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Peel A, Rushworth RL, Torpy DJ. Novel agents to treat adrenal insufficiency: findings of preclinical and early clinical trials. Expert Opin Investig Drugs 2024; 33:115-126. [PMID: 38284211 DOI: 10.1080/13543784.2024.2311207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/24/2024] [Indexed: 01/30/2024]
Abstract
INTRODUCTION Adrenal insufficiency currently affects over 300/million population, with higher morbidity and mortality compared to the general population. Current glucocorticoid replacement therapy is limited by a lack of reliable biomarkers to guide dosing, inter-patient variation in metabolism and narrow therapeutic window. Increased morbidity and mortality may relate to unappreciated under- or over-exposure to glucocorticoids and impaired cortisol circadian rhythm. New agents are required to emulate physiological cortisol secretion and individualize glucocorticoid dosing. AREAS COVERED History of glucocorticoid therapy, current limitations, and novel chronotherapeutic glucocorticoid delivery mechanisms. Literature search incorporated searches of PubMed and Embase utilizing terms such as adrenal insufficiency, Chronocort, Plenadren, continuous subcutaneous hydrocortisone infusion (CHSI), and glucocorticoid receptor modulator. EXPERT OPINION Glucocorticoid chronotherapy is necessary to optimize glucocorticoid exposure and minimize complications. Current oral chronotherapeutics provide improved dosing functionality, but are modifiable only in specific increments and cannot accommodate ultradian cortisol variation. Current data show improvement in quality of life but not morbidity or mortality outcomes. CHSI has significant potential for individualized glucocorticoid dosing, but would require a suitable biomarker of glucocorticoid adequacy to be implementable. Avenues for future research include determining a glucocorticoid sufficiency biomarker, development of interstitial or systemic cortisol monitoring, or development of glucocorticoid receptor modulators.
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Affiliation(s)
- Andrew Peel
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Australia, Sydney, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
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2
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Allosso F, Dalakas K, Bergthorsdottir R, Chantzichristos D, Hessman E, Nwaru BI, Bobbio E, Pasquali D, Johannsson G, Esposito D. Mortality in patients with adrenal insufficiency: a protocol for a systematic review and meta-analysis. BMJ Open 2024; 14:e076582. [PMID: 38286708 PMCID: PMC10826553 DOI: 10.1136/bmjopen-2023-076582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 01/12/2024] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Adrenal insufficiency (AI) is a rare disorder characterised by an impaired secretion of glucocorticoids from the adrenal glands. Treatment strategies for AI have developed over time with reduced glucocorticoid replacement doses and improved circadian exposure regimens, but whether this has resulted in better survival is unknown. The main purpose of this systematic review is to gather and synthesise available evidence on long-term mortality in patients with AI. The secondary aim is to study causes of death, with focus on cardiovascular and infectious diseases, in AI patients. METHODS AND ANALYSIS Studies published from the inception of respective databases (Medline, Embase, Cochrane and Web of Science) until the end of May 2023 will be systematically synthetised. Observational studies with a reference population will be included, and their quality will be assessed using the Newcastle-Ottawa scale. Data collected will be narratively integrated and a meta-analysis will be performed to pool data from studies considered homogeneous. The systematic review will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This will be the first systematic review assessing mortality and causes of death in AI patients. The findings of this systematic review will be of value for both patients and healthcare providers. ETHICS AND DISSEMINATION This systematic review does not require ethical approval or informed consent because it will be based on previously published data only and does not implicate any direct contact with individual patients. The research results will be presented at scientific conferences and submitted for publication in an internationally recognised peer-reviewed scientific journal. PROSPERO REGISTRATION NUMBER CRD42023416253.
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Affiliation(s)
- Francesca Allosso
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Konstantinos Dalakas
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ragnhildur Bergthorsdottir
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dimitrios Chantzichristos
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Hessman
- Biomedical Library, Gothenburg University Library, University of Gothenburg, Gothenburg, Sweden
| | - Bright I Nwaru
- Krefting Research Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Emanuele Bobbio
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- University of Gothenburg, Gothenburg, Sweden
| | - Daniela Pasquali
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Daniela Esposito
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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3
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Sævik ÅB, Ueland G, Åkerman AK, Methlie P, Quinkler M, Jørgensen AP, Höybye C, Debowska AWJ, Nedrebø BG, Dahle AL, Carlsen S, Tomkowicz A, Sollid ST, Nermoen I, Grønning K, Dahlqvist P, Grimnes G, Skov J, Finnes T, Valland SF, Wahlberg J, Holte SE, Kämpe O, Bensing S, Husebye ES, Øksnes M. Altered biomarkers for cardiovascular disease and inflammation in autoimmune Addison's disease - a cross-sectional study. Eur J Endocrinol 2023; 189:438-447. [PMID: 37807083 DOI: 10.1093/ejendo/lvad136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 08/01/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE Increased prevalence of cardiovascular disease has been reported in autoimmune Addison's disease (AAD), but pathomechanisms are poorly understood. DESIGN Cross-sectional study. METHODS We compared serum levels of 177 cardiovascular and inflammatory biomarkers in 43 patients with AAD at >18-h glucocorticoid withdrawal and 43 matched controls, overall and stratified for sex. Biomarker levels were correlated with the frequency of adrenal crises and quality of life (QoL) by AddiQoL-30. Finally, we investigated changes in biomarker levels following 250 µg tetracosactide injection in patients without residual adrenocortical function (RAF) to explore glucocorticoid-independent effects of high ACTH. RESULTS Nineteen biomarkers significantly differed between patients with AAD and controls; all but 1 (ST1A1) were higher in AAD. Eight biomarkers were significantly higher in female patients compared with controls (IL6, MCP1, GAL9, SPON2, DR4, RAGE, TNFRSF9, and PGF), but none differed between male patients and controls. Levels of RAGE correlated with the frequency of adrenal crises (r = 0.415, P = .006) and AddiQoL-30 scores (r = -0.347, P = .028) but not after correction for multiple testing. PDL2 and leptin significantly declined 60 min after injection of ACTH in AAD without RAF (-0.15 normalized protein expression [NPX], P = .0001, and -0.25 NPX, P = .0003, respectively). CONCLUSIONS We show that cardiovascular and inflammatory biomarkers are altered in AAD compared with controls, particularly in women. RAGE might be a marker of disease severity in AAD, associated with more adrenal crises and reduced QoL. High ACTH reduced PDL2 and leptin levels in a glucocorticoid-independent manner but the overall effect on biomarker profiles was small.
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Affiliation(s)
- Åse Bjorvatn Sævik
- Department of Clinical Science, University of Bergen, Bergen 5021, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen 5021, Norway
| | - Grethe Ueland
- Department of Clinical Science, University of Bergen, Bergen 5021, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen 5021, Norway
- Department of Medicine, Haukeland University Hospital, Bergen 5021, Norway
| | - Anna-Karin Åkerman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm 171 77, Sweden
- Department of Medicine, Örebro University Hospital, Örebro 702 17, Sweden
| | - Paal Methlie
- Department of Clinical Science, University of Bergen, Bergen 5021, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen 5021, Norway
- Department of Medicine, Haukeland University Hospital, Bergen 5021, Norway
| | - Marcus Quinkler
- Practice for Endocrinology and Nephrology, Endocrinology in Charlottenburg, Berlin 10627, Germany
| | | | - Charlotte Höybye
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm 171 77, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm 171 77, Sweden
| | | | | | - Anne Lise Dahle
- Department of Internal Medicine, Haugesund Hospital, Haugesund 5528, Norway
| | - Siri Carlsen
- Department of Endocrinology, Stavanger University Hospital, Stavanger 4019, Norway
| | - Aneta Tomkowicz
- Department of Medicine, Sørlandet Hospital, Kristiansand 4604, Norway
| | - Stina Therese Sollid
- Department of Medicine, Drammen Hospital, Vestre Viken Health Trust, Drammen 3004, Norway
| | - Ingrid Nermoen
- Department of Endocrinology, Akershus University Hospital, Lørenskog 1478, Norway
| | - Kaja Grønning
- Department of Endocrinology, Akershus University Hospital, Lørenskog 1478, Norway
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå 907 37, Sweden
| | - Guri Grimnes
- Division of Internal Medicine, University Hospital of North Norway, Tromsø 9019, Norway
- Tromsø Endocrine Research Group, Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø 9019, Norway
| | - Jakob Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Trine Finnes
- Section of Endocrinology, Innlandet Hospital Trust, Hamar 2318, Norway
| | - Susanna F Valland
- Section of Endocrinology, Innlandet Hospital Trust, Hamar 2318, Norway
| | - Jeanette Wahlberg
- Department of Endocrinology, Linköping University, Linköping 581 85, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping 581 85, Sweden
| | | | - Olle Kämpe
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen 5021, Norway
- Department of Endocrinology, Karolinska University Hospital, Stockholm 171 77, Sweden
- Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm 171 77, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm 171 77, Sweden
| | - Eystein Sverre Husebye
- Department of Clinical Science, University of Bergen, Bergen 5021, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen 5021, Norway
- Department of Medicine, Haukeland University Hospital, Bergen 5021, Norway
- Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Marianne Øksnes
- Department of Clinical Science, University of Bergen, Bergen 5021, Norway
- K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen 5021, Norway
- Department of Medicine, Haukeland University Hospital, Bergen 5021, Norway
- Department of Medicine (Solna), Karolinska University Hospital, Karolinska Institutet, Stockholm 171 77, Sweden
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Harbeck B, Kropp P, Kreitschmann-Andermahr I. Glucocorticoid replacement therapy for primary and secondary adrenal insufficiency and their impact on cognition. Front Endocrinol (Lausanne) 2023; 14:1153595. [PMID: 37008924 PMCID: PMC10064134 DOI: 10.3389/fendo.2023.1153595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/07/2023] [Indexed: 03/19/2023] Open
Abstract
Patients with adrenal insufficiency (AI) are treated with conventional or modified-release glucocorticoid (GC) replacement therapy (GRT). Although current GRT regimens aim to mimic the physiological circadian pattern of cortisol secretion, temporary phases of hypo- and hypercortisolism are common. There is good evidence that prolonged phases of hypo- or hypercortisolism are associated with impaired cognitive functioning. However, little is known about cognitive functioning in patients with AI regarding the effects of dosage and duration of glucocorticoid replacement therapy. There is also little data available comparing the effects of GC therapy on patients with primary and secondary forms of AI as well as with respect to different formulas. This Mini-Review gives an overview of the current studies on GRT for primary and secondary AI and their impact on cognition. Strengths and weaknesses of the studies and their Implications for clinical daily routine are discussed with a special emphasis on practical considerations for the treating endocrinologist.
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Affiliation(s)
- Birgit Harbeck
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Medizinisches Versorgungszentrum (MVZ) Amedes Experts, Endocrinology, Hamburg, Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, University of Rostock, Rostock, Germany
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Patel P, Kelschenbach K. Case of Junctional Rhythm in the Setting of Acute Adrenal Insufficiency. Cureus 2022; 14:e27605. [PMID: 36059370 PMCID: PMC9436483 DOI: 10.7759/cureus.27605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/02/2022] [Indexed: 11/18/2022] Open
Abstract
Primary adrenal insufficiency occurs when the production of glucocorticoid and mineralocorticoid hormones from the adrenal cortex decreases. Cardiovascular manifestations, although a rare sequela in acute adrenal insufficiency, include arrhythmias, heart failure and ischemia. Rapid identification and treatment are crucial as mortality can occur rapidly. We present a patient with no underlying adrenal dysfunction who presented with worsening renal function and subsequent development of acute adrenal insufficiency manifesting with hypothermia, hypotension, and junctional rhythm requiring vasopressor support along with hydrocortisone therapy.
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Papierska L, Rabijewski M, Migda B, Leszczyńska D, Nowak K, Łebek-Szatańska A, Glinicki P, Zgliczyński W. Evaluation of plasma ACTH in the metyrapone test is insufficient for the diagnosis of secondary adrenal insufficiency. Front Endocrinol (Lausanne) 2022; 13:1004129. [PMID: 36440206 PMCID: PMC9684459 DOI: 10.3389/fendo.2022.1004129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/23/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To determine whether a single measurement of ACTH instead of less available in daily practice 11-deoxycortisol assay is sufficient to rule out or confirm secondary adrenal insufficiency (SAI) in the short Metyrapone test. DESIGN A retrospective analysis of diagnostic tests (Metyrapone and Synacthen tests) performed at our Center between 2016 and 2018 in patients with suspicion of secondary adrenal insufficiency. MATERIAL AND METHODS In 103 patients short metyrapone test was performed with assessment of 11-deoxycortisol and ACTH concentration after Metyrapone administered at midnight. In 89 of them short Synacthen (SST) test was also done (1 or/and 250 mcg 1-24ACTH). ROC curves have been performed to evaluate the diagnostic performance of ACTH level in metyrapone test as the predictor of secondary adrenal insufficiency (SAI) analysing sensitivity and specificity for various possible thresholds proposed in literature. RESULTS 40 (39%) of examined subjects were diagnosed as SAI, basing on post-Metyrapone 11-deoxycortisol concentration below 70 μg/l. In this group ACTH concentration was 128.1 ng/l (95% CI 96.8-159.4) versus 289.9 ng/l (95% CI 249.1-330.9) in patients with proper adrenal response. There was only a moderate positive correlation between ACTH and 11-deoxycortisol concentrations (r=0.5; p<0.05). The best cut off value of ACTH in relation to 11-deoxycortisol serum concentrations was 147 ng/l - with sensitivity of 73.2% and specificity 83.9%. However, plasma ACTH was>200ng/ml (the highest threshold proposed in literature) in 8 cases (20%) with positive diagnosis of SAI made on the basis of low 11-deoxycortisole and confirmed in short Synacthen test. CONCLUSION Our results indicate that for a valuable evaluation of the results of the metyrapone test, the more readily available plasma ACTH assay cannot replace the measurement of 11-deoxycortisol concentrations.
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Affiliation(s)
- Lucyna Papierska
- Department of Endocrinology, Medical Centre for Postgraduate Education, Warsaw, Poland
- *Correspondence: Lucyna Papierska,
| | - Michał Rabijewski
- Department of Reproductive Health, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Bartosz Migda
- Diagnostic Ultrasound Lab, Department of Pediatric Radiology, Medical Faculty, Medical University of Warsaw, Warsaw, Poland
| | | | - Karolina Nowak
- Department of Endocrinology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | | | - Piotr Glinicki
- Department of Endocrinology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Wojciech Zgliczyński
- Department of Endocrinology, Medical Centre for Postgraduate Education, Warsaw, Poland
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Blacha AK, Kropp P, Rahvar AH, Flitsch J, van de Loo I, Harbeck B. Poor quality of life and sleep in patients with adrenal insufficiency-another cause of increased mortality? Ir J Med Sci 2021; 191:1653-1658. [PMID: 34389925 PMCID: PMC9308573 DOI: 10.1007/s11845-021-02731-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 07/28/2021] [Indexed: 11/26/2022]
Abstract
Background Patients with adrenal insufficiency (AI) are treated with glucocorticoid replacement therapy (GRT). Although current glucocorticoid regimens aim to mimic the physiological circadian rhythm of cortisol secretion, temporary phases of hypo- and hypercortisolism are common undesired effects which lead to a variety of consequences like increased cardiovascular risk and premature mortality. Additionally, poor quality of life (QoL) and impaired sleep have been reported. However, little is known about these topics regarding the effects of daily dosage, duration of therapy, and patients with different forms of AI (primary, PAI, and secondary, SAI). Methods In this study, 40 adults with AI substituted with hydrocortisone (HC) and 20 matched healthy controls completed questionnaires evaluating depressive symptoms, subjective health status, quality of sleep and daytime sleepiness. Furthermore, demographic data, dosage of HC, duration of therapy and co-medication were evaluated. Patients were compared in different groups. Results Patients assessed general health significantly worse than controls; likewise, daytime sleepiness was reported significantly more often. Depressive symptoms differed significantly in the two groups but did not reach clinically relevant scores. There was no difference between patients with PAI and SAI. High dosage of hydrocortisone had negative impact on mental health but not on sleep quality or daytime sleepiness. Conclusions The present data highlight that poor QoL and impaired sleep are still severe and underrated issues in current GRT and might be additional factors for premature mortality in patients with AI. Some AI patients reach normal or near-normal self-assessed QoL and sleep, even despite unphysiological replacement.
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Affiliation(s)
- Antje K Blacha
- I. Department of Medicine, University of Luebeck, Luebeck, Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, University of Rostock, Rostock, Germany
| | - Amir H Rahvar
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Birgit Harbeck
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Amedes Experts, Hamburg, Germany.
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Rahvar AH, Riesel M, Graf T, Harbeck B. Cardiovascular outcome in patients with adrenal insufficiency-a therapeutic dilemma. Endocrine 2021; 72:582-585. [PMID: 33400177 DOI: 10.1007/s12020-020-02571-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Amir-Hossein Rahvar
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Tobias Graf
- Department of Cardiology, University Hospital Luebeck, Luebeck, Germany
| | - Birgit Harbeck
- University of Luebeck, Luebeck, Germany.
- MVZ Amedes Experts, Endocrinology, Hamburg, Germany.
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Blacha AK, Rahvar AH, Flitsch J, van de Loo I, Kropp P, Harbeck B. Impaired attention in patients with adrenal insufficiency - Impact of unphysiological therapy. Steroids 2021; 167:108788. [PMID: 33412217 DOI: 10.1016/j.steroids.2020.108788] [Citation(s) in RCA: 6] [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: 08/09/2020] [Revised: 12/14/2020] [Accepted: 12/28/2020] [Indexed: 12/26/2022]
Abstract
Patients with adrenal insufficiency (AI) are treated with glucocorticoid (GC) replacement therapy. Although current GC regimens aim to mimic the physiological circadian rhythm of cortisol secretion, temporary phases of hypo- and hypercortisolism are common undesired effects. Both conditions may lead to impairment in cognitive functioning. At present, little is known about cognitive functioning in patients with AI, especially regarding the effects of dosage and duration of glucocorticoid replacement therapy. There is also little data available comparing the effects of GC therapy on patients with primary (PAI) and secondary (SAI) forms of AI. In this study 40 adults with AI (21 PAI, 19 SAI) substituted with hydrocortisone (HC) and 20 matched healthy controls underwent 10 different neuropsychological tests evaluating memory, executive functioning, attention, psychomotricity and general intellectual ability. Furthermore demographic data, dosage of HC, duration of therapy and co-medication were evaluated. Patients were compared in groups with regard to diagnosis, dosage and duration of therapy. Patients showed worse performance than controls in attention, though patients with PAI and SAI seemed to be equally impaired. There were no limitations in intellectual abilities or memory function. High dosage of HC was found to impair attention, visual-motoric skills and executive functioning while the duration of therapy showed no significant impact on cognitive functions. In conclusion, our study showed that AI patients on HC replacement therapy reveal significant cognitive deficits concerning attention. There was no difference between patients with PAI and SAI. Furthermore, high dosage seems to have a negative impact especially on executive functioning.
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Affiliation(s)
| | - Amir H Rahvar
- University Medical Center Hamburg-Eppendorf, Germany
| | - Jörg Flitsch
- University Medical Center Hamburg-Eppendorf, Germany
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Walton JC, Walker WH, Bumgarner JR, Meléndez-Fernández OH, Liu JA, Hughes HL, Kaper AL, Nelson RJ. Circadian Variation in Efficacy of Medications. Clin Pharmacol Ther 2020; 109:1457-1488. [PMID: 33025623 DOI: 10.1002/cpt.2073] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/13/2020] [Indexed: 12/22/2022]
Abstract
Although much has been learned about circadian clocks and rhythms over the past few decades, translation of this foundational science underlying the temporal regulation of physiology and behavior to clinical applications has been slow. Indeed, acceptance of the modern study of circadian rhythms has been blunted because the phenomenology of cyclic changes had to counteract the 20th century dogma of homeostasis in the biological sciences and medicine. We are providing this review of clinical data to highlight the emerging awareness of circadian variation in efficacy of medications for physicians, clinicians, and pharmacists. We are suggesting that gold-standard double-blind clinical studies should be conducted to determine the best time of day for optimal effectiveness of medications; also, we suggest that time of day should be tracked and reported as an important biological variable in ongoing clinical studies hereafter. Furthermore, we emphasize that time of day is, and should be considered, a key biological variable in research design similar to sex. In common with biomedical research data that have been historically strongly skewed toward the male sex, most pharmaceutical data have been skewed toward morning dosing without strong evidence that this is the optimal time of efficacy.
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Affiliation(s)
- James C Walton
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - William H Walker
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Jacob R Bumgarner
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - O Hecmarie Meléndez-Fernández
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Jennifer A Liu
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Heather L Hughes
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Alexis L Kaper
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Randy J Nelson
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
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Nowotny H, Reisch N. [Modified-release hydrocortisone for glucocorticoid deficiency]. Internist (Berl) 2020; 61:565-572. [PMID: 32394073 DOI: 10.1007/s00108-020-00795-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The central circadian pacemaker in the suprachiasmatic nucleus and interaction of clock genes with the hypothalamus pituitary adrenal axis are responsible for very distinct cortisol concentrations. Unphysiologically high doses of glucocorticoids that do not follow the circadian rhythm lead to increased rates of morbidity, mortality and reduced quality of life. OBJECTIVES Does a switch to modified-release hydrocortisone in multimorbid elderly patients offer benefits compared to a conventional therapy regime? METHODS Evaluation, analysis and discussion of statistics, recent research results and expert advice. RESULTS Overdosage and unphysiological timing of cortisol administration result in higher incidences of obesity, hypertension, hyperglycemia, coronary heart disease and cardiac events. Body weight, body mass index and HbA1c decline with Plenadren® (Shire Pharmaceuticals Ireland Limited, Dublin, Ireland) treatment compared to conventional therapy. CD16+ natural killer cells and natural killer cytotoxycity are reduced, and the incidence of respiratory-tract infections is increased, with conventional therapy compared to Plenadren®. Cortisol influences sleep pattern and sleep quality by its circadian secretion. CONCLUSION Novel modified-release hydrocortisone preparations offer diverse benefits with regard to their effect on metabolism, cardiovascular risk, immunity and sleep, which might be beneficial in particular in multimorbid elderly.
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Affiliation(s)
- H Nowotny
- Medizinische Klinik IV, Klinikum der Universität München, Ziemssenstraße 1, 80336, München, Deutschland
| | - N Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Ziemssenstraße 1, 80336, München, Deutschland.
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Abstract
Adrenal insufficiency patients are treated with glucocorticoid replacement therapy. However, mimicking the in vivo circadian rhythm of cortisol levels is challenging, and suboptimal replacement increases the risk of mortality from cardiovascular disease. We herein report a case of coronary spastic angina (CSA) with simultaneous low early-morning serum cortisol levels in a patient undergoing corticosteroid replacement therapy for primary adrenal insufficiency. Steroid therapy is reportedly effective for refractory angina, but underlying adrenal deficiency has never been revealed. Our case intimates the probable risk of CSA as a complication of relative adrenal insufficiency and highlights the effectiveness of dexamethasone in these patients.
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Affiliation(s)
- Yuki Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Ko Harada
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Miho Yasuda
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Yasuhiro Nakano
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Kou Hasegawa
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Fumio Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
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13
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Ebrahimi F, Widmer A, Wagner U, Mueller B, Schuetz P, Christ-Crain M, Kutz A. Association of adrenal insufficiency with patient-oriented health-care outcomes in adult medical inpatients. Eur J Endocrinol 2019; 181:701-709. [PMID: 31581127 PMCID: PMC6977938 DOI: 10.1530/eje-19-0469] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 10/03/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Adrenal insufficiency in the outpatient setting is associated with excess morbidity, mortality, and impaired quality of life. Evidence on its health-care burden in medical inpatients is scarce. The aim of this study was to assess the health-care burden of primary adrenal insufficiency (PAI) and secondary adrenal insufficiency (SAI) among hospitalized inpatients. DESIGN AND METHODS In this nationwide cohort study, adult medical patients with either PAI or SAI hospitalized between 2011 and 2015 were compared with propensity-matched (1:1) medical controls, respectively. The primary outcome was 30-day all-cause in-hospital mortality. Main secondary outcomes included ICU admission rate, length-of-hospital stay, 30-day and 1-year all-cause readmission rates. RESULTS In total, 594 hospitalized cases with PAI and 4880 cases with SAI were included. Compared with matched controls, in-hospital mortality was not increased among PAI or SAI patients, respectively. Patients with adrenal insufficiency were more likely to be admitted to ICU (PAI: OR 1.9 (95% CI, 1.27 to 2.72) and SAI: OR 1.5 (95% CI, 1.35 to 1.75)). Length of hospital stay was prolonged by 1.0 days in PAI patients (8.9 vs 7.9 days (95% CI, 0.06 to 1.93)), and by 3.3 days in SAI patients (12.1 vs 8.8 days (95% CI, 2.82 to 3.71)), when compared with matched controls. Patients with SAI were found to have higher 30-day and 1-year readmission rates (14.1 vs 12.1% and 50.0 vs 40.7%; P < 0.001) than matched controls. CONCLUSIONS While no difference in in-hospital mortality was found, adrenal insufficiency was associated with prolonged length of hospital stay, and substantially higher rates of ICU admission and hospital readmission.
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Affiliation(s)
- Fahim Ebrahimi
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Andrea Widmer
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Ulrich Wagner
- Division of Health and Social Affairs, Section Health, Swiss Federal Office for Statistics, Neuchâtel, Switzerland
- Foundation National Institute for Cancer Epidemiology and Registration (NICER), University of Zurich, Zurich, Switzerland
| | - Beat Mueller
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Division of Endocrinology, Diabetes, and Metabolism, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Division of Endocrinology, Diabetes, and Metabolism, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Mirjam Christ-Crain
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Alexander Kutz
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Correspondence should be addressed to A Kutz;
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14
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Jiang L, Xue C, Dai S, Chen S, Chen P, Sham PC, Wang H, Li M. DESE: estimating driver tissues by selective expression of genes associated with complex diseases or traits. Genome Biol 2019; 20:233. [PMID: 31694669 PMCID: PMC6836538 DOI: 10.1186/s13059-019-1801-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/25/2019] [Indexed: 02/08/2023] Open
Abstract
The driver tissues or cell types in which susceptibility genes initiate diseases remain elusive. We develop a unified framework to detect the causal tissues of complex diseases or traits according to selective expression of disease-associated genes in genome-wide association studies (GWASs). This framework consists of three components which run iteratively to produce a converged prioritization list of driver tissues. Additionally, this framework also outputs a list of prioritized genes as a byproduct. We apply the framework to six representative complex diseases or traits with GWAS summary statistics, which leads to the estimation of the lung as an associated tissue of rheumatoid arthritis.
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Affiliation(s)
- Lin Jiang
- Zhongshan School of Medicine, Center for Precision Medicine, Sun Yat-sen University, Guangzhou, 510080, China.,Department of Pituitary Tumour Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China
| | - Chao Xue
- Zhongshan School of Medicine, Center for Precision Medicine, Sun Yat-sen University, Guangzhou, 510080, China.,Key Laboratory of Tropical Disease Control (SYSU), Ministry of Education, Guangzhou, 510080, China
| | - Sheng Dai
- Zhongshan School of Medicine, Center for Precision Medicine, Sun Yat-sen University, Guangzhou, 510080, China
| | - Shangzhen Chen
- Zhongshan School of Medicine, Center for Precision Medicine, Sun Yat-sen University, Guangzhou, 510080, China
| | - Peikai Chen
- Department of Psychiatry, The Centre for Genomic Sciences, State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - Pak Chung Sham
- Department of Psychiatry, The Centre for Genomic Sciences, State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - Haijun Wang
- Department of Pituitary Tumour Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China.
| | - Miaoxin Li
- Zhongshan School of Medicine, Center for Precision Medicine, Sun Yat-sen University, Guangzhou, 510080, China. .,Key Laboratory of Tropical Disease Control (SYSU), Ministry of Education, Guangzhou, 510080, China. .,Department of Psychiatry, The Centre for Genomic Sciences, State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China.
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15
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Huang D, Kreitler K, Tilton S, Cavarocchi NC, Hirose H. Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation Support in a Patient with Panhypopituitarism: A Case Report. Cureus 2019; 11:e4995. [PMID: 31497426 PMCID: PMC6726413 DOI: 10.7759/cureus.4995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We present a 58-year-old female with a past history of a pituitary adenoma resected two years prior to admission who developed polymorphic ventricular tachycardia and cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We noted that the patient had stopped taking all of her medications six months prior to presentation. An extensive workup revealed acute panhypopituitarism with secondary hypothyroidism, secondary adrenal insufficiency, and central diabetes insipidus. She was immediately initiated on thyroid and adrenal hormone replacement therapy as well as fluid replacement. Within five days of her medical treatment, the patient's cardiac function improved and she was successfully weaned from VA-ECMO and subsequently discharged home with appropriate hormone replacement therapy.
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Affiliation(s)
- Denis Huang
- Surgery, Thomas Jefferson University, Philadelphia, USA
| | - Kristin Kreitler
- Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Scott Tilton
- Surgery, Critical Care, Penn Presbyterian Medical Center, Philadelphia, USA
| | | | - Hitoshi Hirose
- Cardiothoracic Surgery, Thomas Jefferson University, Philadelphia, USA
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16
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Rahvar AH, Riesel M, Graf T, Harbeck B. Adrenal insufficiency treated with conventional hydrocortisone leads to elevated levels of Interleukin-6: a pilot study. Endocrine 2019; 64:727-729. [PMID: 31102070 DOI: 10.1007/s12020-019-01956-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/09/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Amir-Hossein Rahvar
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | | | - Tobias Graf
- Department of Cardiology, University Hospital Luebeck, Luebeck, Germany
| | - Birgit Harbeck
- University of Luebeck, Luebeck, Germany
- MVZ Amedes Experts, Endocrinology, Hamburg, Germany
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17
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Oprea A, Bonnet NCG, Pollé O, Lysy PA. Novel insights into glucocorticoid replacement therapy for pediatric and adult adrenal insufficiency. Ther Adv Endocrinol Metab 2019; 10:2042018818821294. [PMID: 30746120 PMCID: PMC6360643 DOI: 10.1177/2042018818821294] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 12/04/2018] [Indexed: 02/04/2023] Open
Abstract
Adrenal insufficiency is defined as impaired adrenocortical hormone synthesis. According to its source, the deficit is classified as primary (adrenal steroidogenesis impairment), secondary (pituitary adrenocorticotropic hormone deficit) or tertiary (hypothalamic corticotropin-releasing hormone deficit). The management of adrenal insufficiency resides primarily in physiological replacement of glucocorticoid secretion. Standard glucocorticoid therapy is shrouded in several controversies. Along the difficulties arising from the inability to accurately replicate the pulsatile circadian cortisol rhythm, come the uncertainties of dose adjustment and treatment monitoring (absence of reliable biomarkers). Furthermore, side effects of inadequate replacement significantly hinder the quality of life of patients. Therefore, transition to circadian hydrocortisone therapy gains prominence. Recent therapeutic advancements consist of oral hydrocortisone modified-release compounds (immediate, delayed and sustained absorption formulations) or continuous subcutaneous hydrocortisone infusion. In addition to illustrating the current knowledge on conventional glucocorticoid regimens, this review outlines the latest research outcomes. We also describe the management of pediatric patients and suggest a novel strategy for glucocorticoid replacement therapy in adults.
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Affiliation(s)
- Alina Oprea
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Nicolas C. G. Bonnet
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Olivier Pollé
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Philippe A. Lysy
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Pôle PEDI, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Av. Hippocrate 10, B-1200 Brussels, Belgium
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18
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Pleurotus albidus Modulates Mitochondrial Metabolism Disrupted by Hyperglycaemia in EA.hy926 Endothelial Cells. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2859787. [PMID: 30018977 PMCID: PMC6029507 DOI: 10.1155/2018/2859787] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/05/2018] [Accepted: 05/20/2018] [Indexed: 11/17/2022]
Abstract
Hyperglycaemia exacerbates the production of reactive oxygen species (ROS), contributing to the multiple complications associated with diabetes. Mitochondrial dysfunction is also known to be associated with diabetes. Therefore, the aim of this work was to study the effect of Pleurotus albidus extract on the mitochondrial dysfunction induced by hyperglycaemia in EA.hy926 endothelial cells. The results showed that P. albidus treatment prevented the increase in the activity of complex I of the electron transport chain and minimized the ROS production induced by hyperglycaemia. In addition, the extract minimized oxidative damage to lipids and proteins, caused an imbalance in the antioxidant enzyme activities of superoxide dismutase and catalase, and decreased the nitric oxide levels induced by hyperglycaemia. These data contribute to our understanding of the mitochondrial disorder induced by hyperglycaemia as well as establishing the conditions required to minimize these alterations.
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