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Laulhé M, Dumaine C, Chevenne D, Leye F, Faye A, Dozières B, Strullu M, Viala J, Hogan J, Houdouin V, Léger J, Simon D, Carel JC, Storey C, Guilmin-Crépon S, Martinerie L. Glucocorticoid induced adrenal insufficiency in children: Morning cortisol values to avoid LDSST. Front Pediatr 2022; 10:981765. [PMID: 36589156 PMCID: PMC9798323 DOI: 10.3389/fped.2022.981765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Glucocorticoid-induced adrenal insufficiency (GI-AI) is a common side effect of glucocorticoid therapy. However, its diagnosis currently relies on the realization of a Low Dose Short Synacthen Test (LD-SST) that requires an outpatient hospital and several blood samples. Our goal was to evaluate whether morning cortisol values could predict the response to LD-SST, in children, to avoid useless dynamic tests and facilitate diagnosis of glucocorticoid induced adrenal insufficiency. STUDY DESIGN We recorded data of 91 pediatric patients who underwent a LD-SST in our center between 2016 and 2020 in a retrospective observational study. We selected LD-SST realized following administration of supra-physiologic doses of glucocorticoids during more than 3 weeks and performed at least four weeks after treatment was stopped. Adrenal deficiency was defined as a plasma cortisol concentration inferior to 500 nmol/l at LD-SST. RESULTS Glucocorticoid-induced adrenal insufficiency was diagnosed in 60% of our cohort. Morning cortisol values were predictive of the response to the LD-SST (AUC ROC 0.78). A plasma cortisol concentration of less than 144 nmol/l predicted glucocorticoid induced adrenal insufficiency with a specificity of 94% and a value over 317 nmol/l predicted recovery of the HPA axis with a sensitivity of 95%. We did not find any other predictive factor for glucocorticoid-induced adrenal insufficiency. CONCLUSIONS Morning cortisol values can safely assess recovery of the HPA axis in children treated chronically with glucocorticoids. Using these thresholds, more than 50% of LD-SST could be avoided in children.
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Affiliation(s)
- Margaux Laulhé
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France.,Université Paris-Saclay, Inserm 1185, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France
| | - Cécile Dumaine
- General Pediatrics and Infectious Diseases Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Didier Chevenne
- Biochemistry Unit, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Fallou Leye
- Clinical Epidemiology Unit, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Albert Faye
- General Pediatrics and Infectious Diseases Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France.,UFR Médecine, Université Paris Cité, Paris, France
| | - Blandine Dozières
- Pediatric Neurology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Marion Strullu
- UFR Médecine, Université Paris Cité, Paris, France.,Pediatric Hematology and Immunology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Jérome Viala
- UFR Médecine, Université Paris Cité, Paris, France.,Pediatric Gastroenterology and Hepatology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Julien Hogan
- UFR Médecine, Université Paris Cité, Paris, France.,Pediatric Nephrology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Véronique Houdouin
- UFR Médecine, Université Paris Cité, Paris, France.,Pediatric Pulmonology and Allergology Department, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France
| | - Juliane Léger
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France.,UFR Médecine, Université Paris Cité, Paris, France
| | - Dominique Simon
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France
| | - Jean-Claude Carel
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France.,UFR Médecine, Université Paris Cité, Paris, France.,Université Paris Cité, Inserm 1141, NeuroDiderot, Paris, France
| | - Caroline Storey
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France
| | - Sophie Guilmin-Crépon
- Clinical Epidemiology Unit, AP-HP, Hôpital Universitaire Robert-Debré, Paris, France.,UFR Médecine, Université Paris Cité, Paris, France
| | - Laetitia Martinerie
- Pediatric Endocrinology Department, AP-HP, Reference Center for Growth and Development Endocrine Diseases Hôpital Universitaire Robert-Debré, Paris, France.,Université Paris-Saclay, Inserm 1185, Physiologie et Physiopathologie Endocriniennes, Le Kremlin-Bicêtre, France.,UFR Médecine, Université Paris Cité, Paris, France
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Akurugu WA, Van Heerden CJ, Mulder N, Zöllner EW. Hypothalamic-pituitary-adrenal axis suppression in asthma: A glucocorticoid receptor polymorphism may protect. Pediatr Allergy Immunol 2021; 32:273-279. [PMID: 32969491 DOI: 10.1111/pai.13379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Asthmatic children on corticosteroids can develop hypothalamic-pituitary-adrenal axis suppression (HPAS). Single nucleotide polymorphisms (SNPs) rs242941 and rs1876828 of the corticotrophin-releasing hormone receptor 1 (CRHR1) gene were associated with lower stimulated cortisol (F) levels, whereas rs41423247 of the glucocorticoid receptor (NR3C1) gene was associated with higher basal F levels. The objective of the current study was to confirm whether these three SNPs are associated with HPAS in asthmatic children. METHODS DNA was extracted from saliva obtained from 95 asthmatic children, who had previously undergone basal F and metyrapone testing. Thirty-six children were classified as suppressed. Non-suppressed children were subclassified according to their post-metyrapone adrenocorticotropin (PMTP ACTH) level into a middle (106-319 pg/mL) and a high (>319 pg/mL) ACTH response group. TaqMan® polymerase chain reaction assays were utilized. RESULTS Only rs41423247 was inversely associated with HPAS (OR = 0.27 [95% CI 0.06-0.90]). Its GC genotype was inversely associated with HPAS (log odds = -1.28, P = .021). √PMTP ACTH was associated with CC (effect size = 10.85, P = .005) and GC genotypes (effect size = 4.06, P = .023). The C allele is inherited as a dominant trait (effect size = -1.31 (95% CI -2.39--0.33; P = .012). In the high ACTH response group, both genotypes affected the PMTP ACTH (effect sizes 1.41 and 15.46; P-values .023 and <2 × 10-26 for GC and CC, respectively). CONCLUSIONS The C allele of rs41423247 was found to be protective against HPAS. CC genotype is associated with the highest PMTP ACTH response.
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Affiliation(s)
- Wisdom Alemya Akurugu
- Computational Biology, Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Nicola Mulder
- Computational Biology, Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | - Ekkehard Werner Zöllner
- Paediatric Endocrine & Diabetes Unit, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
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Dinces SM, Rowell LN, Benson J, Hile SN, Tang AC, Annett RD. Normalized Cortisol Reactivity Predicts Future Neuropsychological Functioning in Children With Mild/Moderate Asthma. Front Psychol 2019; 10:2570. [PMID: 31803112 PMCID: PMC6877752 DOI: 10.3389/fpsyg.2019.02570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 10/30/2019] [Indexed: 12/28/2022] Open
Abstract
Cortisol reactivity to adrenocorticotropic hormone (ACTH) has been associated with neuropsychological processes including attention and memory in children with asthma. While cortisol reactivity to a psychological stressor is often considered a measure of current neuroendocrine functioning, this study examines the association of the cortisol reactivity and subsequent neuropsychological functioning. Using prospective data from the Childhood Asthma Management Program (CAMP), we explored the predictive ability of cortisol reactivity to ACTH and children's later attention and memory using traditional and an alternative cortisol reactivity (normalized cortisol) measures. Cortisol reactivity was assessed at study entry and 1-year follow-up, and neuropsychological functioning was assessed at 3-year follow-up. Cortisol reactivity was assessed through plasma cortisol concentrations collected at baseline (CORTBASELINE) and 30 min post-ACTH challenge (CORTPOST-A CTH). An alternative measure of cortisol reactivity was developed through post-ACTH stimulation cortisol, normalized by cortisol by baseline (CORTNORM -ACTH). CORT B ASELINE positively predicted year 3 attention, while CORTNORM -ACTH negatively predicted attention, suggesting convergence of cortisol variables in prediction of neuropsychological function. Year 1 CORTACTH positively predicted child memory at year 3; Year 1 CORTNORM-ACTH negatively predicted year 3 sustained attentions. These findings demonstrate that HPA reactivity, including the application of normalized cortisol reactivity, can predict subsequent neuropsychological functioning of children with mild to moderate asthma.
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Affiliation(s)
- Sarah M. Dinces
- Department of Psychology, The University of New Mexico, Albuquerque, NM, United States
| | - Lauren N. Rowell
- Department of Psychology, The University of New Mexico, Albuquerque, NM, United States
| | - Jennifer Benson
- Department of Psychology, The University of New Mexico, Albuquerque, NM, United States
| | - Sarah N. Hile
- Department of Psychology, The University of New Mexico, Albuquerque, NM, United States
| | - Akaysha C. Tang
- Faculty of Education, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Robert D. Annett
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, United States
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Wolthers OD, Mersmann S, Dissanayake S. A Pilot Study of the Normative Range of Overnight Urinary Free Cortisol Corrected for Creatinine in Children. Clin Drug Investig 2018; 38:313-318. [PMID: 29256049 DOI: 10.1007/s40261-017-0609-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND For more than a decade, urinary free cortisol corrected for creatinine (OUFCC) has been used to assess the systemic bioactivity of inhaled corticosteroids in children with asthma. Paediatric normative ranges, however, have not been established. The aim of the present study was to define a preliminary range for OUFCC in Tanner stage 1 children. METHODS A post hoc analysis was performed of 26 Tanner stage one children (aged 5-11 years) with mild asthma only requiring prn (pro re nata) treatment with short-acting β2-agonists, who participated in a 3-way cross-over knemometry study. The study comprised a run-in, two washout periods and three treatment periods (2 weeks each). Urine was collected at the end of each period. A normative range was derived using the 95% prediction interval for the geometric mean OUFCC, calculated from run-in and washout periods. RESULTS Twenty-six children contributed 41 OUFCC values. The geometric mean OUFCC was 9.0 nmol/mmol (95% PI: 3.6, 22.7 nmol/mmol). CONCLUSIONS The OUFCC preliminary normative range was 3.6 to 22.7 nmol/mmol in Tanner stage one children. A larger study in healthy children is warranted to confirm these findings and to assess potential differences in OUFCC across developmental stages and age groups, and by gender and race. EUDRACT NUMBER 2013-004719-32, CLINICALTRIALS. GOV IDENTIFIER NCT02063139.
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Affiliation(s)
- Ole D Wolthers
- Asthma and Allergy Clinic, Children's Clinic Randers, Dytmaersken 9, 8900, Randers, Denmark.
| | - Sabine Mersmann
- Biostatistics and Clinical Data Science, Mundipharma Research GmbH & Co. KG, Limburg, Germany
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Rao Bondugulapati LN, Rees DA. Inhaled corticosteroids and HPA axis suppression: how important is it and how should it be managed? Clin Endocrinol (Oxf) 2016; 85:165-9. [PMID: 27038017 DOI: 10.1111/cen.13073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/19/2016] [Accepted: 03/29/2016] [Indexed: 12/12/2022]
Abstract
Inhaled corticosteroids (ICS) are established as a cornerstone of management for patients with bronchoconstrictive lung disease. However, systemic absorption may lead to suppression of the hypothalamic-pituitary-adrenal (HPA) axis in a significant minority of patients. This is more likely in 'higher risk' patients exposed to high cumulative ICS doses, and in those treated with frequent oral corticosteroids or drugs which inhibit cytochrome p450 3A4. Hypothalamic-pituitary-adrenal axis suppression is frequently unrecognized, such that some patients, notably children, only come to light when an adrenal crisis is precipitated by physical stress. To minimize this risk, 'higher risk' patients and those with previously identified suppressed cortisol responses to Synacthen testing should undergo an education programme to inform them about sick day rules. A review of ICS therapy should also be undertaken to ensure that the dose administered is the minimum required to control symptoms.
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Affiliation(s)
| | - D A Rees
- Neurosciences and Mental Health Research Institute, School of Medicine, Cardiff University, Cardiff, UK
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Silva ESD, Pinheiro CS, Quintella CM, Ferreira F, C Pacheco LG, Alcântara-Neves NM. Advances in patent applications related to allergen immunotherapy. Expert Opin Ther Pat 2016; 26:657-68. [PMID: 27011299 DOI: 10.1517/13543776.2016.1170809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Allergies are among the most prevalent chronic diseases worldwide. Allergen-specific immunotherapy is used as an alternative treatment to pharmacotherapy. These immunotherapies are performed with crude extracts, which have disadvantages when compared to the new approaches, among them are recombinant proteins and hypoallergens. This review aims to assess immunotherapy for allergies through patent application analysis spanning recent decades. AREAS COVERED Patents referring to allergen immunotherapies used in allergy treatment. Data were obtained from the Espacenet® website, using the Cooperative Patent Classification (CPC) system. Two-hundred-and-one patent applications were analyzed, taking into consideration their classification by the type of technology and applicant. EXPERT OPINION Allergen-specific immunotherapy represents the only potentially curative therapeutic intervention for the treatment of allergic diseases. The extract-based immunotherapy is being replaced by the use of recombinant allergens, highlighting the hypoallergenic forms, which have low IgE-binding while retaining T-cell reactivity. It is expected that the development of hypoallergens will expand the scope of allergen-specific immunotherapy, especially if associated with alternative systems for expression and delivery systems with future potential. Furthermore, these new developments will likely address the problem of long-term protocols in allergen-specific immunotherapy, thus allowing better patient adherence and compliance.
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Affiliation(s)
- Eduardo Santos da Silva
- a Instituto de Ciências da Saúde - ICS , Universidade Federal da Bahia (UFBA) , Salvador , Bahia , Brazil.,b Programa de Pós-Graduação em Biotecnologia da Rede Nordeste de Biotecnologia (RENORBIO) , Universidade Estadual do Ceará , Fortaleza , Brazil
| | - Carina Silva Pinheiro
- a Instituto de Ciências da Saúde - ICS , Universidade Federal da Bahia (UFBA) , Salvador , Bahia , Brazil
| | | | - Fatima Ferreira
- d Department of Molecular Biology , University of Salzburg , Salzburg , Austria
| | - Luis Gustavo C Pacheco
- a Instituto de Ciências da Saúde - ICS , Universidade Federal da Bahia (UFBA) , Salvador , Bahia , Brazil
| | - Neuza Maria Alcântara-Neves
- a Instituto de Ciências da Saúde - ICS , Universidade Federal da Bahia (UFBA) , Salvador , Bahia , Brazil.,b Programa de Pós-Graduação em Biotecnologia da Rede Nordeste de Biotecnologia (RENORBIO) , Universidade Estadual do Ceará , Fortaleza , Brazil
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Cavkaytar O, Vuralli D, Arik Yilmaz E, Buyuktiryaki B, Soyer O, Sahiner UM, Kandemir N, Sekerel BE. Evidence of hypothalamic-pituitary-adrenal axis suppression during moderate-to-high-dose inhaled corticosteroid use. Eur J Pediatr 2015; 174:1421-31. [PMID: 26255048 DOI: 10.1007/s00431-015-2610-9] [Citation(s) in RCA: 23] [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: 05/05/2015] [Revised: 07/26/2015] [Accepted: 07/29/2015] [Indexed: 11/26/2022]
Abstract
The possible risk of adverse effects due to regular use of inhaled corticosteroids (ICS) is a real concern. Our aim was to describe the factors that have an impact on hypothalamic-pituitary-adrenal axis suppression (HPA-AS) in children and adolescents taking ICS regularly. The HPA axis status of patients who were on moderate-to-high-dose ICS [>176 and >264 μg/day fluticasone propionate-hydrofluoroalkane (FP-HFA) for patients 0-11 and ≥12 years, respectively] was investigated. Various types of ICS were converted to FP-HFA equivalent according to National Asthma Education and Prevention Program (NAEPP) guidelines. Participants with a baseline (8 a.m.) serum cortisol <15 μg/dL underwent a low-dose ACTH stimulation test (LDAT) to diagnose HPA-AS. Among 91 patients, 60 (75.9 %) participants underwent LDAT, and seven (7.7, 95 % CI 3.5-15.3 %) were diagnosed with HPA-AS. Ciclesonide was more frequently used by the participants with HPA-AS compared to patients with a normal HPA axis (42.9 vs. 4.8 %, p = 0.009). Use of ICS at moderate-to-high doses for at least 7 months distinguished participants with HPA-AS from those with a normal HPA axis. Among the duration, type, and dose of ICS, solely the use of ICS with a body mass index (BMI)-adjusted daily dose of ≥22 μg FP was found to increase the risk for HPA-AS (odds ratio (OR) 7.22, 95 % confidence interval (CI) 1.23-42.26, p = 0.028). The receiver operating characteristics (ROC) curve analysis revealed a cutoff value of 291 μg/day FP (area under the curve (AUC) = 0.840, p = 0.003) for predicting HPA-AS Conclusion: The prevalence of HPA-AS was found to be 7.7 % in children taking not only high-dose ICS but also moderate-dose ICS. Dose alone was found to be an actual risk factor for HPA-AS.
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Affiliation(s)
- Ozlem Cavkaytar
- Department of Pediatric Allergy, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Dogus Vuralli
- Department of Pediatric Endocrinology, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Ebru Arik Yilmaz
- Department of Pediatric Allergy, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Betul Buyuktiryaki
- Department of Pediatric Allergy, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Ozge Soyer
- Department of Pediatric Allergy, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Umit M Sahiner
- Department of Pediatric Allergy, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Nurgun Kandemir
- Department of Pediatric Endocrinology, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
| | - Bulent E Sekerel
- Department of Pediatric Allergy, Faculty of Medicine, Hacettepe University, Sıhhıye, 06100, Ankara, Turkey.
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Moore TA, Schmid KK, French JA. Comparison of cortisol samples in the first two weeks of life in preterm infants. J Pediatr Endocrinol Metab 2015; 28:415-20. [PMID: 25389990 DOI: 10.1515/jpem-2014-0246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 09/29/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Growing literature on negative childhood stress emphasizes the need to understand cortisol values from varying biomarker samples. OBJECTIVE This work aimed to examine cortisol samples for usability, associations, and individual stability in neonates. SUBJECTS The sample consisted of preterm infants (n=31). MATERIALS AND METHODS Analyses on cortisol collected from cord blood and from saliva and urine samples on days 1, 7, and 14 included Spearman correlations and paired t-tests. RESULTS Usability rates were 80.6% (cord blood), 85.9% (saliva), and 93.5% (urine). Salivary and urinary cortisol levels had significant correlation on day 1 only (p=0.004). Significant differences in individual stability of cortisol concentrations existed except in urine on days 1 and 7 and in saliva on days 7 and 14. CONCLUSIONS Usability was highest for urine samples. We found little correlation between cortisol sample levels at each time; individual stability of cortisol concentrations was minimal. Interpretation of cortisol findings in all studies should be performed cautiously.
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Zöllner EW, Lombard CJ, Galal U, Hough S, Irusen EM, Weinberg E. Screening for hypothalamic-pituitary-adrenal axis suppression in asthmatic children remains problematic: a cross-sectional study. BMJ Open 2013; 3:e002935. [PMID: 23906954 PMCID: PMC3733311 DOI: 10.1136/bmjopen-2013-002935] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 06/28/2013] [Accepted: 07/03/2013] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To determine which parameter is the most useful screening test for hypothalamic-pituitary-adrenal suppression in asthmatic children. DESIGN Cross-sectional study. SETTING Paediatric allergy clinics in Cape Town, South Africa. PARTICIPANTS 143 asthmatic children of mostly mixed ancestry, aged 5-12 years. OUTCOME MEASURES Primary outcome measures included Spearman correlation coefficients (r) calculated between the postmetyrapone (PMTP) serum adrenocorticotropic hormone (ACTH), 11-deoxycortisol (11DOC), 11DOC+ cortisol (C) and height, weight, height velocity, weight velocity, change in systolic blood pressure from supine to standing, early morning urinary free cortisol (UFC), morning C, ACTH and dehydroepiandrosterone sulfate (DHEAS). Secondary outcome measures were the receiver operating characteristics (ROC) curve and the diagnostic statistics for the most promising test. RESULTS All screening variables were weakly correlated with the three PMTP outcomes. Only DHEAS and UFC (nmol/m(2)) were statistically significant-DHEAS for PMTP ACTH and 11DOC (r=0.20, p=0.025 and r=0.21, p=0.017); UFC (nmol/m(2)) for PMTP 11DOC and 11DOC+C (r=0.19, p=0.033 and r=0.20, p=0.022). The area under ROC curve for DHEAS in the 5-year to 9-year age group was 0.69 (95% CI 0.47 to 0.92). At DHEAS cut-off of 0.2 µmol/L: sensitivity=0.88 (CI 0.47 to 1.00), specificity=0.61 (CI 0.42 to 0.78), positive predictive value=0.37 (CI 0.16 to 0.62), negative predictive value=0.95 (CI 0.75 to 1.00), accuracy=0.67 (CI 0.50 to 0.81), positive likelihood ratio=2.26 (CI 1.35 to 3.78), negative likelihood ratio=0.20 (CI 0.03 to 1.30). CONCLUSIONS No parameter is useful as a universal screening test. DHEAS may be suitable to exclude HPAS before adrenarche. Further research is needed to confirm these findings and identify factors, for example, genetic that may predict or protect against HPAS.
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Affiliation(s)
- Ekkehard Werner Zöllner
- Paediatric Endocrine Unit, Department of Paediatrics, Stellenbosch University, Tygerberg Children's Hospital, Cape Town, South Africa
- Endocrine Unit, Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Carl J Lombard
- Biostatistics Unit, Medical Research Council, Cape Town, South Africa
| | - Ushma Galal
- Biostatistics Unit, Medical Research Council, Cape Town, South Africa
| | - Stephen Hough
- Division of Endocrinology, Department of Medicine, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Elvis M Irusen
- Pulmonology Division, Department of Medicine, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Eugene Weinberg
- Allergy Unit, Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
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Zöllner EW, Lombard CJ, Galal U, Hough FS, Irusen EM, Weinberg E. Hypothalamic-pituitary-adrenal axis suppression in asthmatic school children. Pediatrics 2012; 130:e1512-9. [PMID: 23147980 DOI: 10.1542/peds.2012-1147] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Hypothalamic-pituitary-adrenal axis suppression (HPAS) when treating children with corticosteroids is thought to be rare. Our objective was to determine the prevalence of and predictive factors for various degrees of HPAS. METHODS Clinical features of HPAS, doses, adherence, asthma score, and lung functions were recorded in 143 asthmatic children. The overnight metyrapone test was performed if morning cortisol was >83 nmol/L. Spearman correlations coefficients (r) were calculated between 3 postmetyrapone outcomes and each continuous variable. A multiple linear regression model of √postmetyrapone adrenocorticotropic hormone (ACTH) and a logistic regression model for HPAS were developed. RESULTS Hypocortisolemia was seen in 6.1% (1.8-10.5), hypothalamic-pituitary suppression (HPS) in 22.2% (14.5-29.9), adrenal suppression in 32.3% (23.7-40.9), HPAS in 16.3% (9.3-23.3), and any hypothalamic-pituitary-adrenal axis dysfunction in 65.1% (56.5-72.9). Log daily nasal steroid (NS) dose/m(2) was associated with HPAS in the logistic regression model (odds ratio = 3.7 [95% confidence interval: 1.1-13.6]). Daily inhaled corticosteroids (ICSs) + NS dose/m(2) predicted HPAS in the univariate logistic regression model (P = .038). Forced expiratory volume in 1 second/forced vital capacity <80% was associated with HPAS (odds ratio = 4.1 [95% confidence interval: 1.0-14.8]). Daily ICS + NS/m(2) dose was correlated with the postmetyrapone ACTH (r = -0.29, P < .001). BMI (P = .048) and percent adherence to ICS (P < .001) and NS (P = .002) were predictive of √postmetyrapone ACTH (R(2) = .176). CONCLUSIONS Two-thirds of children on corticosteroids may have hypothalamic-pituitary-adrenal axis dysfunction. In one-third, central function had recovered but adrenal suppression persisted. Predictive factors for HPAS are NS use, BMI, and adherence to ICS and NS.
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Affiliation(s)
- Ekkehard Werner Zöllner
- Paediatric Endocrine Unit, Tygerberg Children’s Hospital, University of Stellenbosch, Cape Town, South Africa.
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Smith RW, Downey K, Gordon M, Hudak A, Meeder R, Barker S, Smith WG. Prevalence of hypothalamic-pituitary-adrenal axis suppression in children treated for asthma with inhaled corticosteroid. Paediatr Child Health 2012; 17:e34-9. [PMID: 23633903 PMCID: PMC3381924 DOI: 10.1093/pch/17.5.e34] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2012] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To determine the prevalence of hypothalamic-pituitary-adrenal (HPA) axis suppression in asthmatic children on inhaled corticosteroids (ICS). METHODS Clinical and demographic variables were recorded on preconstructed, standardized forms. HPA axis suppression was measured by morning serum cortisol levels and confirmed by low-dose adrenocorticotropic hormone stimulation testing. RESULTS In total, 214 children participated. Twenty children (9.3%, 95% CI 5.3% to 13.4%) had HPA axis suppression. Odds of HPA axis suppression increased with ICS dose (OR 1.005, 95% CI 1.003 to 1.009, P<0.001). All children with HPA axis suppression were on a medium or lower dose of ICS for their age (200 μg/day to 500 μg/day). HPA axis suppression was not predicted by drug type, dose duration, concomitant use of long-acting beta-agonist or nasal steroid, or clinical features. CONCLUSION Laboratory evidence of HPA axis suppression exists in children taking ICS for asthma. Children should be regularly screened for the presence of HPA axis suppression when treated with high-dose ICS (>500 μg/day). Consideration should be given to screening children on medium-dose ICS.
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Affiliation(s)
- Ryan W Smith
- Department of Medicine and Health, University College Cork, Cork, Ireland
| | - Kim Downey
- Regional Paediatric Asthma Center, Orillia Soldiers’ Memorial Hospital, Orillia
| | - Michelle Gordon
- Regional Paediatric Asthma Center, Orillia Soldiers’ Memorial Hospital, Orillia
- Department of Paediatrics, University of Toronto, Toronto
- Department of Paediatrics, Northern Ontario School of Medicine, Sudbury
| | - Alan Hudak
- Regional Paediatric Asthma Center, Orillia Soldiers’ Memorial Hospital, Orillia
- Department of Paediatrics, Northern Ontario School of Medicine, Sudbury
| | - Rob Meeder
- Regional Paediatric Asthma Center, Orillia Soldiers’ Memorial Hospital, Orillia
- Department of Paediatrics, Schulich School of Medicine, University of Western Ontario, London, Ontario
| | - Sarah Barker
- Regional Paediatric Asthma Center, Orillia Soldiers’ Memorial Hospital, Orillia
| | - W Gary Smith
- Regional Paediatric Asthma Center, Orillia Soldiers’ Memorial Hospital, Orillia
- Department of Paediatrics, University of Toronto, Toronto
- Department of Paediatrics, Northern Ontario School of Medicine, Sudbury
- Department of Paediatrics, Schulich School of Medicine, University of Western Ontario, London, Ontario
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