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Herath M, Langdahl B, Ebeling PR, Milat F. Challenges in the diagnosis and management of glucocorticoid-induced osteoporosis in younger and older adults. Clin Endocrinol (Oxf) 2022; 96:460-474. [PMID: 34811782 DOI: 10.1111/cen.14637] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/16/2021] [Accepted: 10/26/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Glucocorticoids constitute a considerable risk for developing osteoporosis in both younger and older adults. However, currently available bone imaging modalities and fracture-risk assessment tools do not adequately capture the dramatic changes in bone microarchitecture, heterogeneity of glucocorticoid exposure, the impact of chronic disease and other osteoporosis risk factors on the assessment of osteoporosis in these individuals. DESIGN A narrative review is presented, following a systematic search of the literature from 2000 to 2021. RESULTS Our current appreciation of glucocorticoid-induced osteoporosis (GIO) is focused on older populations, with limited evidence to guide the investigation, risk assessment and treatment in premenopausal women and men less than 50 years. The impact of the underlying chronic disease on secondary osteoporosis in these younger adults is also poorly understood. CONCLUSION Through this narrative review, we provide a comprehensive overview of and recommendations for optimising the management of this common cause of secondary osteoporosis younger and older adults.
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Affiliation(s)
- Madhuni Herath
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Bente Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter R Ebeling
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Frances Milat
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
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Frara S, Allora A, di Filippo L, Formenti AM, Loli P, Polizzi E, Tradati D, Ulivieri FM, Giustina A. Osteopathy in mild adrenal Cushing's syndrome and Cushing disease. Best Pract Res Clin Endocrinol Metab 2021; 35:101515. [PMID: 33795196 DOI: 10.1016/j.beem.2021.101515] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pathophysiology and effects of endogenous glucocorticoid (GC) excess on skeletal endpoints as well as awareness and management of bone fragility are reviewed. Cushing's syndrome (CS) increase the risk of fracture affecting prevalently bone quality. Bone antiresorptive agents (SERMs, bisphosphonates and denosumab) as well as teriparatide increase bone mineral density and in some instances reduce fracture risk. Awareness and management of bone health in CS can be improved.
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Affiliation(s)
- Stefano Frara
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Agnese Allora
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Luigi di Filippo
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paola Loli
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Daniele Tradati
- Department of Orthopedics and Traumatology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Fabio Massimo Ulivieri
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, Milan, Italy.
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Eller-Vainicher C, Falchetti A, Gennari L, Cairoli E, Bertoldo F, Vescini F, Scillitani A, Chiodini I. DIAGNOSIS OF ENDOCRINE DISEASE: Evaluation of bone fragility in endocrine disorders. Eur J Endocrinol 2019; 180:EJE-18-0991.R1. [PMID: 31042675 DOI: 10.1530/eje-18-0991] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/29/2019] [Indexed: 12/12/2022]
Abstract
An underlying disease affecting bone health is present in up to 40% and 60% of osteoporotic post-menopausal women and men respectively. Among the disorders leading to a secondary form of osteoporosis, the endocrine diseases are highly represented. A frequent finding in patients affected with an endocrine-related forms of bone disease is that the skeletal fragility is partially independent of the bone density, since the fracture risk in these patients is related more to a reduction of bone quality than to a decrease of bone mass. As a consequence, bone mineral density evaluation by dual-X-ray Absorptiometry may be inadequate for establishing the risk of fracture in the setting of the endocrine-related forms of osteoporosis. In the recent years several attempts to non-invasively estimating bone quality have been done. Nowadys, some new tools are available in the clinical practice for optimizing the fracture risk estimation in patients with endocrine disorders. The aim of this review is to summarise the evidences regarding the role of the different imaging tools for evaluating bone density and bone quality in the most frequent forms of endocrine-related osteoporosis, such as obesity, diabetes, acromegaly, thyrotoxicosis, primary hyperparathyroidism, hypercortisolism and hypogonadism. For each of these disorders, data regarding both the current available tools and the future possible new techniques for assessing bone fragility in patients with endocrine diseases are reported.
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Affiliation(s)
- Cristina Eller-Vainicher
- C Eller-Vainicher, Endocrinology and Diabetology Units, Department of Medical Sciences and Community, Fondazione Ca'Granda Ospedale Maggiore Policlinico IRCCS, Milan, 20122, Italy
| | - Alberto Falchetti
- A Falchetti, Endocrinology, EndOsMet, Villa Donatello Private Hospital, , Florence, Italy
| | - Luigi Gennari
- L Gennari, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Elisa Cairoli
- E Cairoli, Unit for Bone Metabolism Diseases and Diabetes and Lab of Endocrine and Metabolic Research, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesco Bertoldo
- F Bertoldo, Bone Metabolism and Osteoncology Unit, Dept. Medicine, Universita degli Studi di Verona, Verona, Italy
| | - Fabio Vescini
- F Vescini, Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia Udine, Udine, Italy
| | - Alfredo Scillitani
- A Scillitani, Unit of Endocrinology, Casa Sollievo della Sofferenza Scientific Institute, San Giovanni Rotondo, 71013, Italy
| | - Iacopo Chiodini
- I Chiodini, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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An Atraumatic Symphysiolysis with a Unilateral Injured Sacroiliac Joint in a Patient with Cushing's Disease: A Loss of Pelvic Stability Related to Ligamentous Insufficiency? Case Rep Orthop 2016; 2016:9250938. [PMID: 26904337 PMCID: PMC4745920 DOI: 10.1155/2016/9250938] [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: 11/23/2015] [Accepted: 01/04/2016] [Indexed: 11/29/2022] Open
Abstract
Glucocorticoids are well known for altering bone structure and elevating fracture risk. Nevertheless, there are very few reports on pelvic ring fractures, compared to other bones, especially with a predominantly ligamentous insufficiency, resulting in a rotationally unstable pelvic girdle. We report a 39-year-old premenopausal woman suffering from an atraumatic symphysiolysis and disruption of the left sacroiliac joint. She presented with external rotational pelvic instability and immobilization. Prior to the injury, she received high-dose glucocorticoids for a tentative diagnosis of rheumatoid arthritis over two months. This diagnosis was not confirmed. Other causes leading to the unstable pelvic girdle were excluded by several laboratory and radiological examinations. Elevated basal cortisol and adrenocorticotropic hormone levels were measured and subsequent corticotropin-releasing hormone stimulation, dexamethasone suppression test, and petrosal sinus sampling verified the diagnosis of adrenocorticotropic hormone-dependent Cushing's disease. The combination of adrenocorticotropic hormone-dependent Cushing's disease and the additional application of exogenous glucocorticoids is the most probable cause of a rare atraumatic rotational pelvic instability in a premenopausal patient. To the authors' knowledge, this case presents the first description of a rotationally unstable pelvic ring fracture involving a predominantly ligamentous insufficiency in the context of combined exogenous and endogenous glucocorticoid elevation.
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dos Santos CV, Vieira Neto L, Madeira M, Alves Coelho MC, de Mendonça LMC, Paranhos-Neto FDP, Lima ICB, Gadelha MR, Farias MLF. Bone density and microarchitecture in endogenous hypercortisolism. Clin Endocrinol (Oxf) 2015; 83:468-74. [PMID: 25940452 DOI: 10.1111/cen.12812] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 02/01/2015] [Accepted: 04/27/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Osteoporosis is a serious and underestimated complication of endogenous hypercortisolism that results in an increased risk of fractures, even in patients with normal or slightly decreased bone mineral density (BMD). Alterations in bone microarchitecture, a very important component of bone quality, may explain bone fragility. The aim of this study was to investigate bone density and microarchitecture in a cohort of patients with endogenous Cushing's syndrome (CS). DESIGN Cross-sectional study. PATIENTS Thirty patients with endogenous active CS and fifty-one age-, sex- and body mass index-matched controls were included. MEASUREMENTS Participants were studied for areal BMD (dual-energy X-ray absorptiometry) of the lumbar spine (LS), femoral neck (FN), total femur (TF) and radius (33%), and for volumetric bone density (vBMD) and structure using high-resolution peripheral quantitative computed tomography (HR-pQCT) of the distal radius and distal tibia. RESULTS Patients with active CS exhibited lower areal BMD and Z-score values in the LS, FN and TF (P < 0·003 for all comparisons). At HR-pQCT, the patients with CS also had lower cortical area (P = 0·009 at the radius and P = 0·002 at the tibia), lower cortical thickness (P = 0·02 at the radius and P = 0·002 at the tibia), lower cortical density (P = 0·008 at the tibia) and lower total vBMD (P = 0·002 at the tibia). After the exclusion of hypogonadal individuals, the patients with CS maintained the same microarchitectural and densitometric alterations described above. CONCLUSIONS Endogenous hypercortisolism has deleterious effects on bone, especially on cortical bone microstructure. These effects seem to be a more important determinant of bone impairment than gonadal status.
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Affiliation(s)
- Camila V dos Santos
- Division of Endocrinology, Department of Internal Medicine, Clementino Fraga Filho University Hospital-Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Brazil
| | - Leonardo Vieira Neto
- Division of Endocrinology, Department of Internal Medicine, Clementino Fraga Filho University Hospital-Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Brazil
- Division of Endocrinology of Lagoa Federal Hospital, Rio de Janeiro, Brazil
| | - Miguel Madeira
- Division of Endocrinology, Department of Internal Medicine, Clementino Fraga Filho University Hospital-Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Brazil
- Division of Endocrinology of Bonsucesso Federal Hospital, Rio de Janeiro, Brazil
| | - Maria Caroline Alves Coelho
- Division of Endocrinology, Department of Internal Medicine, Clementino Fraga Filho University Hospital-Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Brazil
| | - Laura Maria Carvalho de Mendonça
- Division of Rheumatology, Department of Internal Medicine, Clementino Fraga Filho University Hospital-Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Brazil
| | - Francisco de Paula Paranhos-Neto
- Division of Endocrinology, Department of Internal Medicine, Clementino Fraga Filho University Hospital-Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Brazil
| | - Inayá Corrêa Barbosa Lima
- Nuclear Instrumentation Laboratory, COPPE-PEN, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mônica R Gadelha
- Division of Endocrinology, Department of Internal Medicine, Clementino Fraga Filho University Hospital-Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Brazil
| | - Maria Lucia Fleiuss Farias
- Division of Endocrinology, Department of Internal Medicine, Clementino Fraga Filho University Hospital-Federal University of Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, Brazil
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Abstract
It was assumed that resolution of hypercortisolism in Cushing syndrome (CS) was followed by normalization of morbidity; however, in the last decade evidence is accumulating that patients with cured CS still have increased morbidity and mortality after the biochemical control of hypercortisolism. Patients with CS have an increased cardiovascular and metabolic risk and persistent accumulation of central fat, with an unfavorable adipokine profile, not only during the active phase of the disease but also long after biochemical remission. Clinical management should be particularly careful in identifying global cardiovascular risk, as a primary goal during the followup of these patients, aimed at improving global vascular morbidity. Moreover bone mass is reduced not only due to the endogenous hypercortisolism but also due to duration and dose of exogenous glucocorticoid (GC) replacement therapy after surgery. Thus, therapy in operated patients with inhibition of the hypothalamic-pituitary-adrenal axis should be reduced to the lowest dose and duration possible. Specific treatments should be considered in patients with decreased bone mass, aimed at reducing the increased fracture incidence. Finally, cognitive and health related quality of life impairments, described in active disease, are still abnormal after endocrine cure. Thus, residual morbidity persists in cured CS, suggesting irreversibility of GC-induced phenomena, typical of chronic hypercortisolism.
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Trementino L, Appolloni G, Ceccoli L, Marcelli G, Concettoni C, Boscaro M, Arnaldi G. Bone complications in patients with Cushing's syndrome: looking for clinical, biochemical, and genetic determinants. Osteoporos Int 2014; 25:913-21. [PMID: 24126765 DOI: 10.1007/s00198-013-2520-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 09/17/2013] [Indexed: 10/26/2022]
Abstract
SUMMARY This is the first study examining the impact of both clinical, biochemical, and genetic determinants in the occurrence of bone complications in patients with overt Cushing's syndrome (CS). It demonstrates that the degree and duration of hypercortisolism seem to play a major role in bone loss and fractures development in these patients. INTRODUCTION Bone loss and fractures are a common complication of CS. We investigate the role of gender, disease etiology, duration, and degree of hypercortisolism as well as the impact of glucocorticoid receptor (GR) polymorphisms on the development of bone complications in CS. METHODS Fifty-two patients with active CS (38 Cushing's disease and 14 with cortisol-secreting adrenal adenoma) were genotyped for GR polymorphisms (BclI, N363S, ER22/23EK, and A3669G). In all patients, clinical, hormonal, and biochemical markers of bone turnover, densitometric parameters [lumbar spine and left femur bone mineral density (BMD), T-score, Z-score] as well as the prevalence of bone demineralization and both vertebral and peripheral fractures were assessed. RESULTS No differences were found in bone complications according to gender, disease etiology, and genetic variants distribution. Fractured patients compared to non-fractured ones showed increased levels of urinary free cortisol (UFC) and a more compromised densitometric profile. UFC levels correlated with the occurrence of vertebral fractures (r = 0.43, p = 0.009) while midnight serum cortisol correlated with L1-L4 BMD values (r = -0.35, p = 0.04). Disease duration correlated with the presence of peripheral fractures (r = 0.36, p = 0.04). CONCLUSIONS While GR gene variants as well as gender and disease etiology seem not to play a role, the degree and duration of hypercortisolism seem to be the major determinants of bone loss and fractures in this group of patients. More investigations are needed to understand the real impact of these determinants on the development of bone complications in patients with hypercortisolism.
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Affiliation(s)
- L Trementino
- Division of Endocrinology, Polytechnic University of Marche, Via Conca 71, 60020, Torrette di Ancona, (AN), Italy
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Tóth M, Grossman A. Glucocorticoid-induced osteoporosis: lessons from Cushing's syndrome. Clin Endocrinol (Oxf) 2013; 79:1-11. [PMID: 23452135 DOI: 10.1111/cen.12189] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 10/24/2012] [Accepted: 02/12/2013] [Indexed: 01/06/2023]
Abstract
Glucocorticoid-induced osteoporosis (GIO) is the most frequent form of secondary bone disorders. Most of our knowledge on its pathogenesis and treatment has been obtained by investigating patients treated with exogenous glucocorticoids. This review will focus on the bone disorder in endogenous Cushing's syndrome, updating recent advances in its pathophysiology, diagnostic aspects and the various predictors which are important in determining bone mineral density (BMD) and fracture risk. We now know strong evidence that beside BMD, bone microarchitecture, one of the most important elements of bone quality, is a key factor in determining fracture risk. Recently, two new methods (spinal deformity index and trabecular bone score) have been shown to be useful markers of bone microarchitecture in GIO. Investigations of GIO in endogenous Cushing's syndrome have also contributed to our understanding on its natural history and reversibility. Relying on recently published guidelines for management of exogenous GIO, a short list of suggestions is provided regarding the optimal diagnostic and therapeutic approach to patients with endogenous GIO.
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Affiliation(s)
- Miklós Tóth
- 2nd Department of Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary.
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Arnaldi G, Mancini T, Tirabassi G, Trementino L, Boscaro M. Advances in the epidemiology, pathogenesis, and management of Cushing's syndrome complications. J Endocrinol Invest 2012; 35:434-48. [PMID: 22652826 DOI: 10.1007/bf03345431] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Cushing's syndrome (CS) is a clinical condition resulting from chronic exposure to glucocorticoid excess. As a consequence, hypercortisolism contributes significantly to the early development of systemic disorders by direct and/or indirect effects. Complications such as obesity, hypertension, diabetes, dyslipidemia, and hypercoagulability cause premature atherosclerosis and increase cardiovascular mortality. Impairment of the skeletal system is a relevant cause of morbidity and disability in these patients especially due to the high prevalence of vertebral fractures. In addition, muscle weakness, emotional lability, depression, and impairment of quality of life are very common. Clinical management of these patients is complex and should be particularly careful in identifying global cardiovascular risks and aim at controlling all complications. Although the primary goal in the prevention and treatment of complications is the correction of hypercortisolism, treatment does not completely eliminate these comorbidities. Given that cardiovascular risk and fracture risk can persist after cure, early detection of each morbidity could prevent the development of irreversible damage. In this review we present the various complications of CS and their pathogenetic mechanisms. We also suggest the clinical management of these patients based on our extensive clinical experience and on the available literature.
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Affiliation(s)
- G Arnaldi
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy.
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Szappanos A, Toke J, Lippai D, Patócs A, Igaz P, Szücs N, Füto L, Gláz E, Rácz K, Tóth M. Bone turnover in patients with endogenous Cushing's syndrome before and after successful treatment. Osteoporos Int 2010; 21:637-45. [PMID: 19513576 DOI: 10.1007/s00198-009-0978-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 05/07/2009] [Indexed: 10/20/2022]
Abstract
UNLABELLED We investigated bone turnover and its restoration in a large number of patients in the active phase and after cure of endogenous Cushing's syndrome. Furthermore, the usefulness of serum osteocalcin and collagen breakdown products as potential markers of active Cushing's syndrome was also evaluated. INTRODUCTION Suppressed bone formation is one of the most characteristic features of Cushing's syndrome (CS). Despite numerous previous reports, many aspects of the disturbed bone metabolism of these patients are unexplored. In this study, we investigated the time course of bone marker changes after the cure of CS as well as correlations between bone markers and serum cortisol concentrations. METHODS Eighty-seven patients with CS were studied. Patients were followed up to 48 months after surgical cure. Serum osteocalcin (OC) and collagen breakdown products (CTX) were measured with immunochemiluminescence method and compared to the results of 161 healthy controls. RESULTS OC showed a negative, while CTX displayed a positive correlation with serum cortisol. Patients with diabetes mellitus and myopathy had significantly lower serum OC levels compared to those without these complications. The area under the curve of OC obtained by receiver-operating characteristics analysis for the discrimination of patients with CS from healthy controls was 0.9227. Postoperative OC increased rapidly from the first few days or weeks reaching its maximum at the sixth month and remained stable after the 24th postoperative month. CONCLUSIONS Our study demonstrated significant correlations between serum cortisol and both bone formation and resorption markers in the active phase of CS. We propose that OC may serve as a sensitive biologic marker of glucocorticoid activity in endogenous CS during its active phase and it may reflect the clinical cure of the disease.
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Affiliation(s)
- A Szappanos
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
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Abstract
The activity of the pituitary-adrenal axis can profoundly impact on body composition. This is dramatically seen in Cushing's syndrome (CS) but changes in body composition are also implicated in depression and alcoholic pseudocushing's. The pathophysiological mechanisms underlying these changes remain poorly understood. Changes to body composition in CS include increased fat mass, decreased bone mass, thinning of the skin and reduced lean mass. Why these tissues are affected so dramatically is unclear. Additionally, the change in body composition between individuals varies considerably for reasons which are only now becoming evident. This paper reviews the phenotypic changes with altered pituitary-adrenal axis activity and discusses the mechanisms involved. The primary focus is on adipose, bone, muscle and skin since the most dramatic changes are seen in these tissues.
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Affiliation(s)
- Eva Fernandez-Rodriguez
- Division of Medical Sciences, The Institute of Biomedical Research, The Medical School, The University of Birmingham, Birmingham , B15 2TH, UK
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12
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Füto L, Toke J, Patócs A, Szappanos A, Varga I, Gláz E, Tulassay Z, Rácz K, Tóth M. Skeletal differences in bone mineral area and content before and after cure of endogenous Cushing's syndrome. Osteoporos Int 2008; 19:941-9. [PMID: 18043854 DOI: 10.1007/s00198-007-0514-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Accepted: 10/26/2007] [Indexed: 11/24/2022]
Abstract
UNLABELLED We examined bone densitometric data in a four-year follow-up period before and after the cure of CS. Plasma cortisol concentrations were similar, but the duration of estimated glucocorticoid excess was longer in patients with prevalent bone fractures compared to those without fractures. After therapy of CS, bone area, BMC and BMD increased significantly at the LS and femur during follow-up, but they decreased at the forearm, suggesting redistribution of bone minerals from the peripheral to the axial skeleton. INTRODUCTION Only a few studies report the changes in bone mineral density (BMD) after the cure of Cushing's syndrome (CS). METHODS Forty-one patients with Cushing's disease, 21 patients with adrenal CS and 6 patients with ectopic CS were prospectively enrolled. BMD, bone mineral content (BMC) and bone area were measured by DXA. RESULTS No significant correlations were found between serum cortisol concentrations and baseline bone densitometric data. After successful therapy of CS, bone area and BMD increased significantly at the lumbar spine (LS) and femur during follow-up, but they decreased at the forearm. The progressive increase in BMC at the LS had a significant negative correlation with the change of the BMC of radius in the first and second follow-up years. The change in the body mass index was an independent predictor for changes in BMC both at the LS and at the forearm at the second year of remission. CONCLUSIONS The regional differences and the time-dependent changes of BMC suggest that the source of marked increase in axial BMC after the cure of CS is, at least partly, due to the redistribution of bone minerals from the peripheral to the axial skeleton.
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Affiliation(s)
- L Füto
- Department of Internal Medicine, Ferenc Markhot Hospital, Eger, Hungary
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13
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Kaji H, Yamauchi M, Chihara K, Sugimoto T. Glucocorticoid excess affects cortical bone geometry in premenopausal, but not postmenopausal, women. Calcif Tissue Int 2008; 82:182-90. [PMID: 18278571 DOI: 10.1007/s00223-008-9106-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Accepted: 01/07/2008] [Indexed: 10/22/2022]
Abstract
Glucocorticoid (GC) excess causes a great increase in fracture risk, but the effects of GC excess on cortical bone geometry are unknown. The present study was performed to examine the effects of GC excess on cortical bone geometry in both premenopausal and postmenopausal women. Ninety-six women receiving oral GC treatments and 10 women with Cushing syndrome (CS) were each compared to age-matched control subjects using peripheral quantitative computed tomography. Total area, periosteal circumference, and polar strength strain index (SSIp) were significantly lower in GC-treated patients compared with control subjects in premenopausal women but not in postmenopausal women. Moreover, cortical area and thickness as well as periosteal circumference and SSIp were significantly lower in patients with CS compared to controls in premenopausal women but not in postmenopausal women. Total area, cortical area, cortical thickness, periosteal circumference, as well as SSIp were significantly lower in GC-treated patients with vertebral fractures compared to those without vertebral fractures in premenopausal women but not in postmenopausal women. In conclusion, endogenous or exogenous GC excess affects bone geometry of forearms of premenopausal, but not postmenopausal, women. These effects of GC excess on bone geometry may provide a strength loss mechanism beneath increased vertebral fracture risk.
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Affiliation(s)
- Hiroshi Kaji
- Division of Diabetes, Metabolism, and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
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Chiodini I, Torlontano M, Carnevale V, Trischitta V, Scillitani A. Skeletal involvement in adult patients with endogenous hypercortisolism. J Endocrinol Invest 2008; 31:267-76. [PMID: 18401211 DOI: 10.1007/bf03345601] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Overt endogenous glucocorticoid excess is a well-recognized cause of bone loss and osteoporotic fractures. Cortisol excess inhibits bone formation, increases bone resorption, impairs calcium absorption from the gut, and affects the secretion of several hormones (in particular gonadotropins and GH), cytokines, and growth factors, influencing bone metabolism. The glucocorticoid excess mainly affects trabecular bone, leading to vertebral fractures in up to 70% of patients. Osteoporotic fractures may be the presenting symptom of an otherwise silent glucocorticoid excess and can precede the diagnosis of hypercortisolism by up to 2 yr. The removal of glucocorticoid excess leads to a recovery of bone mass which is, however, often incomplete and delayed, although it reduces the risk of osteoporotic fractures. Bisphosphonate therapy has been suggested to be useful in maintaining bone mass in these patients. Subclinical hypercortisolism, a condition of impaired hypothalamic- adrenal-axis homeostasis without the classical signs and symptoms of glucocorticoid excess, is a recently defined entity, which has been shown to be associated to increased bone resorption, bone loss, and high prevalence of vertebral fractures regardless of gonadal status. However, data about the effect of this subtle glucocorticoid excess on bone are still scarce and conflicting. Moreover, it is not yet known whether removing the cause of subclinical hypercortisolism leads to a recovery of bone mass and reduces the risk of osteoporotic fractures. Finally, recent data suggest that subclinical hypercortisolism is a common and underrated finding in patients with established osteoporosis. In summary, it is crucial to evaluate the risk of osteoporosis and fractures in patients with glucocorticoid excess; on the other hand, it also seems advisable to screen for glucocorticoid excess patients with osteoporotic fractures without known secondary causes of osteoporosis.
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Affiliation(s)
- I Chiodini
- Unit of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Ospedale Maggiore Policlinico, IRCCS, University of Milan, Milan, Italy
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Bone Mineral Density Before and After Surgical Cure of Cushing’s Syndrome Due to Adrenocortical Adenoma: Prospective Study. World J Surg 2008; 32:890-6. [DOI: 10.1007/s00268-007-9394-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kristo C, Jemtland R, Ueland T, Godang K, Bollerslev J. Restoration of the coupling process and normalization of bone mass following successful treatment of endogenous Cushing's syndrome: a prospective, long-term study. Eur J Endocrinol 2006; 154:109-18. [PMID: 16381999 DOI: 10.1530/eje.1.02067] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Endogenous Cushing's syndrome (CS) is associated with bone loss and an increased risk of fractures. However, the long-term outcome of treatment on bone health has not been adequately clarified. DESIGN We followed 33 patients with active CS prospectively before and twice after treatment (mean follow-up 33 (n = 25) and 71 months (n = 18), respectively). The patients were compared to age-, sex- and body mass index (BMI)-matched controls, also followed longitudinally. METHODS Bone mineral indices (bone mineral density (BMD), bone mineral content (BMC) and bone area) were evaluated in the lumbar spine (LS), femoral neck (FN), and total body (TB) by dual-energy X-ray absorptiometry (DXA). Biochemical markers of bone turnover were assessed by serum levels of osteocalcin and C-terminal telopeptides of Type-1 collagen (CTX-1). RESULTS Mann-Whitney rank sum tests showed that BMD of the LS, FN and TB was reduced by 14.8% (P < 0.001), 15.7% (P < 0.001), and 9.2% (P < 0.001) in CS vs. controls at baseline, with markedly reduced serum osteocalcin (P = 0.014) and increased CTX-1 (P = 0.012) levels, but no correlation between markers. At first follow-up, BMD was increased in LS (7.9%, P < 0.001) and FN (3.5%, P = 0.003) compared to baseline. The time-dependent rise in BMD (LS (r = 0.59; P = 0.002) and FN (r = 0.52; P = 0.007); Spearman's rank correlation), in CS was paralleled by increased osteocalcin (275%, P < 0.001) and correlation between biochemical markers (r = 0.92, P < 0.001; Pearson's correlation). TB BMD did not increase significantly before the second follow-up, when BMD Z-scores were normalized in all three compartments. CONCLUSION Our observations demonstrate restoration of coupled bone remodeling and normalization of bone mineral density in all measured skeletal compartments of treated CS patients after prolonged recovery, first significant in predominantly trabecular bone (i.e. lumbar spine).
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Affiliation(s)
- Cybèle Kristo
- Section of Endocrinology, Rikshospitalet University Hospital, Oslo, Norway.
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Abstract
PURPOSE OF REVIEW Much of our education about endocrine disorders focuses on their diagnosis and treatment. Although the musculoskeletal manifestations of endocrine disorders are well documented, they are often overlooked. This review will discuss new developments regarding those rheumatic manifestations. RECENT FINDINGS Diabetic research is investigating connective tissue alterations in hand syndromes. A recent review elucidated the natural history of diabetic muscle infarction. Research has identified factors that stimulate osteoblast activity in diffuse idiopathic skeletal hyperostosis and bone loss in diabetics. Accumulating evidence documents thyroid disease coexisting with connective tissue disorders. Reports document cases of vasculitis occurring after propylthiouracil treatment. Finally, data clarifies the effects of thyroid dysfunction, hyperparathyroidism, acromegaly and hypercortisolism on bone. SUMMARY Current research mainly relates to the effects of endocrine disorders on bone. As we advance our understanding of mechanisms that lead to rheumatic disorders in endocrine disease, we will improve our ability to treat them.
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Affiliation(s)
- Dana Jacobs-Kosmin
- Division of Rheumatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Abstract
Structural and functional impairment of skeletal system is a relevant cause of morbidity and disability in patients with Cushing's syndrome (CS). Approximately 30-50% of patients with CS experience fractures (particularly at the spinal level) consistent with the 50% incidence of osteoporosis. Growth failure, pubertal arrest are the hallmarks of CS in children and growing adolescents leading to reduced final adult height and peak bone mass. The decrease in osteoblast number and function, through different mechanisms, seems to play a central role in the bone loss in CS. Patients with CS have decreased serum levels of osteocalcin and alkaline phosphatase. Considering the preferential bone loss in the cancellous skeleton it is reasonable to measure BMD, possibly with Dual X-rays absorptiometry (DEXA) at lumbar spine, in all patients with CS. Patients cured from CS have increased prevalence of spine damage: therefore, a radiological follow-up of the skeleton should be included in the management of patients with CS not only during the active phase but also after cure. Glucocorticoid-induced osteoporosis is reversible. The recovery of bone loss in CS is slow, taking approximately ten years to become complete. In the meanwhile, patients with severe osteopenia are exposed to a high risk of fracture. Alendronate may induce a more rapid improvement in BMD than cortisol normalization alone and it could be useful in patients with persistent postsurgical hypercortisolism to prevent further bone loss. The decision to discontinue antiresorptive therapy should be based on clinical monitoring and DEXA measurements.
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Affiliation(s)
- Tatiana Mancini
- Division of Medicine, San Marino Hospital, Republic of San Marino
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