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Kaye AD, Khaled ME, Bembenick KN, Lacey J, Tandon A, Kelkar RA, Derouen AG, Ballaera C, Chandler D, Ahmadzadeh S, Shekoohi S, Varrassi G. Alkindi Sprinkle for Pediatric Patients With Primary Adrenocortical Insufficiency: A Narrative Review. Cureus 2024; 16:e56031. [PMID: 38606228 PMCID: PMC11007452 DOI: 10.7759/cureus.56031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 03/12/2024] [Indexed: 04/13/2024] Open
Abstract
Adrenocortical insufficiency, also known as adrenal insufficiency (AI), is an endocrine disorder characterized by inadequate production of adrenal hormones, including glucocorticoids and mineralocorticoids (MCs). The condition can be categorized as primary, secondary, or tertiary AI, depending on the location of the defect. Classical symptoms of AI include weakness, fatigue, abdominal pain, tachycardia, hypotension, electrolyte imbalances, and hyperpigmentation. In children, the most common cause of AI is classical congenital adrenal hyperplasia, which results from a deficiency in the 21-hydroxylase enzyme. The 21-hydroxylase enzyme produces all steroids, such as cortisol and aldosterone. AI management primarily involves hormone replacement therapy, typically with oral hydrocortisone and MC supplementation. However, the administration of hydrocortisone to pediatric patients presents challenges related to the lack of available dose-appropriate formulations. Historically, crushed or split adult tablets were used for the pediatric treatment of AI, although this poses an increased risk of under- or overtreatment. Inadequate dosing in the pediatric population can adversely affect growth, development, and metabolic health. Alkindi Sprinkle is a pediatric-specific hydrocortisone oral granule preparation that manages cortisol levels to help facilitate accurate therapeutic dosing. Alkindi offers several advantages, including accurate dosing, taste masking, and ease of administration. The present investigation describes AI, the management of AI, and the treatment of pediatric AI using Alkindi Sprinkle, including clinical efficacy.
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Affiliation(s)
- Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Munira E Khaled
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | | | - John Lacey
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, New Orleans, USA
| | - Anamika Tandon
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, New Orleans, USA
| | - Rucha A Kelkar
- School of Medicine, Medical University of South Carolina, Charleston, USA
| | - Alyssa G Derouen
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Corrado Ballaera
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Debbie Chandler
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Shahab Ahmadzadeh
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sahar Shekoohi
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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Al-Rayess H, Lahoti A, Simpson LL, Palzer E, Thornton P, Heksch R, Kamboj M, Stanley T, Regelmann MO, Gupta A, Raman V, Mehta S, Geffner ME, Sarafoglou K. Practice Variation among Pediatric Endocrinologists in the Dosing of Glucocorticoids in Young Children with Congenital Adrenal Hyperplasia. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1871. [PMID: 38136073 PMCID: PMC10742174 DOI: 10.3390/children10121871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023]
Abstract
A Pediatric Endocrine Society (PES) Drugs and Therapeutics Committee workgroup sought to determine the prescribing practices of pediatric endocrinologists when treating children <10 years of age with congenital adrenal hyperplasia (CAH). Our workgroup administered a 32-question online survey to PES members. There were 187 respondents (88.9% attending physicians), mostly from university-affiliated clinics (~80%). Ninety-eight percent of respondents prescribed the short-acting glucocorticoid hydrocortisone to treat young children, as per the Endocrine Society CAH Guidelines, although respondents also prescribed long-acting glucocorticoids such as prednisolone suspension (12%), prednisone tablets (9%), and prednisone suspension (6%). Ninety-seven percent of respondents indicated that they were likely/very likely to prescribe hydrocortisone in a thrice-daily regimen, as per CAH Guidelines, although 19% were also likely to follow a twice-daily regimen. To achieve smaller doses, using a pill-cutter was the most frequent method recommended by providers to manipulate tablets (87.2%), followed by dissolving tablets in water (25.7%) to create a daily batch (43.7%) and/or dissolving a tablet for each dose (64.6%). Thirty-one percent of providers use pharmacy-compounded hydrocortisone suspension to achieve doses of <2.5 mg. Our survey shows that practices among providers in the dosing of young children with CAH vary greatly and sometimes fall outside of the CAH Guidelines-specifically when attempting to deliver lower, age-appropriate hydrocortisone doses.
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Affiliation(s)
- Heba Al-Rayess
- Department of Pediatrics, Division of Endocrinology, University of Minnesota Medical School, Minneapolis, MN 55454, USA;
| | - Amit Lahoti
- Department of Pediatrics, Division of Endocrinology, Nationwide Children’s Hospital at The Ohio State University, Columbus, OH 43205, USA; (A.L.); (M.K.)
| | - Leslie Long Simpson
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN 55455, USA; (L.L.S.); (E.P.)
| | - Elise Palzer
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN 55455, USA; (L.L.S.); (E.P.)
| | - Paul Thornton
- Division of Endocrinology and Diabetes, Cook Children’s Medical Center, Fort Worth, TX 76104, USA;
| | - Ryan Heksch
- Center for Diabetes and Endocrinology, Department of Pediatrics, Akron Children’s Hospital, Akron, OH 44308, USA;
| | - Manmohan Kamboj
- Department of Pediatrics, Division of Endocrinology, Nationwide Children’s Hospital at The Ohio State University, Columbus, OH 43205, USA; (A.L.); (M.K.)
| | - Takara Stanley
- Pediatric Endocrine Unit and Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA;
| | - Molly O. Regelmann
- Division of Pediatric Endocrinology and Diabetes, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY 10467, USA;
| | - Anshu Gupta
- Division of Pediatric Endocrinology, Children’s Hospital of Richmond, Virginia Commonwealth University, Richmond, VA 23298, USA;
| | - Vandana Raman
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Utah, Salt Lake City, UT 84112, USA;
| | - Shilpa Mehta
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, New York Medical College, Valhalla, NY 10595, USA
| | - Mitchell E. Geffner
- The Saban Research Institute, Children’s Hospital Los Angeles, The Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA;
| | - Kyriakie Sarafoglou
- Department of Pediatrics, Division of Endocrinology, University of Minnesota Medical School, Minneapolis, MN 55454, USA;
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, USA
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Alsamet HM. Considerations regarding oral medications delivery to patients on nasoenteral tubes. NUTR CLIN METAB 2022. [DOI: 10.1016/j.nupar.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Prete A, Auchus RJ, Ross RJ. Clinical advances in the pharmacotherapy of congenital adrenal hyperplasia. Eur J Endocrinol 2021; 186:R1-R14. [PMID: 34735372 PMCID: PMC8679847 DOI: 10.1530/eje-21-0794] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 11/04/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patients with 21-hydroxylase deficiency congenital adrenal hyperplasia (21OHD-CAH) have poor health outcomes with increased mortality, short stature, impaired fertility, and increased cardiovascular risk factors such as obesity. To address this, there are therapies in development that target the clinical goal of treatment, which is to control excess androgens with an adrenal replacement dose of glucocorticoid. METHODS Narrative review of publications on recent clinical developments in the pharmacotherapy of congenital adrenal hyperplasia. SUMMARY Therapies in clinical development target different levels of the hypothalamo-pituitary-adrenal axis. Two corticotrophin-releasing factor type 1 (CRF1) receptor antagonists, Crinecerfont and Tildacerfont, have been trialled in poorly controlled 21OHD-CAH patients, and both reduced ACTH and androgen biomarkers while patients were on stable glucocorticoid replacement. Improvements in glucocorticoid replacement include replacing the circadian rhythm of cortisol that has been trialled with continuous s.c. infusion of hydrocortisone and Chronocort, a delayed-release hydrocortisone formulation. Chronocort optimally controlled 21OHD-CAH in 80% of patients on an adrenal replacement dose of hydrocortisone, which was associated with patient-reported benefits including restoration of menses and pregnancies. Adrenal-targeted therapies include the steroidogenesis-blocking drug Abiraterone acetate, which reduced adrenal androgen biomarkers in poorly controlled patients. CONCLUSIONS CRF1 receptor antagonists hold promise to avoid excess glucocorticoid replacement in patients not controlled on standard or circadian glucocorticoid replacement such as Chronocort. Gene and cell therapies are the only therapeutic approaches that could potentially correct both cortisol deficiency and androgen excess.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, Departments of Pharmacology and Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Richard J Ross
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Correspondence should be addressed to R J Ross;
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Walsh J, Schaufelberger D, Iurian S, Klein S, Batchelor H, Turner R, Gizurarson S, Boltri L, Alessandrini E, Tuleu C. Path towards efficient paediatric formulation development based on partnering with clinical pharmacologists and clinicians, a conect4children expert group white paper. Br J Clin Pharmacol 2021; 88:5034-5051. [PMID: 34265091 DOI: 10.1111/bcp.14989] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/10/2021] [Accepted: 07/07/2021] [Indexed: 12/18/2022] Open
Abstract
Improved global access to novel age-appropriate formulations for paediatric subsets, either of new chemical entities or existing drugs, is a priority to ensure that medicines meet the needs of these patients. However, despite regulatory incentives, the introduction to the market of paediatric formulations still lags behind adult products. This is mainly caused by additional complexities associated with the development of acceptable age-appropriate paediatric medicines. This position paper recommends the use of a paediatric Quality Target Product Profile as an efficient tool to facilitate early planning and decision making across all teams involved in paediatric formulation development during the children-centric formulation design for new chemical entities, or to repurpose/reformulate off-patent drugs. Essential key attributes of a paediatric formulation are suggested and described. Moreover, greater collaboration between formulation experts and clinical colleagues, including healthcare professionals, is advocated to lead to safe and effective, age-appropriate medicinal products. Acceptability testing should be a secondary endpoint in paediatric clinical trials to ensure postmarketing adherence is not compromised by a lack of acceptability. Not knowing the indications and the related age groups and potential dosing regimens early enough is still a major hurdle for efficient paediatric formulation development; however, the proposed paediatric Quality Target Product Profile could be a valuable collaborative tool for planning and decision making to expedite paediatric product development, particularly for those with limited experience in developing a paediatric product.
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Affiliation(s)
- Jennifer Walsh
- BioCity Nottingham, Jenny Walsh Consulting Ltd, Nottingham, UK
| | - Daniel Schaufelberger
- School of Medicine, All Children's Hospital, Schaufelberger Consulting LLC and Johns Hopkins University, St. Petersburg, FL, USA
| | - Sonia Iurian
- Department of Pharmaceutical Technology and Biopharmacy, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Sandra Klein
- Department of Pharmacy, Institute of Biopharmaceutics and Pharmaceutical Technology, University of Greifswald, Greifswald, Germany
| | - Hannah Batchelor
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Roy Turner
- Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Sveinbjörn Gizurarson
- Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland; and Pharmacy Department, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Luigi Boltri
- Pharmaceutical Development, Adare Pharmaceuticals, Milan, Italy
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Coope H, Parviainen L, Withe M, Porter J, Ross RJ. Hydrocortisone granules in capsules for opening (Alkindi) as replacement therapy in pediatric patients with adrenal insufficiency. Expert Opin Orphan Drugs 2021. [DOI: 10.1080/21678707.2021.1903871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | | | | | | | - Richard J Ross
- Diurnal Ltd, Cardiff, UK
- Academic Unit of Diabetes, Endocrinology and Reproduction,The University of Sheffield, Sheffield, UK
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Neumann U, Braune K, Whitaker MJ, Wiegand S, Krude H, Porter J, Digweed D, Voet B, Ross RJM, Blankenstein O. A Prospective Study of Children Aged 0-8 Years with CAH and Adrenal Insufficiency Treated with Hydrocortisone Granules. J Clin Endocrinol Metab 2021; 106:e1433-e1440. [PMID: 32888021 PMCID: PMC7947757 DOI: 10.1210/clinem/dgaa626] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 09/02/2020] [Indexed: 12/17/2022]
Abstract
CONTEXT Children with congenital adrenal hyperplasia (CAH) and adrenal insufficiency (AI) require daily hydrocortisone replacement with accurate dosing. OBJECTIVE Prospective study of efficacy and safety of hydrocortisone granules in children with AI and CAH monitored by 17-OHP (17-hydroxyprogesterone) saliva profiles. METHODS Seventeen children with CAH (9 male) and 1 with hypopituitarism (male), aged from birth to 6 years, had their hydrocortisone medication changed from pharmacy compounded capsules to hydrocortisone granules. Patients were followed prospectively for 2 years. In children with CAH, the therapy was adjusted by 17-OHP salivary profiles every 3 months. The following parameters were recorded: hydrocortisone dose, height, weight, pubertal status, adverse events, and incidence of adrenal crisis. RESULTS The study medication was given thrice daily, and the median duration of treatment (range) was 795 (1-872) days, with 150 follow-up visits. Hydrocortisone doses were changed on 40/150 visits, with 32 based on salivary measurements and 8 on serum 17-OHP levels. The median daily mg/m2 hydrocortisone dose (range) at study entry for the different age groups 2-8 years, 1 month to 2 years, <28 days was 11.9 (7.2-15.5), 9.9 (8.6-12.2), and 12.0 (11.1-29.5), respectively, and at end of the study was 10.2 (7.0-14.4), 9.8 (8.9-13.1), and 8.6 (8.2-13.7), respectively. There were no trends for accelerated or reduced growth. No adrenal crises were observed despite 193 treatment-emergent adverse events, which were mainly common childhood illnesses. INTERPRETATION This first prospective study of glucocorticoid treatment in children with AI and CAH demonstrates that accurate dosing and monitoring from birth results in hydrocortisone doses at the lower end of the recommended dose range and normal growth, without occurrence of adrenal crises.
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Affiliation(s)
- Uta Neumann
- Charité Universitaetsmedizin Berlin, Berlin, Germany
- Correspondence and Reprint Requests: Uta Neumann, Charité-Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail:
| | | | | | | | - Heiko Krude
- Charité Universitaetsmedizin Berlin, Berlin, Germany
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Al-Rayess H, Fleissner K, Jaber M, Brundage RC, Sarafoglou K. Manipulation of Hydrocortisone Tablets Leads to Iatrogenic Cushing Syndrome in a 6-Year-Old Girl With CAH. J Endocr Soc 2020; 4:bvaa091. [PMID: 32803093 PMCID: PMC7417883 DOI: 10.1210/jendso/bvaa091] [Citation(s) in RCA: 9] [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: 05/19/2020] [Accepted: 07/02/2020] [Indexed: 12/18/2022] Open
Abstract
Currently there are no commercially available hydrocortisone formulations for the treatment of children with congenital adrenal hyperplasia (CAH) that allow for smaller doses (0.1-1.25 mg) and incremental adjustments needed to control excess androgen production and avoid the negative effects of overtreatment. This lack of availability has led physicians to recommend dividing hydrocortisone 5-mg tablets into 4 to 6 pieces, compounding capsules or hydrocortisone suspension, or crushing 5- or 10-mg tablets in 5 or 10 mL of water. We report a case of iatrogenic Cushing syndrome in a 6-year 11-month-old girl with salt-wasting CAH treated with hydrocortisone tablets that were administered after crushing and dispersing into water to obtain the prescribed dose. She presented with poor growth, increasing body mass index (BMI), excess downy hair, round facies, and gastric ulcers. Her hydrocortisone dose was 8.1 mg/m2/day. Results for all adrenal steroid concentrations were undetectable at 8 am, 12 hours after her last dose. The year prior to presentation her parents began dissolving 10 mg of hydrocortisone in 10 mL of water and using this preparation over the course of 24 hours, which coincided with rapid increase of BMI. We switched her to a pharmacy-compounded alcohol-free hydrocortisone suspension with total daily doses ranging from 6.5 to 8.2 mg/m2/day, which resulted in resolution of her cushingoid features, a decrease in BMI, and catch-up growth. Our case highlights that manipulation of hydrocortisone tablets by parents can result in great variability in dosing and the need for commercially available pediatric formulations allowing for smaller dosing required in young children.
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Affiliation(s)
- Heba Al-Rayess
- Department of Pediatrics, Division of Endocrinology, University of Minnesota, Minneapolis, Minnesota
| | - Kristin Fleissner
- Department of Pediatrics, Division of Endocrinology, University of Minnesota, Minneapolis, Minnesota
| | - Mu'taz Jaber
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Richard C Brundage
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Kyriakie Sarafoglou
- Department of Pediatrics, Division of Endocrinology, University of Minnesota, Minneapolis, Minnesota.,Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
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Daniel E, Whitaker MJ, Keevil B, Wales J, Ross RJ. Accuracy of hydrocortisone dose administration via nasogastric tube. Clin Endocrinol (Oxf) 2019; 90:66-73. [PMID: 30311954 PMCID: PMC6334520 DOI: 10.1111/cen.13876] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/26/2018] [Accepted: 10/01/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Hydrocortisone via nasogastric (NG) tube is used in sick children with adrenal insufficiency; however, there is no licensed formulation for NG administration. METHODS We investigated hydrocortisone recovery after passage through NG tubes in vitro for three formulations: liquid suspension, crushed tablets mixed with water, and hydrocortisone granules designed for oral administration to children. Cortisol was measured by LC-MS/MS. RESULTS Hydrocortisone content was variable and recovery low after preparation in syringe and prior to passage through NG tubes. For doses, 0.5 and 2.0 mg mean percentage recovery was as follows: liquid suspension 57% and 58%; crushed tablets 46% and 30%; and hydrocortisone granules 78% and 71%. Flushing the administering syringe increased recovery. Hydrocortisone recovery after passage with flushing through 6-12Fr gauge NG tubes was variable: liquid suspension 61%-92%, crushed tablets 40%-174%, hydrocortisone granules 61%-92%. Administration of hydrocortisone granules occluded 6 and 8Fr NG tubes; however, administration using a sampling needle to prevent granules being administered gave a recovery of 74%-98%. CONCLUSIONS The administration of hydrocortisone through NG tubes is possible; however, current methods deliver a variable dose of hydrocortisone, generally less than that prescribed. Attention should be placed on the technique used to optimize drug delivery such as flushing of the administering syringe. Hydrocortisone granules block small NG tubes but behaved as well as the commonly used liquid suspension when prepared with a filtering needle that filters out granules.
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Affiliation(s)
| | | | - Brian Keevil
- Manchester Academic Health Science Centre (MAHSC), The University of ManchesterManchesterUK
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