47.6 (19.8-57.3) postoperatively, p = 0.005; Mental Component Summary (MCS) 33.8 (11.8–62.0) preoperatively vs. 52.7 (16.4–59.8) postoperatively, p = 0.004. These improvements were not seen in patients with benign non-functional or malignant tumours. Patients with malignant tumours reported no difference in SF-36 scores before or after adrenalectomy compared with patients with benign non-functional tumours. Conclusions Adrenalectomy improved HRQoL in patients with benign functional tumours. Adrenalectomy did not improve HRQoL in patients with benign non-functional tumours or in patients with malignant tumours. Electronic supplementary material The online version of this article (10.1007/s00423-019-01844-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Erik Nordenström
- Department of Surgery, Skåne University Hospital, 22185, Lund, Sweden
| | - Martin Almquist
- Department of Surgery, Skåne University Hospital, 22185, Lund, Sweden
| | - Anders Bergenfelz
- Department of Surgery, Skåne University Hospital, 22185, Lund, Sweden
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24
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Steenaard RV, Michon LA, Haak HR. Health-Related Quality of Life in Adrenocortical Carcinoma. Cancers (Basel) 2019; 11:E1500. [PMID: 31597261 PMCID: PMC6826350 DOI: 10.3390/cancers11101500] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 09/26/2019] [Accepted: 10/04/2019] [Indexed: 12/20/2022] Open
Abstract
Insight into the health-related quality of life (HRQoL) impact of adrenocortical carcinoma (ACC) is important. The disease and its treatment options potentially have an impact on HRQoL. For patients with limited survival, HRQoL research is of utmost importance. We will therefore provide an overview of HRQoL studies in patients with ACC. We found six studies that measured HRQoL in 323 patients with ACC (3 cross-sectional, 1 cohort, 2 trials), all indicating a reduced HRQoL compared to the general population. The FIRMACT trial found that HRQoL of patients with ACC was reduced compared to the general population, and that chemotherapy-mitotane further reduced HRQoL even though survival improved. Clinical aspects of the disease, including cortisol and aldosterone production and adrenal insufficiency have shown great impact on HRQoL in benign disease, even after the recovery of hormonal status. However, the impact of malignant adrenal disease and treatment options on HRQoL including adrenalectomy, radiotherapy, mitotane therapy, and chemotherapy have not been sufficiently studied in patients with ACC. Although the number of HRQoL studies in patients with ACC is limited, the existing literature does indicate that ACC has a large impact on patients' HRQoL, with disease specific aspects. Further HRQoL research in patients with ACC is essential to improve patient-centered care, preferably by using an ACC-specific HRQoL questionnaire.
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Affiliation(s)
- Rebecca V Steenaard
- Department of Internal Medicine, Máxima MC, 5631 Eindhoven/Veldhoven, The Netherlands.
- CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht University, 6200 Maastricht, The Netherlands.
| | - Laura A Michon
- Department of Internal Medicine, Máxima MC, 5631 Eindhoven/Veldhoven, The Netherlands.
| | - Harm R Haak
- Department of Internal Medicine, Máxima MC, 5631 Eindhoven/Veldhoven, The Netherlands.
- CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht University, 6200 Maastricht, The Netherlands.
- Department of Internal Medicine, Division of General Internal Medicine, Maastricht University Medical Centre+, 6229 Maastricht, The Netherlands.
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25
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Abstract
PURPOSE OF REVIEW Despite the declaration of an opioid epidemic, opioid use remains prevalent. Side-effects of chronic opioid use continue to be problematic. Opioid-induced endocrinopathies have been well documented, yet opioid-induced adrenal insufficiency (OIAI) remains underappreciated. This review summarizes what is currently known regarding the prevalence, predictive factors for the development and effect of treatment of OIAI. RECENT FINDINGS Although several case reports have highlighted the development of adrenal crisis among those receiving chronic opioids, only a few studies have systematically assessed patients for OIAI. The heterogeneity of these small studies presents challenges when trying to assess prevalence of or potential risk factors for OIAI. The estimated prevalence of OIAI among those treated with chronic opioids ranges from 8.3 to 29% and is more likely in those receiving higher doses of opioids. Reduced health-related quality of life variables and altered pain perception has been associated with lower cortisol levels; however, the effect of glucocorticoid replacement on the parameters remains unknown. SUMMARY Further research is critical to better identify those at greatest risk and guide optimal management of OIAI. Frontline providers should remain vigilant for possibility of OIAI among chronic opioid users.
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Affiliation(s)
- Diane Donegan
- Department of Endocrinology and Diabetes, Indiana University School of Medicine, Indiana, USA
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26
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Sorgdrager FJH, Werumeus Buning J, Bos EH, Van Beek AP, Kema IP. Hydrocortisone Affects Fatigue and Physical Functioning Through Metabolism of Tryptophan: A Randomized Controlled Trial. J Clin Endocrinol Metab 2018; 103:3411-3419. [PMID: 29982583 DOI: 10.1210/jc.2018-00582] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/27/2018] [Indexed: 12/19/2022]
Abstract
CONTEXT Hydrocortisone (HC) treatment influences health-related quality of life (HRQOL) in secondary adrenal insufficiency (AI). Glucocorticoids regulate tryptophan metabolism through the kynurenine pathway, which modulates mood and energy homeostasis. OBJECTIVE This study investigated whether tryptophan metabolism mediated the effect of HC dose on HRQOL in patients with secondary AI. DESIGN, SETTING, AND PATIENTS Forty-seven patients with secondary AI participated in this double-blind randomized controlled cross-over trial in the University Medical Center Groningen. INTERVENTION Patients were treated for two 10-week periods with a daily HC dose of 0.2 to 0.3 mg/kg and 0.4 to 0.6 mg/kg body weight, respectively. MAIN OUTCOME MEASURES Diary data and questionnaires were used to assess HRQOL. Tryptophan, kynurenine and 3-hydroxykynurenine were measured in serum and dialyzed plasma and the kynurenine-to-tryptophan ratio (Kyn/Trp ratio) ratio was calculated. RESULTS A higher dose HC was associated with increased levels of tryptophan (95% CI for mean difference 0.37 to 12.5, P = 0.038), reduced levels of kynurenine (95% CI, -0.49 to -0.10, P = 0.004) and 3-hydroxykynurenine (95% CI, -10.6 to -2.35, P = 0.003), and a reduced Kyn/Trp ratio (95% CI, -0.84 to -0.50, P < 0.001). The Kyn/Trp ratio mediated the effect of a higher dose HC on fatigue (P = 0.041) and physical functioning (P = 0.005). CONCLUSION Metabolism of tryptophan through the kynurenine pathway is reduced after a 10-week treatment with a higher dose HC and plays a role in the effect of HC on fatigue and physical functioning in patients with secondary AI.
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Affiliation(s)
- Freek J H Sorgdrager
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, RB Groningen, Netherlands
| | - Jorien Werumeus Buning
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, RB Groningen, Netherlands
| | - Elske H Bos
- Interdisciplinary Center Psychopathology and Emotion Regulation, University of Groningen, University Medical Center Groningen, RB Groningen, Netherlands
- Department of Developmental Psychology, University of Groningen, TS Groningen, Netherlands
| | - André P Van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, RB Groningen, Netherlands
| | - Ido P Kema
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, RB Groningen, Netherlands
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