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Pathophysiology of Mild Hypercortisolism: From the Bench to the Bedside. Int J Mol Sci 2022; 23:ijms23020673. [PMID: 35054858 PMCID: PMC8775422 DOI: 10.3390/ijms23020673] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/31/2021] [Accepted: 01/05/2022] [Indexed: 02/07/2023] Open
Abstract
Mild hypercortisolism is defined as biochemical evidence of abnormal cortisol secretion without the classical detectable manifestations of overt Cushing’s syndrome and, above all, lacking catabolic characteristics such as central muscle weakness, adipose tissue redistribution, skin fragility and unusual infections. Mild hypercortisolism is frequently discovered in patients with adrenal incidentalomas, with a prevalence ranging between 5 and 50%. This high variability is mainly due to the different criteria used for defining this condition. This subtle cortisol excess has also been described in patients with incidentally discovered pituitary tumors with an estimated prevalence of 5%. To date, the mechanisms responsible for the pathogenesis of mild hypercortisolism of pituitary origin are still not well clarified. At variance, recent advances have been made in understanding the genetic background of bilateral and unilateral adrenal adenomas causing mild hypercortisolism. Some recent data suggest that the clinical effects of glucocorticoid (GC) exposure on peripheral tissues are determined not only by the amount of the adrenal GC production but also by the peripheral GC metabolism and by the GC sensitivity. Indeed, in subjects with normal cortisol secretion, the combined estimate of cortisol secretion, cortisone-to-cortisol peripheral activation by the 11 beta-hydroxysteroid dehydrogenase enzyme and GC receptor sensitizing variants have been suggested to be associated with the presence of hypertension, diabetes and bone fragility, which are three well-known consequences of hypercortisolism. This review focuses on the pathophysiologic mechanism underlying both the different sources of mild hypercortisolism and their clinical consequences (bone fragility, arterial hypertension, subclinical atherosclerosis, cardiovascular remodeling, dyslipidemia, glucose metabolism impairment, visceral adiposity, infections, muscle damage, mood disorders and coagulation).
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Apaydın T, Yavuz DG. Assessment of non-traumatic vertebral fractures in Cushing's syndrome patients. J Endocrinol Invest 2021; 44:1767-1773. [PMID: 33420960 DOI: 10.1007/s40618-020-01496-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/29/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE Hypercortisolism has detrimental effects on bone metabolism with the consequences of bone loss and bone fractures. We aimed to evaluate the frequency of vertebral fragility fractures and to determine the factors associated with Cushing's syndrome (CS). METHODS A total of 135 patients diagnosed with Cushing's syndrome [108 patients with Cushing's disease and 27 patients with adrenocortical adenoma] and 107 healthy controls were included in this cross-sectional study. The available clinical, laboratory, and radiologic data of patients with CS were recorded, retrospectively. Lateral vertebral radiograms were evaluated for vertebral fragility fractures according to Genant's semi-quantitative method. Bone mineral density (BMD) was determined using a Dual-energy X-ray absorptiometry (DEXA). RESULTS Vertebral fragility fractures (VFs) were observed in 75.3% (n = 61) of the patients. The median number of VFs was six (min-max: 2-12). All patients with vertebral fractures had thoracic VF, and 50.7% of the patients had lumbar fragility fractures. Thirty-three (40.7%) patients with vertebral fractures had normal bone densitometry values. Osteoporosis and osteopenia were observed in 16.2% and 40.7% of the patients, respectively. The duration of active disease, the presence of ACTH-secreting pituitary adenoma, and 24-h urinary cortisol did not influence the presence of vertebral fractures. Vertebral fractures were independently associated with age, FSH, LH levels, and lumbar BMD (R2 = 68.18%, p = 0.028). The femoral neck BMD (but not lumbar BMD) was independently associated with age, BMI, and PTH levels (R2 = 48.48%, p < 0.001). CONCLUSION Vertebral fracture frequency was higher in CS patients. Most of the patients with vertebral fractures had multiple fractures. Although low lumbar BMD was associated with VF, patients with CS with normal bone densitometry could experience VF. Vertebral radiograph evaluations as a part of routine evaluation for silent vertebral fractures may help to prevent further fractures in patients with CS.
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Affiliation(s)
- T Apaydın
- Department of Endocrinology and Metabolism, Marmara University School of Medicine, Istanbul, Turkey.
| | - D G Yavuz
- Department of Endocrinology and Metabolism, Marmara University School of Medicine, Istanbul, Turkey
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Martins CS, de Castro M. Generalized and tissue specific glucocorticoid resistance. Mol Cell Endocrinol 2021; 530:111277. [PMID: 33864884 DOI: 10.1016/j.mce.2021.111277] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 12/20/2022]
Abstract
Glucocorticoids (GCs) are steroid hormones that influence several physiologic functions and are among the most frequently prescribed drugs worldwide. Resistance to GCs has been observed in the context of the familial generalized GC resistance (Chrousos' syndrome) or tissue specific GC resistance in chronic inflammatory states. In this review, we have summarized the major factors that influence individual glucocorticoid sensitivity/resistance. The fine-tuning of GC action is determined in a tissue-specific fashion that includes the combination of different GC receptor promoters, translation initiation sites, splice isoforms, interacting proteins, post-translational modifications, and alternative mechanisms of signal transduction.
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Affiliation(s)
- Clarissa Silva Martins
- Department of Internal Medicine - Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, SP, Brazil; School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil
| | - Margaret de Castro
- Department of Internal Medicine - Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, SP, Brazil.
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Povoroznyuk VV, Dedukh NV, Bystrytska MA, Shapovalov VS. Bone remodeling stages under physiological conditions and glucocorticoid in excess: Focus on cellular and molecular mechanisms. REGULATORY MECHANISMS IN BIOSYSTEMS 2021. [DOI: 10.15421/022130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This review provides a rationale for the cellular and molecular mechanisms of bone remodeling stages under physiological conditions and glucocorticoids (GCs) in excess. Remodeling is a synchronous process involving bone resorption and formation, proceeding through stages of: (1) resting bone, (2) activation, (3) bone resorption, (4) reversal, (5) formation, (6) termination. Bone remodeling is strictly controlled by local and systemic regulatory signaling molecules. This review presents current data on the interaction of osteoclasts, osteoblasts and osteocytes in bone remodeling and defines the role of osteoprogenitor cells located above the resorption area in the form of canopies and populating resorption cavities. The signaling pathways of proliferation, differentiation, viability, and cell death during remodeling are presented. The study of signaling pathways is critical to understanding bone remodeling under normal and pathological conditions. The main signaling pathways that control bone resorption and formation are RANK / RANKL / OPG; M-CSF – c-FMS; canonical and non-canonical signaling pathways Wnt; Notch; MARK; TGFβ / SMAD; ephrinB1/ephrinB2 – EphB4, TNFα – TNFβ, and Bim – Bax/Bak. Cytokines, growth factors, prostaglandins, parathyroid hormone, vitamin D, calcitonin, and estrogens also act as regulators of bone remodeling. The role of non-encoding microRNAs and long RNAs in the process of bone cell differentiation has been established. MicroRNAs affect many target genes, have both a repressive effect on bone formation and activate osteoblast differentiation in different ways. Excess of glucocorticoids negatively affects all stages of bone remodeling, disrupts molecular signaling, induces apoptosis of osteocytes and osteoblasts in different ways, and increases the life cycle of osteoclasts. Glucocorticoids disrupt the reversal stage, which is critical for the subsequent stages of remodeling. Negative effects of GCs on signaling molecules of the canonical Wingless (WNT)/β-catenin pathway and other signaling pathways impair osteoblastogenesis. Under the influence of excess glucocorticoids biosynthesis of biologically active growth factors is reduced, which leads to a decrease in the expression by osteoblasts of molecules that form the osteoid. Glucocorticoids stimulate the expression of mineralization inhibitor proteins, osteoid mineralization is delayed, which is accompanied by increased local matrix demineralization. Although many signaling pathways involved in bone resorption and formation have been discovered and described, the temporal and spatial mechanisms of their sequential turn-on and turn-off in cell proliferation and differentiation require additional research.
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Lakatos P, Szili B, Bakos B, Takacs I, Putz Z, Istenes I. Thyroid Hormones, Glucocorticoids, Insulin, and Bone. Handb Exp Pharmacol 2020; 262:93-120. [PMID: 32036458 DOI: 10.1007/164_2019_314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Several endocrine systems have important effects on bone tissue. Thyroid hormones are essential for normal growth and development. Excess of these hormones will result in clinically significant changes that may require intervention. Glucocorticoids also have a marked effect on bone metabolism by several pathways. Their endogenous or exogenous excess will induce pathological processes that might elevate the risk of fractures. Insulin and the carbohydrate metabolism elicit a physiological effect on bone; however, the lack of insulin (type 1 diabetes) or insulin resistance (type 2 diabetes) have deleterious influence on bone tissue.
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Affiliation(s)
- Peter Lakatos
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary.
| | - Balazs Szili
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Bence Bakos
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Istvan Takacs
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Putz
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Ildiko Istenes
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
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Piasecka M, Papakokkinou E, Valassi E, Santos A, Webb SM, de Vries F, Pereira AM, Ragnarsson O. Psychiatric and neurocognitive consequences of endogenous hypercortisolism. J Intern Med 2020; 288:168-182. [PMID: 32181937 DOI: 10.1111/joim.13056] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 12/18/2022]
Abstract
Psychiatric and neurocognitive symptoms due to hypercortisolism were already described by Harvey Cushing in his original paper on patients with Cushing's syndrome (CS). Nowadays, it is well known that psychiatric and cognitive complaints are two of the most common, and most distressing, symptoms in patients with CS. Psychiatric symptoms are indeed a major clinical manifestation of CS. The most commonly observed psychiatric conditions are depression and anxiety, whilst mania and psychosis are less common. Several domains of cognitive function are impaired at diagnosis, including episodic and working memory, executive function and attention. Following treatment, one-fourth of the patients still experience depressed mood, and the cognitive impairments are only partially restored. Consequently, quality of life in patients with CS is severely and persistently affected. Neuroimaging studies have also illustrated the deleterious effects of hypercortisolism on the brain by demonstrating reduced grey matter volumes and cortical thickness, altered resting-state functional responses and during cognitive tasks, as well as widespread reduced white matter integrity, especially in structures important for cognitive function and emotional processing, both before and after successful abrogation of hypercortisolism. In this paper, we summarize the current knowledge on the psychiatric and neurocognitive consequences of hypercortisolism in patients with CS, both before, and after successful treatment. In addition, we review the structural and functional brain abnormalities associated with hypercortisolism and discuss the influence of these factors on quality of life.
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Affiliation(s)
- M Piasecka
- From the, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - E Papakokkinou
- From the, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - E Valassi
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, Univ Autonoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - A Santos
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, Univ Autonoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - S M Webb
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, Univ Autonoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - F de Vries
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - A M Pereira
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - O Ragnarsson
- From the, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Haalen FM, Dijk EHC, Savas M, Brinks J, Dekkers OM, Dijkman G, Rossum EFC, Biermasz NR, Boon CJF, Pereira AM. Hair cortisol concentrations in chronic central serous chorioretinopathy. Acta Ophthalmol 2020; 98:390-395. [PMID: 31608607 DOI: 10.1111/aos.14269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 09/14/2019] [Indexed: 01/20/2023]
Abstract
PURPOSE Central serous chorioretinopathy (CSC), a distinct form of macular degeneration, has been associated with glucocorticoid use and possibly also with an increased endogenous activity of the hypothalamic-pituitary-adrenal (HPA) axis. To estimate long-term glucocorticoid exposure, measurement of hair cortisol concentrations (HCC) has emerged. This cross-sectional study aimed to investigate HCC, as a reflection of chronic endogenous steroid exposure, in a cohort of patients with chronic CSC (cCSC). METHODS Hair cortisol concentrations (HCC) were determined in 48 patients with cCSC and 230 population-based controls (Lifelines cohort study), not using exogenous corticosteroids. RESULTS Increased HCC (defined as >10.49 pg/mg) were present in 2 (4%) patients with cCSC and 13 (6%) controls. Mean HCC values were not different between patients and controls, and no difference in HCC was found between patients with active cCSC disease and patients with inactive disease. No correlation between HCC and urinary free cortisol (UFC) levels in patients with cCSC was found. CONCLUSIONS This study shows that HCC in patients with cCSC are not elevated compared to population-based controls, and no association between HCC and cCSC severity was found. This finding questions the previous suggestion that cCSC is associated with increased HPA axis activity. In line, HCC do not seem useful in monitoring cCSC disease activity.
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Affiliation(s)
- Femke M. Haalen
- Department of Medicine Division of Endocrinology, and Center for Endocrine Tumors Leiden University Medical Center Leiden the Netherlands
| | - Elon H. C. Dijk
- Department of Ophthalmology Leiden University Medical Center Leiden the Netherlands
| | - Mesut Savas
- Department of Internal Medicine Division of Endocrinology Erasmus MC University Medical Center Rotterdam Rotterdam the Netherlands
| | - Joost Brinks
- Department of Ophthalmology Leiden University Medical Center Leiden the Netherlands
| | - Olaf M. Dekkers
- Department of Medicine Division of Endocrinology, and Center for Endocrine Tumors Leiden University Medical Center Leiden the Netherlands
- Department of Medicine Division of Epidemiology Leiden University Medical Center Leiden the Netherlands
| | - Greet Dijkman
- Department of Ophthalmology Leiden University Medical Center Leiden the Netherlands
| | - Elisabeth F. C. Rossum
- Department of Internal Medicine Division of Endocrinology Erasmus MC University Medical Center Rotterdam Rotterdam the Netherlands
| | - Nienke R. Biermasz
- Department of Medicine Division of Endocrinology, and Center for Endocrine Tumors Leiden University Medical Center Leiden the Netherlands
| | - Camiel J. F. Boon
- Department of Ophthalmology Leiden University Medical Center Leiden the Netherlands
- Department of Ophthalmology Amsterdam University Medical Centers Academic Medical Center University of Amsterdam Amsterdam the Netherlands
| | - Alberto M. Pereira
- Department of Medicine Division of Endocrinology, and Center for Endocrine Tumors Leiden University Medical Center Leiden the Netherlands
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Müller LM, Kienitz T, Deutschbein T, Riester A, Hahner S, Burger-Stritt S, Berr CM, Oßwald A, Braun L, Rubinstein G, Reincke M, Quinkler M. Glucocorticoid Receptor Polymorphisms Influence Muscle Strength in Cushing's Syndrome. J Clin Endocrinol Metab 2020; 105:5587858. [PMID: 31613324 DOI: 10.1210/clinem/dgz052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 09/24/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT An important clinical feature of Cushing's syndrome (CS) is proximal muscle myopathy caused by glucocorticoid induced protein metabolism. However, interindividual differences cannot be explained solely by the pure extent of hypercortisolemia. OBJECTIVE To evaluate the effects of glucocorticoid receptor (GR) polymorphisms (BclI, N363S, ER22/23EK and A3669G), which influence peripheral glucocorticoid sensitivity on muscular function in endogenous CS. METHODS 205 patients with proven endogenous CS (128 central, 77 adrenal) from 3 centers of the German Cushing's Registry and 125 subjects, in whom CS was ruled out, were included. All subjects were assessed for grip strength (via hand grip dynamometer) and performed a chair-rising test (CRT). DNA samples were obtained from peripheral blood leukocytes for GR genotyping. RESULTS In patients with active CS, normalized handgrip strength of the dominant and nondominant hand was higher in A3669G minor allele than in wildtype carriers (P = .006 and P = .021, respectively). CS patients in remission and ruled-out CS showed no differences in handgrip strength regarding A3669G minor allele and wildtype carriers. Male CS patients harboring the ER22/23EK wildtype presented lower hand grip strength than minor allele carriers (P = .049 dominant hand; P = .027 nondominant hand). The other polymorphisms did not influence handgrip strength. CRT showed no differences regarding GR polymorphisms carrier status. CONCLUSION Handgrip strength seems to be more susceptible to hypercortisolism in A3669G wildtype than in A3669G minor allele carriers. This might partially explain the inter-individual differences of glucocorticoid-induced myopathy in patients with endogenous CS. ER22/23EK polymorphism seems to exert sex-specific differences.
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Affiliation(s)
- Lisa Marie Müller
- Endocrinology in Charlottenburg, Berlin, Germany
- Clinical Endocrinology CCM, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
- Clinical Endocrinology CCM, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, Germany
| | - Stephanie Burger-Stritt
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, Würzburg, Germany
| | - Christina M Berr
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Andrea Oßwald
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Leah Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
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Kharazmi M, Michaëlsson K, Schilcher J, Eriksson N, Melhus H, Wadelius M, Hallberg P. A Genome-Wide Association Study of Bisphosphonate-Associated Atypical Femoral Fracture. Calcif Tissue Int 2019; 105:51-67. [PMID: 31006051 DOI: 10.1007/s00223-019-00546-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/08/2019] [Indexed: 02/07/2023]
Abstract
Atypical femoral fracture is a well-documented adverse reaction to bisphosphonates. It is strongly related to duration of bisphosphonate use, and the risk declines rapidly after drug withdrawal. The mechanism behind bisphosphonate-associated atypical femoral fracture is unclear, but a genetic predisposition has been suggested. With the aim to identify common genetic variants that could be used for preemptive genetic testing, we performed a genome-wide association study. Cases were recruited mainly through reports of adverse drug reactions sent to the Swedish Medical Products Agency on a nation-wide basis. We compared atypical femoral fracture cases (n = 51) with population-based controls (n = 4891), and to reduce the possibility of confounding by indication, we also compared with bisphosphonate-treated controls without a current diagnosis of cancer (n = 324). The total number of single-nucleotide polymorphisms after imputation was 7,585,874. A genome-wide significance threshold of p < 5 × 10-8 was used to correct for multiple testing. In addition, we performed candidate gene analyses for a panel of 29 genes previously implicated in atypical femoral fractures (significance threshold of p < 5.7 × 10-6). Compared with population controls, bisphosphonate-associated atypical femoral fracture was associated with four isolated, uncommon single-nucleotide polymorphisms. When cases were compared with bisphosphonate-treated controls, no statistically significant genome-wide association remained. We conclude that the detected associations were either false positives or related to the underlying disease, i.e., treatment indication. Furthermore, there was no significant association with single-nucleotide polymorphisms in the 29 candidate genes. In conclusion, this study found no evidence of a common genetic predisposition for bisphosphonate-associated atypical femoral fracture. Further studies of larger sample size to identify possible weakly associated genetic traits, as well as whole exome or whole-genome sequencing studies to identify possible rare genetic variation conferring a risk are warranted.
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Affiliation(s)
- Mohammad Kharazmi
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - Karl Michaëlsson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jörg Schilcher
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Niclas Eriksson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Håkan Melhus
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Mia Wadelius
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Pär Hallberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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10
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Hardy RS, Zhou H, Seibel MJ, Cooper MS. Glucocorticoids and Bone: Consequences of Endogenous and Exogenous Excess and Replacement Therapy. Endocr Rev 2018; 39:519-548. [PMID: 29905835 DOI: 10.1210/er.2018-00097] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/08/2018] [Indexed: 02/02/2023]
Abstract
Osteoporosis associated with long-term glucocorticoid therapy remains a common and serious bone disease. Additionally, in recent years it has become clear that more subtle states of endogenous glucocorticoid excess may have a major impact on bone health. Adverse effects can be seen with mild systemic glucocorticoid excess, but there is also evidence of tissue-specific regulation of glucocorticoid action within bone as a mechanism of disease. This review article examines (1) the role of endogenous glucocorticoids in normal bone physiology, (2) the skeletal effects of endogenous glucocorticoid excess in the context of endocrine conditions such as Cushing disease/syndrome and autonomous cortisol secretion (subclinical Cushing syndrome), and (3) the actions of therapeutic (exogenous) glucocorticoids on bone. We review the extent to which the effect of glucocorticoids on bone is influenced by variations in tissue metabolizing enzymes and glucocorticoid receptor expression and sensitivity. We consider how the effects of therapeutic glucocorticoids on bone are complicated by the effects of the underlying inflammatory disease being treated. We also examine the impact that glucocorticoid replacement regimens have on bone in the context of primary and secondary adrenal insufficiency. We conclude that even subtle excess of endogenous or moderate doses of therapeutic glucocorticoids are detrimental to bone. However, in patients with inflammatory disorders there is a complex interplay between glucocorticoid treatment and underlying inflammation, with the underlying condition frequently representing the major component underpinning bone damage.
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Affiliation(s)
- Rowan S Hardy
- University of Birmingham, Birmingham, United Kingdom
| | - Hong Zhou
- Bone Research Program, ANZAC Research Institute, Sydney, New South Wales, Australia
| | - Markus J Seibel
- Bone Research Program, ANZAC Research Institute, Sydney, New South Wales, Australia.,Department of Endocrinology and Metabolism, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mark S Cooper
- Department of Endocrinology and Metabolism, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Adrenal Steroid Laboratory, ANZAC Research Institute, Sydney, New South Wales, Australia
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11
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Mészáros K, Karvaly G, Márta Z, Magda B, Tőke J, Szücs N, Tóth M, Rácz K, Patócs A. Diagnostic performance of a newly developed salivary cortisol and cortisone measurement using an LC-MS/MS method with simple and rapid sample preparation. J Endocrinol Invest 2018; 41:315-323. [PMID: 28815484 DOI: 10.1007/s40618-017-0743-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 08/07/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Late-night salivary cortisol level is one of the first-line tests recommended by the Endocrine Society for the diagnosis of endogenous hypercortisolism. Most routine laboratories measure cortisol levels using immunoassay tests which fail to determine low cortisol levels accurately due to the numerous interfering substances. A liquid chromatography-tandem mass spectrometry (LC-MS/MS) method with simple and rapid sample preparation was developed for the simultaneous measurement of cortisol and cortisone and its performance in the diagnosis of endogenous hypercortisolism was evaluated. METHODS 324 late-night saliva samples were analyzed from which 272 samples were derived from patients with a suspected diagnosis of endogenous hypercortisolism. Salivary cortisol levels were assayed using an electrochemiluminescent immunoassay (ECLIA, Cortisol II, Roche), and simultaneous measurement of cortisol and cortisone was performed using an LC-MS/MS method. RESULTS A strong correlation between cortisol results measured using ECLIA and LC-MS/MS (r 2 = 0.892) was demonstrated. Receiver operating characteristics (ROC) analysis showed good diagnostic performance of cortisol and cortisone levels assayed using LC-MS/MS method and for cortisol measured using ECLIA. CONCLUSIONS Late-night salivary cortisol and cortisone are useful parameters for the diagnosis of hypercortisolism. Using samples obtained from patients where the diagnosis of hypercortisolism is extremely challenging cut-off values for midnight salivary cortisol and cortisone measured by LC-MS/MS method were established.
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Affiliation(s)
- K Mészáros
- Department of Laboratory Medicine, MTA-SE Lendulet Research Group, Hungarian Academy of Sciences, Semmelweis University, 46. Szentkiralyi str, Budapest, 1088, Hungary
- "Lendület" Hereditary Endocrine Tumours Research Group, HAS-SE, Budapest, Hungary
- Bionics Innovation Center, Budapest, Hungary
| | - G Karvaly
- Department of Laboratory Medicine, MTA-SE Lendulet Research Group, Hungarian Academy of Sciences, Semmelweis University, 46. Szentkiralyi str, Budapest, 1088, Hungary
- Bionics Innovation Center, Budapest, Hungary
| | - Z Márta
- MS Metabolomics Research Group, HAS, Budapest, Hungary
| | - B Magda
- MS Metabolomics Research Group, HAS, Budapest, Hungary
| | - J Tőke
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - N Szücs
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - M Tóth
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - K Rácz
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
- Molecular Medicine Research Group, HAS-SE, Budapest, Hungary
| | - A Patócs
- Department of Laboratory Medicine, MTA-SE Lendulet Research Group, Hungarian Academy of Sciences, Semmelweis University, 46. Szentkiralyi str, Budapest, 1088, Hungary.
- "Lendület" Hereditary Endocrine Tumours Research Group, HAS-SE, Budapest, Hungary.
- Bionics Innovation Center, Budapest, Hungary.
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12
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Nordkap L, Almstrup K, Nielsen JE, Bang AK, Priskorn L, Krause M, Holmboe SA, Winge SB, Egeberg Palme DL, Mørup N, Petersen JH, Juul A, Skakkebaek NE, Rajpert-De Meyts E, Jørgensen N. Possible involvement of the glucocorticoid receptor (NR3C1) and selected NR3C1
gene variants in regulation of human testicular function. Andrology 2017; 5:1105-1114. [DOI: 10.1111/andr.12418] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 06/29/2017] [Accepted: 07/20/2017] [Indexed: 12/11/2022]
Affiliation(s)
- L. Nordkap
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - K. Almstrup
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - J. E. Nielsen
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - A. K. Bang
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - L. Priskorn
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - M. Krause
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - S. A. Holmboe
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - S. B. Winge
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - D. L. Egeberg Palme
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - N. Mørup
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - J. H. Petersen
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
- Department of Biostatistics; University of Copenhagen; Copenhagen Denmark
| | - A. Juul
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - N. E. Skakkebaek
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - E. Rajpert-De Meyts
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
| | - N. Jørgensen
- Department of Growth and Reproduction and International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC); Rigshospitalet; University of Copenhagen; Copenhagen Ø Denmark
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13
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Zhao Z, Xue Y, Hong D, Zhang H, Hu Z, Fan S, Chen H. Polymorphisms in the Glucocorticoid Receptor Gene and Associations with Glucocorticoid-Induced Avascular Osteonecrosis of the Femoral Head. Genet Test Mol Biomarkers 2017; 21:322-327. [PMID: 28346829 DOI: 10.1089/gtmb.2016.0260] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Zhanqin Zhao
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Taizhou, China
- College of Animal Science and Technology, Henan University of Science and Technology, Luoyang, China
| | - Yun Xue
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Taizhou, China
- College of Medical Technology and Engineering, Henan University of Science and Technology, Luoyang, China
| | - Dun Hong
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Taizhou, China
| | - Hongjun Zhang
- Department of Orthopedics, Bone-Setting Hospital of Luoyang, Luoyang, China
| | - Zhigang Hu
- College of Medical Technology and Engineering, Henan University of Science and Technology, Luoyang, China
| | - Shunwu Fan
- Department of Orthopedics, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Haixiao Chen
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Taizhou, China
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14
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Zotter Z, Nagy Z, Patócs A, Csuka D, Veszeli N, Kőhalmi KV, Farkas H. Glucocorticoid receptor gene polymorphisms in hereditary angioedema with C1-inhibitor deficiency. Orphanet J Rare Dis 2017; 12:5. [PMID: 28069032 PMCID: PMC5223456 DOI: 10.1186/s13023-016-0552-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 12/09/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Hereditary angioedema caused by C1-inhibitor deficiency (C1-INH-HAE) is a rare, autosomal dominant disorder. C1-INH-HAE is characterized by edema-formation, which may occur in response to stress. The individual's response to stress stimuli is partly genetically determined. Activation of the hypothalamic-pituitary-adrenal axis results in the release of cortisol. In turn, the secreted gluco- and mineralocorticoids affect the metabolism, as well as the cardiovascular and immune systems. We hypothesized that changes in serum cortisol level and polymorphisms of the glucocorticoid receptor (GR) modify the individual sensitivity to stressor stimuli of C1-INH-HAE patients. RESULTS We compared the response to stress with Rahe's Brief Stress and Coping Inventory of 43 C1-INH-HAE patients, 18 angioedema patients and 13 healthy controls. 139 C1-INH-HAE patients and 160 healthy controls were genotyped for glucocorticoid receptor polymorphisms BclI, N363S and A3669G. Serum cortisol levels were determined during attacks and during symptom-free periods in 36 C1-INH-HAE patients. The relationships between clinical, laboratory data and GR SNPs (Single Nucleotide Polymorphisms) were assessed using ANOVA. C1-INH-HAE patients have decreased coping capabilities compared to healthy controls. Cortisol levels were significantly higher during attacks than in symptom-free periods (p = 0.004). The magnitude of the elevation of cortisol levels did not show a significant correlation with any clinical or laboratory data. Among the C1-INH-HAE patients, the carriers of the A3669G allele had significantly lower cortisol levels, and increased body mass index compared with non-carriers. CONCLUSIONS The higher cortisol level observed during attacks may reflect the effect of a stressful situation (such as of the attack itself), on the patients' neuroendocrine system. In A3669G carriers, the lower cortisol levels might reflect altered feedback to the hypothalamic-pituitary-adrenal axis, due to decreased sensitivity to glucocorticoids.
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Affiliation(s)
- Zsuzsanna Zotter
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi street 4, H-1125, Budapest, Hungary.,Department of Urology, Medical Center, Hungarian Defence Forces, Budapest, Hungary
| | - Zsolt Nagy
- 2nd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.,HAS-SE "Lendület" Hereditary Endocrine Tumors Research Group, Hungarian Academy of Sciences, Budapest, Hungary
| | - Attila Patócs
- HAS-SE "Lendület" Hereditary Endocrine Tumors Research Group, Hungarian Academy of Sciences, Budapest, Hungary
| | - Dorottya Csuka
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi street 4, H-1125, Budapest, Hungary
| | - Nóra Veszeli
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi street 4, H-1125, Budapest, Hungary
| | - Kinga Viktória Kőhalmi
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi street 4, H-1125, Budapest, Hungary
| | - Henriette Farkas
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi street 4, H-1125, Budapest, Hungary.
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15
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Chiodini I, Vainicher CE, Morelli V, Palmieri S, Cairoli E, Salcuni AS, Copetti M, Scillitani A. MECHANISMS IN ENDOCRINOLOGY: Endogenous subclinical hypercortisolism and bone: a clinical review. Eur J Endocrinol 2016; 175:R265-R282. [PMID: 27412441 DOI: 10.1530/eje-16-0289] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/13/2016] [Indexed: 01/11/2023]
Abstract
In recent years, the condition of subclinical hypercortisolism (SH) has become a topic of growing interest. This is due to the fact that SH prevalence is not negligible (0.8-2% in the general population) and that, although asymptomatic, this subtle cortisol excess is not harmless, being associated with an increased risk of complications, in particular of osteoporosis and fragility fractures. As specific symptoms of hypercortisolism are absent in SH, the SH diagnosis relies only on biochemical tests and it is a challenge for physicians. As a consequence, even the indications for the evaluation of bone involvement in SH patients are debatable and guidelines are not available. Finally, the relative importance of bone density, bone quality and glucocorticoid sensitivity in SH is a recent field of research. On the other hand, SH prevalence seems to be increased in osteoporotic patients, in whom a vertebral fracture may be the presenting symptom of an otherwise asymptomatic cortisol excess. Therefore, the issue of who and how to screen for SH among the osteoporotic patients is widely debated. The present review will summarize the available data regarding the bone turnover, bone mineral density, bone quality and risk of fracture in patients with endogenous SH. In addition, the role of the individual glucocorticoid sensitivity in SH-related bone damage and the problem of diagnosing and managing the bone consequences of SH will be reviewed. Finally, the issue of suspecting and screening for SH patients with apparent primary osteoporosis will be addressed.
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Affiliation(s)
- I Chiodini
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - C Eller Vainicher
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - V Morelli
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - S Palmieri
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - E Cairoli
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - A S Salcuni
- Endocrine UnitDepartment of Medical Sciences, University of Cagliari, Cagliari, Italy
| | | | - A Scillitani
- Unit of Endocrinology"Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
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16
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Reimondo G, Chiodini I, Puglisi S, Pia A, Morelli V, Kastelan D, Cannavo S, Berchialla P, Giachino D, Perotti P, Cuccurullo A, Paccotti P, Beck-Peccoz P, De Marchi M, Terzolo M. Analysis of BCLI, N363S and ER22/23EK Polymorphisms of the Glucocorticoid Receptor Gene in Adrenal Incidentalomas. PLoS One 2016; 11:e0162437. [PMID: 27649075 PMCID: PMC5029814 DOI: 10.1371/journal.pone.0162437] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/23/2016] [Indexed: 12/14/2022] Open
Abstract
CONTEXT Patients with adrenal incidentalomas (AI) may experience detrimental consequences due to a minimal cortisol excess sustained by adrenal adenoma. SNPs of the glucocorticoid receptor gene (NR3C1) modulate individual sensitivity to glucocorticoids and may interfere with the clinical presentation. OBJECTIVE To compare the frequency of N363S, ER22/23EK and BclI SNPs in patients with AI with the general population and to evaluate whether these SNPs are linked to consequences of cortisol excess. SETTING Multicentric, retrospective analysis of patients referred from 2010 to 2014 to 4 centers (Orbassano, Milano, Messina [Italy] and Zagreb [Croatia]). PATIENTS 411 patients with AI; 153 males and 258 females and 186 from blood donors. MAIN OUTCOMES MEASURES All patients and controls were genotyped for BclI, N363S and ER22/23EK and SNPs frequency was associated with clinical and hormonal features. RESULTS SNP frequency was: SNP frequency was: N363S 5.4% (MAF 0.027), BclI 54.7% (MAF 0.328), ER22/23EK 4.4% (MAF 0.022), without any significant difference between patients and controls. N363S was more frequent in hypertensive patients (p = 0.03) and was associated with hypertension (p = 0.015) in patients with suppressed cortisol after the 1-mg DST. CONCLUSIONS Our results demonstrate that SNPs of the glucocorticoid receptor gene do not play a pathogenetic role for AI. The impact of any single SNP on the phenotypic expression of minimal cortisol excess is limited and their analysis does not provide additional data that may be exploited for patient management.
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Affiliation(s)
- Giuseppe Reimondo
- Internal Medicine 1, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Iacopo Chiodini
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milano Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Soraya Puglisi
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Messina, Policlinico G. Martino Hospital, Messina, Italy
| | - Anna Pia
- Internal Medicine 1, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Valentina Morelli
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milano Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia
| | - Salvatore Cannavo
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Messina, Policlinico G. Martino Hospital, Messina, Italy
| | - Paola Berchialla
- Statistical Unit, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga, Hospital, Orbassano, Italy
| | - Daniela Giachino
- Medical Genetics, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Paola Perotti
- Internal Medicine 1, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Alessandra Cuccurullo
- Medical Genetics, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Piero Paccotti
- Internal Medicine 1, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Paolo Beck-Peccoz
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milano Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Mario De Marchi
- Medical Genetics, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Massimo Terzolo
- Internal Medicine 1, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Italy
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17
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Molnár Á, Kövesdi A, Szücs N, Tóth M, Igaz P, Rácz K, Patócs A. Polymorphisms of the GR and HSD11B1 genes influence body mass index and weight gain during hormone replacement treatment in patients with Addison's disease. Clin Endocrinol (Oxf) 2016; 85:180-8. [PMID: 26800219 DOI: 10.1111/cen.13022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 01/05/2016] [Accepted: 01/13/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Glucocorticoid substitution is essential in patients with chronic primary adrenocortical insufficiency (Addison's disease) and both over-treatment and inadequate dosage have deleterious effects. Individual sensitivity to glucocorticoids is partly genetically determined. CONTEXT To test the hypothesis whether the well-characterized SNPs of the GR and HSD11B1 genes may modulate the individual sensitivity to exogenous glucocorticoids and may influence clinical and/or laboratory parameters and the glucocorticoid substitution dosage in patients with Addison's disease. PATIENTS AND METHODS 68 patients with primary adrenocortical insufficiency were involved. Clinical and laboratory data, as well as the dosage of the hormone replacement therapy were collected. Peripheral blood DNA was isolated, and the GR and HSD11B1 SNPs were examined using allele-specific PCR or Taqman assay on Real Time PCR. RESULTS The allele frequency of the GR N363S polymorphism was higher in patients compared to the control group and the disease appeared significantly earlier in patients harbouring the GR A3669G compared to noncarriers. These patients had higher ACTH level measured at the time of diagnosis. Homozygous BclI carriers had higher body mass index (BMI) and lower total hydrocortisone equivalent supplementation dose needed than heterozygous or noncarriers. The BMI and weight gain during hormone replacement therapy were also higher in carriers of the HSD11B1 rs4844880 treated with glucocorticoids other than dexamethasone. CONCLUSION The BclI polymorphism of the GR gene and the rs4844880 of the HSD11B1 gene may contribute to weight gain and may affect the individual need of glucocorticoid substitution dose in these patients.
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Affiliation(s)
- Ágnes Molnár
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
- Lendület" Hereditary Endocrine Tumours Research Group, Budapest, Hungary
| | - Annamária Kövesdi
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Nikolette Szücs
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Miklós Tóth
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Igaz
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Károly Rácz
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
- Molecular Medicine Research Group, Semmelweis University - Hungarian Academy of Sciences, Budapest, Hungary
| | - Attila Patócs
- Lendület" Hereditary Endocrine Tumours Research Group, Budapest, Hungary
- Molecular Medicine Research Group, Semmelweis University - Hungarian Academy of Sciences, Budapest, Hungary
- Department of Laboratory Medicine, Semmelweis University, Budapest, Hungary
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18
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Roerink SHPP, Wagenmakers MAEM, Smit JWA, van Rossum EFC, Netea-Maier RT, Plantinga TS, Hermus ARMM. Glucocorticoid receptor polymorphisms modulate cardiometabolic risk factors in patients in long-term remission of Cushing's syndrome. Endocrine 2016; 53:63-70. [PMID: 26873309 PMCID: PMC4901092 DOI: 10.1007/s12020-016-0883-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 02/01/2016] [Indexed: 12/13/2022]
Abstract
CONTEXT Glucocorticoid receptor (GR) polymorphisms modulate glucocorticoid (GC) sensitivity and are associated with altered metabolic profiles. OBJECTIVE To evaluate the presence of GR polymorphisms (BclI (rs41423247), N363S (rs56149945), ER22/23EK (rs6189/rs6190), and 9β (rs6198) and investigate their associations with metabolic alterations in patients in long-term remission of Cushing's syndrome (CS). DESIGN AND SETTING Cross-sectional case-control study. PATIENTS AND METHODS Sixty patients in long-term remission of CS were genotyped. Associations between GR polymorphisms and multiple vascular, body composition and metabolic parameters were investigated. MAIN OUTCOME MEASURES Allelic frequencies of the polymorphisms and their associations with several cardiometabolic risk factors. RESULTS This study shows that carriers of the 9β polymorphism have a higher systolic blood pressure and lower resistin levels. The GC sensitizing BclI polymorphism is associated with an adverse cardiometabolic risk factor profile: higher fat percentages of extremities and legs, higher serum leptin and E-selectin levels, and higher intima media thickness in carriers versus non-carriers. CONCLUSIONS The 9β and BclI polymorphisms of the GR adversely affect the cardiometabolic profile in patients who are in remission after the treatment of CS. This suggests that genetically altered GC sensitivity modulates the long-term adverse cardiometabolic effects resulting from (endogenous) hypercortisolism.
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Affiliation(s)
- Sean H P P Roerink
- Division of Endocrinology, Department of Medicine, Radboud University Medical Centre, Geert Grooteplein 8, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - M A E M Wagenmakers
- Division of Endocrinology, Department of Medicine, Radboud University Medical Centre, Geert Grooteplein 8, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - J W A Smit
- Division of Endocrinology, Department of Medicine, Radboud University Medical Centre, Geert Grooteplein 8, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - E F C van Rossum
- Division of Endocrinology, Department of Internal Medicine, Erasmus University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - R T Netea-Maier
- Division of Endocrinology, Department of Medicine, Radboud University Medical Centre, Geert Grooteplein 8, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - T S Plantinga
- Division of Endocrinology, Department of Medicine, Radboud University Medical Centre, Geert Grooteplein 8, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - A R M M Hermus
- Division of Endocrinology, Department of Medicine, Radboud University Medical Centre, Geert Grooteplein 8, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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19
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Iacobone M, Citton M, Scarpa M, Viel G, Boscaro M, Nitti D. Systematic review of surgical treatment of subclinical Cushing's syndrome. Br J Surg 2015; 102:318-30. [PMID: 25640696 DOI: 10.1002/bjs.9742] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/23/2014] [Accepted: 11/11/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Subclinical Cushing's syndrome (SCS) is a condition of biochemical cortisol excess without the classical clinical features of overt hypercortisolism; it may be associated with some consequences of metabolic syndrome. The most appropriate treatment remains controversial. This study aimed to assess the outcomes of adrenalectomy for SCS. METHODS A systematic review was performed. MEDLINE, Embase and Cochrane Databases (1980-2013) were searched for studies reporting the outcomes of unilateral adrenalectomy with respect to hypertension, diabetes, dyslipidaemia, obesity and osteoporosis in patients with SCS. Studies with a questionable diagnosis of SCS, bilateral adrenal involvement and insufficient data were excluded. RESULTS Of the 105 papers screened, seven were selected; there were six retrospective studies and one randomized clinical trial, including 230 patients. Data analysis was limited by heterogeneity in definition of SCS and endpoints. Hypercortisolism was cured in all operated patients. Laparoscopy was the preferred approach, with a morbidity rate of 0·8 per cent. A beneficial effect of surgery on blood pressure, glucometabolic control and obesity was evident in all studies, with cure or improvement in 72, 46 and 39 per cent of patients respectively, compared with conservative management. The results for lipid metabolism were equivocal, because of a decrease in triglyceridaemia but discordant effects on cholesterol metabolism among the different studies. No beneficial effects on osteoporosis were found. CONCLUSION Laparoscopic adrenalectomy seems to be beneficial in reversing several metabolic effects of hypercortisolism, with a low morbidity rate. However, the heterogeneity and low quality of the available studies preclude definitive recommendations.
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Affiliation(s)
- M Iacobone
- Minimally Invasive Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, Padua, Italy
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20
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Ragnarsson O, Glad CAM, Bergthorsdottir R, Almqvist EG, Ekerstad E, Widell H, Wängberg B, Johannsson G. Body composition and bone mineral density in women with Cushing's syndrome in remission and the association with common genetic variants influencing glucocorticoid sensitivity. Eur J Endocrinol 2015; 172:1-10. [PMID: 25422351 DOI: 10.1530/eje-14-0747] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Adverse body compositional features and low bone mineral density (BMD) are the characteristic of patients with active Cushing's syndrome (CS). The aim of this study was to evaluate body composition and BMD in women with CS in long-term remission and the influence of polymorphisms in genes affecting glucocorticoid (GC) sensitivity on these end-points. DESIGN, PATIENTS AND METHODS This was a cross-sectional, case-controlled study, including 50 women previously treated for CS and 50 age and gender-matched controls. Median (interquartile range) remission time was 13 (5-19) years. Body composition and BMD were measured with dual-energy X-ray absorptiometry. Five polymorphisms in four genes associated with GC sensitivity were analysed using TaqMan or Sequenom single-nucleotide polymorphism genotyping. RESULTS Patients with CS in remission had increased abdominal fat mass (P<0.01), whereas BMD was not significantly different at any site between patients and controls. In patients, the NR3C1 Bcl1 polymorphism was associated with reduced total (P<0.05) and femur neck BMD (P<0.05). The polymorphism rs1045642 in the ABCB1 gene was associated with increased abdominal fat mass (P<0.05) and decreased appendicular skeletal muscle mass (P<0.05). GC replacement was associated with reduced total BMD (P<0.01), BMD at lumbar spine (P<0.05) and increased abdominal fat (P<0.01). CONCLUSION Ongoing GC replacement therapy together with polymorphisms in two genes related with GC sensitivity is associated with abdominal obesity and adverse skeletal health in patients with CS in long-term remission.
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Affiliation(s)
- Oskar Ragnarsson
- Institute of Medicine at Sahlgrenska AcademyUniversity of Gothenburg, Göteborg, SwedenDepartment of EndocrinologySkaraborg Hospital, Skövde, SwedenDepartment of Internal MedicineNorra Älvsborgs Hospital, Trollhättan, SwedenDepartment of Internal MedicineSödra Älvsborgs Hospital, Borås, SwedenDepartment of SurgerySahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Camilla A M Glad
- Institute of Medicine at Sahlgrenska AcademyUniversity of Gothenburg, Göteborg, SwedenDepartment of EndocrinologySkaraborg Hospital, Skövde, SwedenDepartment of Internal MedicineNorra Älvsborgs Hospital, Trollhättan, SwedenDepartment of Internal MedicineSödra Älvsborgs Hospital, Borås, SwedenDepartment of SurgerySahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Ragnhildur Bergthorsdottir
- Institute of Medicine at Sahlgrenska AcademyUniversity of Gothenburg, Göteborg, SwedenDepartment of EndocrinologySkaraborg Hospital, Skövde, SwedenDepartment of Internal MedicineNorra Älvsborgs Hospital, Trollhättan, SwedenDepartment of Internal MedicineSödra Älvsborgs Hospital, Borås, SwedenDepartment of SurgerySahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Erik G Almqvist
- Institute of Medicine at Sahlgrenska AcademyUniversity of Gothenburg, Göteborg, SwedenDepartment of EndocrinologySkaraborg Hospital, Skövde, SwedenDepartment of Internal MedicineNorra Älvsborgs Hospital, Trollhättan, SwedenDepartment of Internal MedicineSödra Älvsborgs Hospital, Borås, SwedenDepartment of SurgerySahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Eva Ekerstad
- Institute of Medicine at Sahlgrenska AcademyUniversity of Gothenburg, Göteborg, SwedenDepartment of EndocrinologySkaraborg Hospital, Skövde, SwedenDepartment of Internal MedicineNorra Älvsborgs Hospital, Trollhättan, SwedenDepartment of Internal MedicineSödra Älvsborgs Hospital, Borås, SwedenDepartment of SurgerySahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Håkan Widell
- Institute of Medicine at Sahlgrenska AcademyUniversity of Gothenburg, Göteborg, SwedenDepartment of EndocrinologySkaraborg Hospital, Skövde, SwedenDepartment of Internal MedicineNorra Älvsborgs Hospital, Trollhättan, SwedenDepartment of Internal MedicineSödra Älvsborgs Hospital, Borås, SwedenDepartment of SurgerySahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Bo Wängberg
- Institute of Medicine at Sahlgrenska AcademyUniversity of Gothenburg, Göteborg, SwedenDepartment of EndocrinologySkaraborg Hospital, Skövde, SwedenDepartment of Internal MedicineNorra Älvsborgs Hospital, Trollhättan, SwedenDepartment of Internal MedicineSödra Älvsborgs Hospital, Borås, SwedenDepartment of SurgerySahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Gudmundur Johannsson
- Institute of Medicine at Sahlgrenska AcademyUniversity of Gothenburg, Göteborg, SwedenDepartment of EndocrinologySkaraborg Hospital, Skövde, SwedenDepartment of Internal MedicineNorra Älvsborgs Hospital, Trollhättan, SwedenDepartment of Internal MedicineSödra Älvsborgs Hospital, Borås, SwedenDepartment of SurgerySahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
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Koper JW, van Rossum EFC, van den Akker ELT. Glucocorticoid receptor polymorphisms and haplotypes and their expression in health and disease. Steroids 2014; 92:62-73. [PMID: 25150015 DOI: 10.1016/j.steroids.2014.07.015] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 07/21/2014] [Accepted: 07/24/2014] [Indexed: 02/02/2023]
Abstract
Cortisol is involved in many physiological processes, including immunosuppressive and anti-inflammatory actions, and therefore cortisol and its synthetic analogs are widely used to treat a large number of diseases. In glucocorticoid treatment, a large variability of clinical responses is observed. This variability may, in part, be ascribed to genetic variation in the glucocorticoid receptor (GR) gene. In this review we present a catalogue of the various single nucleotide polymorphisms (SNPs) in the glucocorticoid receptor gene and their consequences for human health and disease. Many different GR SNP association studies have been described. However, most studies come down to only a few SNPs reported with different annotations. In this review we clarified these different annotations to uniform names. Most associations between GR SNPs and phenotype have been found in body composition, metabolism, the cardiovascular system, the immune system and psychiatric illnesses. However, many associations have not been replicated (yet), and future replication studies and meta-analyses are needed. There is a substantial body of evidence for GR SNPs to have effects on clinical phenotype. However, as most SNP frequencies are low and their variation is within the range of the general population, the impact of a single SNP for health and disease in the general population is probably modest. However, in-depth studying of the molecular mechanisms of repeatedly observed clinical associations could lead to new possibilities for drug development. In particular the development of selective glucocorticoid receptor modulators holds promise.
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Affiliation(s)
- Jan W Koper
- Department of Internal Medicine, Section of Endocrinology, Erasmus MC, The Netherlands
| | | | - Erica L T van den Akker
- Department of Pediatrics, Section Endocrinology, Erasmus MC-Sophia, Rotterdam, The Netherlands.
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Ragnarsson O, Glad CAM, Berglund P, Bergthorsdottir R, Eder DN, Johannsson G. Common genetic variants in the glucocorticoid receptor and the 11β-hydroxysteroid dehydrogenase type 1 genes influence long-term cognitive impairments in patients with Cushing's syndrome in remission. J Clin Endocrinol Metab 2014; 99:E1803-7. [PMID: 24915124 DOI: 10.1210/jc.2014-1906] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTEXT Cognitive function is impaired in patients with Cushing's syndrome (CS) in remission. OBJECTIVE The objective of the investigation was to study the effects of polymorphisms in genes associated with glucocorticoid (GC) sensitivity on cognitive function in patients with CS in long-term remission. DESIGN This was a cross-sectional, case-controlled, single-center study. PATIENTS Fifty-three patients with CS in remission and 53 controls matched for age, gender, and educational level participated in the study. MAIN OUTCOME MEASURES Cognitive function, studied using standardized neuropsychological testing, and polymorphisms in the GC receptor (NR3C1; Bcl1 and A3669G), mineralocorticoid receptor (NR3C2; I180V), 11β-hydroxysteroid dehydrogenase type 1 (11βHSD1; rs11119328), and ATP binding cassette B1 (ABCB1; rs1045642) genes were measured. The association between cognitive function and polymorphisms were analyzed using linear regression with adjustments for age and educational level. RESULTS The mean age in patients and controls was 53 ± 14 years. The median (interquartile range) duration of remission was 13 (5-18) years. In patients, the single-nucleotide polymorphism rs11119328 was associated with impairments in processing speed, auditory attention, auditory working memory, and reading speed. This association was not seen in matched controls. The Bcl1 polymorphism was associated with fatigue and worse visual attention and working memory. The remaining single-nucleotide polymorphisms were not associated with cognitive performance. CONCLUSION In this study, polymorphisms in the 11βHSD1 and NR3C1 genes were associated with impaired cognitive function, indicating that GC sensitivity and prereceptor regulation of GC action may play a role in the long-term consequences of CS. The study provides a novel insight into the etiology of cognitive dysfunction in patients with CS in remission.
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Affiliation(s)
- Oskar Ragnarsson
- Institute of Medicine (O.R., C.A.M.G., R.B., G.J.), Institute of Neuroscience and Physiology (P.B.), and Vigilance and Neurocognition Laboratory (D.N.E.), Sahlgrenska Academy, University of Gothenburg, SE-413 45 Göteborg Sweden
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23
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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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24
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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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25
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Moreira RPP, Bachega TASS, Machado MC, Mendonca BB, Bronstein MD, Villares Fragoso MCB. Modulatory effect of BclI GR gene polymorphisms on the obesity phenotype in Brazilian patients with Cushing's disease. Clinics (Sao Paulo) 2013; 68:579-85. [PMID: 23778418 PMCID: PMC3654304 DOI: 10.6061/clinics/2013(05)01] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 01/02/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Patients with Cushing's disease exhibit wide phenotypic variability in the severity of obesity, diabetes and hypertension. In the general population, several glucocorticoid receptor genes (NR3C1) and HSD11B1 polymorphisms are associated with altered glucocorticoid sensitivity and/or metabolism, resulting in an increased or reduced risk of an adverse metabolic profile. Our aim was to analyze the association of NR3C1 and HSD11B1 gene variants with the severity of some clinical and hormonal features of Cushing's disease. METHODS Sixty-four patients presenting with Cushing's disease were diagnosed based on adrenocorticotrophic hormone levels, high-dose dexamethasone suppression tests and/or inferior petrosal sinus sampling and magnetic resonance imaging. The A3669G, ER22/23EK, N363S BclI-NR3C1 and HSD11B1-rs12086634 variants were screened. RESULTS The BclI, HSD11B1-rs12086634 and A3669G variants were found in 36%, 19.5% and 14% of alleles, respectively. The N363S and ER22/23EK polymorphisms were identified in heterozygosis once in only two patients (1.5% of alleles). There were no differences in the weight gain or prevalence of diabetes and hypertension in the patients carrying the abovementioned alleles compared to the wild-type carriers. Interestingly, the mean body mass index (BMI) of the BclI carriers was significantly higher than the non-carriers (34.4±7 kg/m2 vs. 29.6±4.7 kg/m2, respectively). None of the polymorphisms were associated with the basal adrenocorticotrophic hormone, FU levels or F level after dexamethasone suppression testing. CONCLUSION Although Cushing's disease results from increased glucocorticoid secretion, we observed that interindividual variability in the peripheral glucocorticoid sensitivity, mediated by the glucocorticoid receptor, could modulate the obesity phenotype.
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Affiliation(s)
- Ricardo P P Moreira
- Faculdade de Medicina, Universidade de São PauloUnidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, São PauloSP, Brazil
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Damjanovic SS, Antic JA, Ilic BB, Cokic BB, Ivovic M, Ognjanovic SI, Isailovic TV, Popovic BM, Bozic IB, Tatic S, Matic G, Todorovic VN, Paunovic I. Glucocorticoid receptor and molecular chaperones in the pathogenesis of adrenal incidentalomas: potential role of reduced sensitivity to glucocorticoids. Mol Med 2013. [PMID: 23196783 DOI: 10.2119/molmed.2012.00261] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Glucocorticoid (GC) sensitivity depends on glucocorticoid receptor (GR) and heat shock proteins (Hsps). We investigated whether common GR genes (ER22/23EK, N363S, Bcl I, and 9β) and adrenocorticotropin receptor promoter polymorphisms influence susceptibility for unilateral adrenal incidentaloma (AI), plus GR and Hsp expression in tumorous (n = 19), peritumorous (n = 13) and normal adrenocortical (n = 11) tissues. Patients (n = 112), population-matched controls (n = 100) and tumor tissues (n = 32) were genotyped for these polymorphisms. Postdexamethasone serum cortisol was higher in patients (p < 0.001). GR gene variants, larger allele of Bcl I (odds ratio [OR] 2.9; 95% confidence interval [CI] 1.7-5.1; p < 0.001] and minor allele of 9β (OR 3.0; 95% CI 1.6-5.7; p < 0.001) were independent predictors of AI. In patients, the first allele is linked with larger tumors (p = 0.002) and the latter with higher postdexamethasone cortisol levels (p = 0.025). Both allele carriers had lesser waist circumference (p = 0.02), similar adrenocorticotropin and higher basal (p = 0.024) and postdexamethasone cortisol concentrations (p < 0.001). Tumorous and constitutional genotypes were similar. GR-D is the major receptor isoform in normal adrenal cortex by Western blotting. Loss of other receptor isoforms, decrease in immunostaining for GR (p < 0.0001), underexpression of chaperones (p ≤ 0.01) and the presence of inducible Hsp70 were found in adenomas. In conclusion, GR gene variants, C allele of Bcl I and minor allele of 9β, are associated with AIs. Their concurrent presence in patients reduces GC sensitivity. Normal adrenal cortex preferentially expresses GR-D. In adenomas, the lack of other GR isoforms and underexpression of heat shock proteins perhaps permanently impair GC signaling, which could promote dysregulated cortisol production and tumor growth. The innate GC sensitivity probably modifies these effects.
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Affiliation(s)
- Svetozar S Damjanovic
- Centre for Endocrine Oncology and Hereditary Cancer Syndromes, Institute for Endocrinology, Diabetes and Diseases of Metabolism, Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia.
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27
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Giordano R, Marzotti S, Berardelli R, Karamouzis I, Brozzetti A, D'Angelo V, Mengozzi G, Mandrile G, Giachino D, Migliaretti G, Bini V, Falorni A, Ghigo E, Arvat E. BClI polymorphism of the glucocorticoid receptor gene is associated with increased obesity, impaired glucose metabolism and dyslipidaemia in patients with Addison's disease. Clin Endocrinol (Oxf) 2012; 77:863-70. [PMID: 22587831 DOI: 10.1111/j.1365-2265.2012.04439.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECT Although glucocorticoids are essential for health, several studies have shown that glucocorticoids replacement in Addison's disease might be involved in anthropometric and metabolic impairment, with increased cardiovascular risk, namely if conventional doses are used. As the effects of glucocorticoids are mediated by the glucocorticoid receptor, encoded by NR3C1 gene, different polymorphisms in the NR3C1 gene have been linked to altered glucocorticoid sensitivity in general population as well as in patients with obesity or metabolic syndrome. DESIGN We investigated the impact of glucocorticoid receptor gene polymorphisms, including the BclI, N363S and ER22/23EK variants, on anthropometric parameters (BMI and waist circumference), metabolic profile (HOMA, OGTT and serum lipids) and ACTH levels in 50 patients with Addison's disease (34 women and 16 men, age 20-82 year) under glucocorticoids replacement. RESULTS Neither N363S nor ER22/23EK variants were significantly associated with anthropometric, metabolic or hormonal parameters, while patients carrying the homozygous BclI polymorphism GG (n = 4) showed higher (P < 0·05) BMI, waist circumference, HOMA and 2-h glucose levels after OGTT, as well as total cholesterol and triglycerides than those with wild-type genotype CC (n = 28) or heterozygous CG (n = 18). The totality of GG patients was connoted by abdominal adiposity, impaired glucose tolerance/diabetes mellitus or dyslipidaemia, while a lower percentage of CC or CG patients showed some anthropometric and metabolic alterations. CONCLUSION These results suggest that BclI polymorphism may influence the sensitivity to glucocorticoids in patients with Addison's disease and may contribute, along with other factors, to the increase in central adiposity, impaired glucose metabolism and dyslipidaemia.
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Affiliation(s)
- Roberta Giordano
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
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Moutsatsou P, Kassi E, Papavassiliou AG. Glucocorticoid receptor signaling in bone cells. Trends Mol Med 2012; 18:348-59. [PMID: 22578718 DOI: 10.1016/j.molmed.2012.04.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 04/03/2012] [Accepted: 04/13/2012] [Indexed: 12/26/2022]
Abstract
Glucocorticoids are used for treating a wide range of diseases including inflammation and autoimmune disorders. However, there are drawbacks, primarily due to adverse effects on bone cells resulting in osteoporosis. Evidence indicates that the ratio of benefits to adverse effects depends greatly on glucocorticoid receptor (GR)-mediated mechanisms. Delineating GR-mediated signaling in bone cells will allow development of selective GR ligands/agonists (SEGRAs), which would dissociate the positive therapeutic (anti-inflammatory) effects from the negative effects on the skeleton. The present review provides an in-depth account of the current knowledge of GR-mediated transcriptional regulation of specific genes and proteins engaged in the proliferation, differentiation, and apoptosis of bone cells (osteoblasts, osteocytes, osteoclasts). We hope this knowledge will advance research in the development of SEGRAs with improved benefit/risk ratios.
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Affiliation(s)
- Paraskevi Moutsatsou
- Department of Biological Chemistry, University of Athens Medical School, 75, Mikras Asias Street, 11527 Athens, Greece
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Tzanela M, Mantzou E, Saltiki K, Tampourlou M, Kalogeris N, Hadjidakis D, Tsagarakis S, Alevizaki M. Clinical and biochemical impact of BCL1 polymorphic genotype of the glucocorticoid receptor gene in patients with adrenal incidentalomas. J Endocrinol Invest 2012; 35:395-400. [PMID: 21738001 DOI: 10.3275/7840] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adrenal incidentaloma (AI) is a common clinical problem. Subtle hormonal abnormalities are present in a substantial proportion of patients. BCL1 gene polymorphism of the glucocorticoid receptor (GR) is associated with increased sensitivity to glucocorticoid action. The genotype- phenotype associations of this polymomorphism in patients presenting with AI has not been extensively investigated. AIM A cross-sectional study in secondary/tertiary care centers. SUBJECTS/METHODS Ninety-five subjects with AI were genotyped for the BCL1 GR gene polymorphism. Patients underwent an oral glucose tolerance test and a dexamethasone suppression test (DST). The presence of subclinical hypercortisolism, features of metabolic syndrome, and osteoporosis/ osteopenia were also assessed. RESULTS No significant differences in markers of adrenal function between BCL1 carriers and non-carriers were revealed. Also, no difference was found in the features of metabolic syndrome, as well as in bone metabolism and density between these 2 groups. However, DST suppressor patients belonged more frequently to the BCL1 carriers group (41 out of 69 patients, 59.4% vs 9 out of 26 patients, 34.6%, p=0.0039), had smaller total adenoma size (2.4±0.2 cm vs 3.5±0.4 cm, p=0.04), and lower incidence of bilateral adrenal masses (18.8% vs 46.2%, p=0.01). CONCLUSIONS AI patients who also carry the polymorphic BCL1 variant exhibit smaller size adrenal nodules. Those AI patients with complete DST suppression had a higher incidence of the polymorphic BCL1 variant. However, this study failed to demonstrate any significant impact of BCL1 GR polymorphism on the frequency of cortisol-dependent co-morbidities in patients with AI.
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Affiliation(s)
- M Tzanela
- Department of Endocrinology, Evangelismos Hospital, 45-47 Ipsilantous St., Athens, Greece
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Spijker AT, van Rossum EFC. Glucocorticoid sensitivity in mood disorders. Neuroendocrinology 2012; 95:179-86. [PMID: 22076031 DOI: 10.1159/000329846] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 05/31/2011] [Indexed: 01/24/2023]
Abstract
In this review, we provide an overview of recent literature on glucocorticoid (GC) sensitivity in mood disorders. Assessing GC sensitivity is often performed by measuring the cortisol awakening rise (CAR), by challenging the hypothalamic-pituitary-adrenal (HPA) axis using a dexamethasone suppression test (DST) or a dexamethasone/cortisol-releasing hormone test (DEX/CRH); more recently by measuring cortisol as a retrospective calendar in scalp hair. The main findings in mood disorders are higher mean cortisol levels in hair samples and a higher CAR, showing a hyperactivity of the HPA axis. This is in line with the mild resistance for GCs previously observed in challenge tests during mood episodes. GC sensitivity is partly determined by polymorphisms in the genes encoding receptors and other proteins involved in the regulation of the HPA axis. We shortly discuss the glucocorticoid receptor, as well as the mineralocorticoid receptor, the cortisol-releasing hormone receptor-1, and the glucocorticoid receptor co-chaperone FKBP5. Data clearly indicate genetic changes, along with epigenetic changes which influence the set-point and regulation of the HPA axis. Early trauma, as well as influences in utero, appears to be important. Future research is necessary to further clarify the biological background and consequences of an individual's cortisol exposure in relation to mood.
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Affiliation(s)
- A T Spijker
- Department of Mood Disorders, PsyQ The Hague, The Netherlands.
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Trementino L, Appolloni G, Concettoni C, Cardinaletti M, Boscaro M, Arnaldi G. Association of glucocorticoid receptor polymorphism A3669G with decreased risk of developing diabetes in patients with Cushing's syndrome. Eur J Endocrinol 2012; 166:35-42. [PMID: 22048965 DOI: 10.1530/eje-11-0722] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Glucocorticoid receptor (GR) polymorphisms alter glucocorticoid (GC) sensitivity and have been associated with altered metabolic profiles. We evaluate the prevalence of the four GR (NR3C1) polymorphisms BclI, N363S, ER22/23EK, and A3669G in patients with Cushing's syndrome (CS) compared with healthy controls (HC) and we investigate their role in the development of metabolic abnormalities in patients with CS according to their hormonal profile. PATIENTS AND METHODS Sixty-one patients with CS and 71 sex- and age-matched HC were genotyped. RESULTS BclI variant was markedly higher in patients with CS compared with HC (62 vs 41%, P<0.05) while no significant differences were found among other polymorphisms. A very low frequency of N363S and the ER22/23EK was observed. In CS patients, despite the significantly increased levels of morning serum cortisol in BclI carriers compared with wild type no clinical or metabolic differences were found. In contrast, A3669G GR carriers showed a significantly reduced prevalence of type 2 diabetes mellitus compared with wild type (19 vs 68%, P=0.001) despite the higher levels of both serum morning (21.7±6 vs 27.3±8.6 μg/dl, P=0.009) and midnight cortisol (18.8±5.8 vs 24.0±8.0 μg/dl, P=0.01). The negative association between diabetes and A3669G GR polymorphism remained significant when data were adjusted for potential confounding factors. CONCLUSIONS The A3669G polymorphism of the GR gene plays a protective role in patients with CS, attenuating the effects of GC excess on glucose metabolism as shown by their reduced risk of diabetes.
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Affiliation(s)
- Laura Trementino
- Division of Endocrinology, Polytechnic University of Marche, Via Conca 71, 60020 Torrette di Ancona, Italy
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Abstract
CONTEXT Subclinical hypercortisolism (SH) is a condition of biochemical cortisol excess without the classical signs or symptoms of overt hypercortisolism. It is thought to be present in the 5-30% of patients with incidentally discovered adrenal mass (adrenal incidentalomas), which in turn are found in 4-7% of the adult population. Therefore, SH has been suggested to be present in 0.2-2.0% of the adult population. Some studies suggested that this condition is present in 1-10% of patients with diabetes or established osteoporosis. The present manuscript reviews the literature on diagnostic procedures and the metabolic effect of the recovery from SH. EVIDENCE ACQUISITION A PubMed search was used to identify the available studies. The most relevant studies from 1992 to November 2010 have been included in the review. EVIDENCE SYNTHESIS The available data suggest that SH may be associated with chronic complications, such as hypertension, diabetes mellitus, overweight/obesity, and osteoporosis. The available intervention studies suggest that the recovery from SH may lead to the improvement of hypertension and diabetes mellitus. A retrospective study suggests that this beneficial effect could be predicted before surgery. CONCLUSIONS SH is suggested to be associated with some chronic complications of overt cortisol excess. Recovery from this condition seems to improve these complications. However, a large, prospective, randomized study is needed to confirm this hypothesis and to establish the best diagnostic approach to identify patients with adrenal incidentalomas who can benefit from surgery.
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Affiliation(s)
- Iacopo Chiodini
- Department of Medical Sciences, University of Milan, Endocrinology and Diabetology Unit, Fondazione Ospedale Maggiore Policlinico, Istituto di Ricovero e Cura a Carattere Scientifico, Pad. Granelli, Via F. Sforza 35, 20122 Milan, Italy.
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Szappanos A, Patócs A, Gergics P, Bertalan R, Kerti A, Acs B, Feldmann K, Rácz K, Tóth M. The 83,557insA variant of the gene coding 11β-hydroxysteroid dehydrogenase type 1 enzyme associates with serum osteocalcin in patients with endogenous Cushing's syndrome. J Steroid Biochem Mol Biol 2011; 123:79-84. [PMID: 21111044 DOI: 10.1016/j.jsbmb.2010.11.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 11/10/2010] [Accepted: 11/17/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The type 1 and type 2 isoenzymes of the 11β-hydroxysteroid dehydrogenase (HSD11B) play an important role in the prereceptor regulation of glucocorticoid bioavailability and action. The potential importance of gene variants coding HSD11B has not been previously evaluated in patients with endogenous hypercortisolism. The aim of the present study was to explore presumed associations between the 83,557insA variant of the HSD11B1 gene and circulating hormone concentrations, bone turnover and bone mineral density (BMD) in patients with endogenous Cushing's syndrome (CS). PATIENTS AND METHODS Forty one patients with ACTH-producing pituitary adenomas (Cushing's disease-CD), 32 patients with cortisol-producing adrenal tumors (ACS) and 129 healthy control subjects were genotyped for the 83,557insA variant of the HSD11B1 gene using restriction fragment length analysis. BMD was measured by dual-energy X-ray absorptiometry. Serum cortisol, ACTH, osteocalcin (OC) and C-terminal crosslinks (CTX) of human collagen type I (C-telopeptide) were measured by electrochemiluminescence immunoassay. RESULTS No statistically significant differences were found in the allelic frequencies of the 83,557insA polymorphism among patients with CD, ACS and healthy controls. Among all patients with CS, heterozygous carriers of the 83,557insA had significantly higher serum OC as compared to non-carriers. Patients with ACS carrying the 83,557insA variant had higher plasma ACTH concentrations compared to non-carriers. The 83,557insA variant failed to associate with BMD in patients and controls. CONCLUSIONS Our present findings indicate that the 83,557insA variant of the HSD11B1 gene may influence serum markers of bone turnover, but not BMD in patients with endogenous Cushing's syndrome.
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Affiliation(s)
- Agnes Szappanos
- 2nd Department of Medicine, Semmelweis University, 46 Szentkirályi H-1088, Budapest, Hungary
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Morelli V, Donadio F, Eller-Vainicher C, Cirello V, Olgiati L, Savoca C, Cairoli E, Salcuni AS, Beck-Peccoz P, Chiodini I. Role of glucocorticoid receptor polymorphism in adrenal incidentalomas. Eur J Clin Invest 2010; 40:803-11. [PMID: 20584071 DOI: 10.1111/j.1365-2362.2010.02330.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Adrenal incidentalomas (AI) have been associated with and an increased prevalence of metabolic and bone complications. The N363S and BclI polymorphisms of the glucocorticoid receptor (GR) have been associated with an increased sensitivity to glucocorticoid (GC). This observational study aims to evaluate whether BclI and N363S polymorphisms play a role in the development of complications in AI. MATERIALS AND METHODS We enrolled 100 patients with AI (66 F; 34M). The presence of diabetes, arterial hypertension (AH), dyslipidaemia, osteoporosis and vertebral fracture (Fx), waist circumference and the Body Mass Index (BMI) were assessed. DNA samples were genotyped. Patients with wild-type BclI, wild-type N363S and heterozygous BclI polymorphism were classified as carriers of haplotype 1 (H1; n = 86), patients with homozygous BclI and heterozygous N363S polymorphism of GR of haplotype 2 (H2; n = 14). RESULTS We found no clinical or biochemical differences between haplotype 1 and 2 groups, but a higher prevalence of the simultaneous presence of Fx plus AH in H2 patients (H2 n = 7, H1 n = 16, P = 0.01). Logistic regression analysis showed that the presence of Fx and of AH and the combination of the presence of Fx plus AH were associated with the H2 genotype regardless of the degree of cortisol secretion, age, BMI and BMD (OR 4.88, 95%CI 1.47-18.40, P = 0.05; OR 8.25, 95%CI 0.98-69.52, P = 0.05; OR 7.25, 95%CI 1.57-35.78, P = 0.011; respectively). CONCLUSIONS In AI patients, the presence of the haplotype 2 of BclI and N363S is associated with the presence of AH, Fx and with the combination of Fx and AH.
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Affiliation(s)
- Valentina Morelli
- Unit of Endocrinology and Diabetology, Department of Medical Sciences, University of Milan, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
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Adrenal gland and bone. Arch Biochem Biophys 2010; 503:137-45. [PMID: 20542010 DOI: 10.1016/j.abb.2010.06.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 06/05/2010] [Accepted: 06/08/2010] [Indexed: 02/06/2023]
Abstract
The adrenal gland synthesizes steroid hormones from the adrenal cortex and catecholamines from the adrenal medulla. Both cortisol and adrenal androgens can have powerful effects on bone. The overproduction of cortisol in Cushing's disease leads to a dramatic reduction in bone density and an increase risk of fracture. Overproduction of adrenal androgens in congenital adrenal hyperplasia (CAH) leads to marked changes in bone growth and development with early growth acceleration but ultimately a significant reduction in final adult height. The role of more physiological levels of glucocorticoids and androgens on bone metabolism is less clear. Cortisol levels measured in elderly individuals show a weak correlation with measures of bone density and change in bone density over time with a high cortisol level associated with lower bone density and more rapid bone loss. Cortisol levels and the dynamics of cortisol secretion change with age which could also explain some age related changes in bone physiology. It is also now clear that adrenal steroids can be metabolized within bone tissue itself. Local synthesis of cortisol within bone from its inactive precursor cortisone has been demonstrated and the amount of cortisol produced within osteoblasts appears to increase with age. With regard to adrenal androgens there is a dramatic reduction in levels with aging and several studies have examined the impact that restoration of these levels back to those seen in younger individuals has on bone health. Most of these studies show small positive effects in women, not men, but the skeletal sites where benefits are seen varies from study to study.
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