1
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Eguchi E. Primary adrenal insufficiency developed 22 years after the diagnosis of light and heavy chain deposition disease: a case report. CEN Case Rep 2024:10.1007/s13730-024-00893-z. [PMID: 38767838 DOI: 10.1007/s13730-024-00893-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] [Received: 01/18/2024] [Accepted: 05/13/2024] [Indexed: 05/22/2024] Open
Abstract
Monoclonal immunoglobulin deposition diseases (MIDDs), including light and heavy chain deposition disease (LHCDD), are rare and heterogeneous disorders associated with underlying B-cell clonal disorders. Adrenal involvement is a potential extrarenal manifestation of MIDDs; however, limited data are available regarding its prevalence and clinical presentation. Herein, the present report describes, for the first time, a case of primary adrenal insufficiency that developed twenty-two years after a diagnosis of LHCDD had been made. A 69 year-old woman with a 10 year history of hemodialysis suddenly became bedridden after falling down stairs in the absence of focal neurological deficits. Subsequently, she experienced appetite loss, nausea, vomiting, a fever of unknown origin, and unexplained hypotension. Several months later, primary adrenal insufficiency and normal pressure hydrocephalus were diagnosed and successfully managed. The long-term clinical prognosis of MIDDs has not been fully elucidated despite recent advances in the management of the disorders. This report may contribute to improving our understanding of the disease course.
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Affiliation(s)
- Eriko Eguchi
- Department of Internal Medicine, Osaka Roudou Eisei Center Daiichi Hospital, 6-2-2 Mitejima Nishiyodogawa-Ku, Osaka, Osaka, 555-0012, Japan.
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2
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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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3
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Nethathe GD, Lipman J, Anderson R, Fuller PJ, Feldman C. Glucocorticoids with or without fludrocortisone in septic shock: a narrative review from a biochemical and molecular perspective. Br J Anaesth 2024; 132:53-65. [PMID: 38030548 PMCID: PMC10797514 DOI: 10.1016/j.bja.2023.10.034] [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: 08/07/2023] [Revised: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Two randomised controlled trials have reported a reduction in mortality when adjunctive hydrocortisone is administered in combination with fludrocortisone compared with placebo in septic shock. A third trial did not support this finding when hydrocortisone administered in combination with fludrocortisone was compared with hydrocortisone alone. The underlying mechanisms for this mortality benefit remain poorly understood. We review the clinical implications and potential mechanisms derived from laboratory and clinical data underlying the beneficial role of adjunctive fludrocortisone with hydrocortisone supplementation in septic shock. Factors including distinct biological effects of glucocorticoids and mineralocorticoids, tissue-specific and mineralocorticoid receptor-independent effects of mineralocorticoids, and differences in downstream signalling pathways between mineralocorticoid and glucocorticoid binding at the mineralocorticoid receptor could contribute to this interaction. Furthermore, pharmacokinetic and pharmacodynamic disparities exist between aldosterone and its synthetic counterpart fludrocortisone, potentially influencing their effects. Pending publication of well-designed, randomised controlled trials, a molecular perspective offers valuable insights and guidance to help inform clinical strategies.
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Affiliation(s)
- Gladness D Nethathe
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Academy of Critical Care, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
| | - Jeffrey Lipman
- Academy of Critical Care, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Jamieson Trauma Institute and Intensive Care Services, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, 4029, QLD, Australia; Nimes University Hospital, University of Montpellier, Nimes, France
| | - Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Peter J Fuller
- Endocrinology Unit, Monash Health, Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Charles Feldman
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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4
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Mohammadi F, Zahraee H, Izadpanah Kazemi M, Habibi ZS, Taghdisi SM, Abnous K, Khoshbin Z, Chen CH. Recent advances in aptamer-based platforms for cortisol hormone monitoring. Talanta 2024; 266:125010. [PMID: 37541008 DOI: 10.1016/j.talanta.2023.125010] [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: 03/15/2023] [Revised: 07/19/2023] [Accepted: 07/28/2023] [Indexed: 08/06/2023]
Abstract
The stressful conditions of today-life make it urgent the timely prevention and treatment of many physiological and psychological disorders related to stress. According to the significant progress made in the near future, rapid, accurate, and on-spot measurement of cortisol hormone as a dominant stress biomarker using miniaturized digital devices is not far from expected. With a special potency in the fields of diagnosis and healthcare monitoring, aptamer-mediated biosensors (aptasensors) are promising for the quantitative monitoring of cortisol levels in the different matrices (sweat, saliva, urine, cerebrospinal fluid, blood serum, etc.). Accordingly, this in-depth study reviews the superior achievements in the aptasensing strategies to detect cortisol hormone with the synergism of diverse two/three dimensional nanostructured materials, enzymatic amplification components, and antibody motifs. The represented discussions offer a universal perspective to achieve lab-on-chip aptasensing arrays as future user-friendly skin-patchable electronic gadgets for on-site and real-time quantification of cortisol levels.
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Affiliation(s)
- Fatemeh Mohammadi
- Department of Biology, Faculty of Science, Ferdowsi University of Mashhad, Mashhad, Iran; Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamed Zahraee
- Department of Biology, Faculty of Science, Ferdowsi University of Mashhad, Mashhad, Iran; Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Zahra Sadat Habibi
- Department of Environmental Engineering, Faculty of Natural Resources and Environment, University of Birjand, Birjand, Iran
| | - Seyed Mohammad Taghdisi
- Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmaceutical Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Khalil Abnous
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Medicinal Chemistry, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Khoshbin
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Targeted Drug Delivery Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Medicinal Chemistry, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Chih-Hsin Chen
- Department of Chemistry, Tamkang University, New Taipei City, 25137, Taiwan.
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5
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Li Y, Lu L, Androulakis IP. The Physiological and Pharmacological Significance of the Circadian Timing of the HPA Axis: A Mathematical Modeling Approach. J Pharm Sci 2024; 113:33-46. [PMID: 37597751 PMCID: PMC10840710 DOI: 10.1016/j.xphs.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 08/21/2023]
Abstract
As a potent endogenous regulator of homeostasis, the circadian time-keeping system synchronizes internal physiology to periodic changes in the external environment to enhance survival. Adapting endogenous rhythms to the external time is accomplished hierarchically with the central pacemaker located in the suprachiasmatic nucleus (SCN) signaling the hypothalamus-pituitary-adrenal (HPA) axis to release hormones, notably cortisol, which help maintain the body's circadian rhythm. Given the essential role of HPA-releasing hormones in regulating physiological functions, including immune response, cell cycle, and energy metabolism, their daily variation is critical for the proper function of the circadian timing system. In this review, we focus on cortisol and key fundamental properties of the HPA axis and highlight their importance in controlling circadian dynamics. We demonstrate how systems-driven, mathematical modeling of the HPA axis complements experimental findings, enhances our understanding of complex physiological systems, helps predict potential mechanisms of action, and elucidates the consequences of circadian disruption. Finally, we outline the implications of circadian regulation in the context of personalized chronotherapy. Focusing on the chrono-pharmacology of synthetic glucocorticoids, we review the challenges and opportunities associated with moving toward personalized therapies that capitalize on circadian rhythms.
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Affiliation(s)
- Yannuo Li
- Chemical & Biochemical Engineering Department, Piscataway, NJ 08854, USA
| | - Lingjun Lu
- Chemical & Biochemical Engineering Department, Piscataway, NJ 08854, USA
| | - Ioannis P Androulakis
- Chemical & Biochemical Engineering Department, Piscataway, NJ 08854, USA; Biomedical Engineering Department, Rutgers University, Piscataway, NJ 08540, USA.
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6
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Eguchi E. Post-COVID-19 syndrome increased the requirement for corticosteroids in a dialysis patient with preexisting adrenal insufficiency. CEN Case Rep 2023; 12:347-351. [PMID: 36617353 PMCID: PMC9826535 DOI: 10.1007/s13730-023-00772-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 01/04/2023] [Indexed: 01/09/2023] Open
Abstract
A 77-year-old male patient on maintenance hemodialysis therapy who underwent unilateral adrenonephrectomy 9 years ago was transferred to our hospital after 4 months of acute treatment for skull base osteomyelitis. He presented with unexplained hypotension during dialysis sessions. Further evaluation led to a diagnosis of primary adrenal insufficiency, followed by the start of oral hydrocortisone. Six months after admission, the patient was found to have a positive COVID-19 result on a rapid antigen test and mild symptoms. The patient complained of fatigue after the disappearance of the symptoms. Subsequently, the systolic blood pressure gradually declined despite the additional administration of fludrocortisone and caused difficulties in undergoing hemodialysis. The patient's lasting fatigue raised a suspicion of post-COVID-19 syndrome, requiring larger dosages of corticosteroids by stress dosing. Hypotension was interpreted as a symptom associated with adrenal insufficiency. The dosages of corticosteroids were increased beyond the upper recommended limits. The effect eventually stabilized the patient's hemodynamics. Hydrocortisone was increased as follows: 35 mg/day for nondialysis days and 55 mg/day for dialysis days, divided into three or four doses per day (20 mg in the morning, 20 mg before dialysis, 10 mg in the afternoon, and 5 mg in the evening). The dosage of fludrocortisone was increased up to 0.5 mg/day. In conclusion, the requirement for corticosteroids significantly increased in association with post-COVID-19 syndrome. The management of patients with adrenal insufficiency in the context of concomitant post-COVID-19 syndrome needs further investigation.
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Affiliation(s)
- Eriko Eguchi
- Department of Internal Medicine, Osaka Roudou Eisei Center Daiichi Hospital, 6-2-2,Mitejima, Nishiyodogawa-Ku, Osaka City, Osaka, 555-0012, Japan.
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7
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Sarafoglou K, Merke DP, Reisch N, Claahsen-van der Grinten H, Falhammar H, Auchus RJ. Interpretation of Steroid Biomarkers in 21-Hydroxylase Deficiency and Their Use in Disease Management. J Clin Endocrinol Metab 2023; 108:2154-2175. [PMID: 36950738 PMCID: PMC10438890 DOI: 10.1210/clinem/dgad134] [Citation(s) in RCA: 2] [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: 02/06/2023] [Accepted: 03/07/2023] [Indexed: 03/24/2023]
Abstract
The most common form of congenital adrenal hyperplasia is 21-hydroxylase deficiency (21OHD), which in the classic (severe) form occurs in roughly 1:16 000 newborns worldwide. Lifelong treatment consists of replacing cortisol and aldosterone deficiencies, and supraphysiological dosing schedules are typically employed to simultaneously attenuate production of adrenal-derived androgens. Glucocorticoid titration in 21OHD is challenging as it must balance the consequences of androgen excess vs those from chronic high glucocorticoid exposure, which are further complicated by interindividual variability in cortisol kinetics and glucocorticoid sensitivity. Clinical assessment and biochemical parameters are both used to guide therapy, but the specific purpose and goals of each biomarker vary with age and clinical context. Here we review the approach to medication titration for children and adults with classic 21OHD, with an emphasis on how to interpret adrenal biomarker values in guiding this process. In parallel, we illustrate how an understanding of the pathophysiologic and pharmacologic principles can be used to avoid and to correct complications of this disease and consequences of its management using existing treatment options.
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Affiliation(s)
- Kyriakie Sarafoglou
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN 55454, USA
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, USA
| | - Deborah P Merke
- Department of Pediatrics, National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, 80336 Munich, Germany
| | - Hedi Claahsen-van der Grinten
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, SE-17176, Stockholm, Sweden
| | - Richard J Auchus
- Departments of Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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8
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Stagi S, Tufano M, Chiti N, Cerutti M, Li Pomi A, Aversa T, Wasniewska M. Management of Neonatal Isolated and Combined Growth Hormone Deficiency: Current Status. Int J Mol Sci 2023; 24:10114. [PMID: 37373261 DOI: 10.3390/ijms241210114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Congenital growth hormone deficiency (GHD) is a rare disease caused by disorders affecting the morphogenesis and function of the pituitary gland. It is sometimes found in isolation but is more frequently associated with multiple pituitary hormone deficiency. In some cases, GHD may have a genetic basis. The many clinical signs and symptoms include hypoglycaemia, neonatal cholestasis and micropenis. Diagnosis should be made by laboratory analyses of the growth hormone and other pituitary hormones, rather than by cranial imaging with magnetic resonance imaging. When diagnosis is confirmed, hormone replacement should be initiated. Early GH replacement therapy leads to more positive outcomes, including reduced hypoglycaemia, growth recovery, metabolic asset, and neurodevelopmental improvements.
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Affiliation(s)
- Stefano Stagi
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
- Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Maria Tufano
- Paediatric Unit, Mugello's Hospital, 50032 Florence, Italy
| | - Nicolò Chiti
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Matteo Cerutti
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Alessandra Li Pomi
- Department of Human Pathology of Adulthood and Childhood, University of Messina, 98122 Messina, Italy
| | - Tommaso Aversa
- Department of Human Pathology of Adulthood and Childhood, University of Messina, 98122 Messina, Italy
| | - Malgorzata Wasniewska
- Department of Human Pathology of Adulthood and Childhood, University of Messina, 98122 Messina, Italy
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9
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Monge Chacón AG, Wang C, Waqar D, Syeda SA, Kumar R, Meghana DR. Long-Term Usage of Oral Glucocorticoids Leading to Adrenal Insufficiency: A Comprehensive Review of the Literature. Cureus 2023; 15:e38948. [PMID: 37309331 PMCID: PMC10257969 DOI: 10.7759/cureus.38948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/14/2023] Open
Abstract
Systemic glucocorticoid therapy is used worldwide by one to three percent of the general population and 0.5-1.8% on long-term oral glucocorticoid use. It is widely used in conditions such as inflammation, autoimmune diseases, and cancer to inhibit inflammatory responses. One of the possible undesirable side effects of exogenous corticosteroid treatment is adrenal suppression upon discontinuation of the medication and adrenal insufficiency after utilizing the supraphysiologic doses for more than one month. To prevent patients from the unwanted signs and symptoms of adrenal insufficiency, including fatigue, gastrointestinal upset, anorexia/weight loss, etc., better management of the quantity and frequency of exogenous corticosteroid use, as well as better education before starting its use, is needed. For patients actively on exogenous corticosteroids, a close follow-up must be in place to avoid adrenal suppression after the eventual discontinuation of their use. This review article summarizes the important studies to date on this subject, especially oral glucocorticoid use, and analyzes risks such as dose, duration of exposure, and comorbidities of adrenal insufficiency associated with oral glucocorticoid use. We comprehensively include information on those with primary adrenal insufficiency and pediatric patients, hoping to provide better insight and clinical reference.
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Affiliation(s)
| | - Chen Wang
- Medicine, China Medical University, Taichung, TWN
| | - Danish Waqar
- Internal Medicine, Nephrology, Loyola University Medical Center, Chicago, USA
| | | | - Rohan Kumar
- Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
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10
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Zawadzka K, Tylec P, Małczak P, Major P, Pędziwiatr M, Pisarska-Adamczyk M. Total versus partial adrenalectomy in bilateral pheochromocytoma - a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1127676. [PMID: 36998480 PMCID: PMC10043479 DOI: 10.3389/fendo.2023.1127676] [Citation(s) in RCA: 4] [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: 12/19/2022] [Accepted: 02/22/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND In patients with bilateral pheochromocytoma, partial adrenalectomy offers the chance to preserve adrenal function and avoid the need for lifelong steroid supplementation. However, the risk of tumour recurrence raises questions about this procedure. The aim of our study was to compare partial and total adrenalectomy in bilateral pheochromocytoma through a systematic review with meta-analysis. METHODS A systematic search was carried out using databases (MEDLINE, EMBASE, Scopus, Web of Science, CENTRAL) and registers of clinical trials (ClinicalTrials.gov, European Trials Register, WHO International Trials Registry Platform). This meta-analysis included studies up to July 2022 without language restrictions. A random effects model meta-analysis was performed to assess the risk of tumor recurrence, steroid dependence and morbidity in these patients. RESULTS Twenty-five studies were included in the analysis involving 1444 patients. The relative risk (RR) of loss of adrenal hormone function during follow-up and the need for steroid therapy was 0.32 in patients after partial adrenalectomy: RR 0.32, 95% Confidence Interval (CI): 0.26-0.38, P < 0.00001, I2 = 21%. Patients undergoing partial adrenalectomy had a lower odds ratio (OR) for developing acute adrenal crisis: OR 0.3, 95% CI: 0.1-0.91, P=0.03, I2 = 0%. Partial adrenalectomy was associated with a higher risk of recurrence than total adrenalectomy: OR 3.72, 95% CI: 1.54-8.96, P=0.003, I2 = 28%. CONCLUSION Partial adrenalectomy for bilateral pheochromocytoma is a treatment that offers a chance of preserving adrenal hormonal function, but is associated with a higher risk of local tumor recurrence. There was no difference for the risk of metastasis and in overall mortality among the group with bilateral pheochromocytomas undergoing total or partial adrenalectomy. This study is in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) Guidelines (10, 11). SYSTEMATIC REVIEW REGISTRATION https://osf.io/zx3se.
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Affiliation(s)
- Karolina Zawadzka
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
- Jagiellonian University Medical College, Doctoral School of Medical and Health Sciences, Kraków, Poland
| | - Piotr Tylec
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Magdalena Pisarska-Adamczyk
- Department of Medical Education, Jagiellonian University Medical College, Kraków, Poland
- *Correspondence: Magdalena Pisarska-Adamczyk,
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11
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Ayyoubi S, van Kampen EEM, Kocabas LI, Parulski C, Lechanteur A, Evrard B, De Jager K, Muller E, Wilms EW, Meulenhoff PWC, Ruijgrok EJ. 3D printed, personalized sustained release cortisol for patients with adrenal insufficiency. Int J Pharm 2022; 630:122466. [PMID: 36493969 DOI: 10.1016/j.ijpharm.2022.122466] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/27/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
The standard of care for patients with Adrenal Insufficiency (AI) is suboptimal. Administration of hydrocortisone three times a day produces plasma cortisol fluctuations associated with negative health outcomes. Furthermore, there is a high inter-individual variability in cortisol need, necessitating a personalized approach. It is hypothesized that a personalized, sustained release formulation would enhance the pharmacotherapy by mimicking the physiological cortisol plasma concentration at a higher level. Therefore, a novel 24 h sustained release 3D printed (3DP) hydrocortisone formulation has been developed (M3DICORT) by coupling hot-melt extrusion with fused deposition modeling. A uniform drug distribution in the 3DP tablets is demonstrated by a content of 101.66 ± 1.60 % with an acceptance value of 4.01. Furthermore, tablets had a stable 24 h dissolution profile where the intra-batch standard deviation was ± 2.8 % and the inter-batch standard deviation was ± 6.8 %. Tablet height and hydrocortisone content were correlated (R2 = 0.996), providing a tool for easy dose personalization. Tablets maintained critical quality attributes, such as dissolution profile (f2 > 60) and content uniformity after process transfer from a single-screw extruder to a twin-screw extruder. Impurities were observed in the final product which should be mitigated before clinical assessment. To our knowledge, M3DICORT is the first 3DP hydrocortisone formulation specifically developed for AI.
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Affiliation(s)
- S Ayyoubi
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - E E M van Kampen
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - L I Kocabas
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, the Netherlands
| | - C Parulski
- Laboratory of Pharmaceutical Technology and Biopharmacy, Center for Interdisciplinary Research on Medicines (CIRM), Department of Pharmacy, University of Liege (ULiege), Avenue Hippocrate 15, 4000 Liege, Belgium
| | - A Lechanteur
- Laboratory of Pharmaceutical Technology and Biopharmacy, Center for Interdisciplinary Research on Medicines (CIRM), Department of Pharmacy, University of Liege (ULiege), Avenue Hippocrate 15, 4000 Liege, Belgium
| | - B Evrard
- Laboratory of Pharmaceutical Technology and Biopharmacy, Center for Interdisciplinary Research on Medicines (CIRM), Department of Pharmacy, University of Liege (ULiege), Avenue Hippocrate 15, 4000 Liege, Belgium
| | - K De Jager
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - E Muller
- Department of Pharmaceutical Quality Control, The Hague Hospital Pharmacy, Charlotte Jacobslaan 70, 2545 AB The Hague, the Netherlands
| | - E W Wilms
- Department of Pharmaceutical Quality Control, The Hague Hospital Pharmacy, Charlotte Jacobslaan 70, 2545 AB The Hague, the Netherlands
| | - P W C Meulenhoff
- Tridi Pharma B.V. M.H. Trompstraat 7, 3572 XS Utrecht, the Netherlands
| | - E J Ruijgrok
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
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12
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Bugălă NM, Carsote M, Stoica LE, Albulescu DM, Ţuculină MJ, Preda SA, Boicea AR, Alexandru DO. New Approach to Addison Disease: Oral Manifestations Due to Endocrine Dysfunction and Comorbidity Burden. Diagnostics (Basel) 2022; 12:diagnostics12092080. [PMID: 36140482 PMCID: PMC9497746 DOI: 10.3390/diagnostics12092080] [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: 06/02/2022] [Revised: 08/17/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
This review highlights oral anomalies with major clinical impact in Addison disease (AD), including dental health and dermatologic features, through a dual perspective: pigmentation issues and AD comorbidities with oral manifestations. Affecting 92% of AD patients, cutaneomucosal hyperpigmentation is synchronous with or precedes general manifestations by up to a decade, underlying melanocytic infiltration of the basal epidermal layer; melanophages in the superficial dermis; and, rarely, acanthosis, perivascular lymphocytic infiltrate, and hyperkeratosis. Intraoral pigmentation might be the only sign of AD; thus, early recognition is mandatory, and biopsy is helpful in selected cases. The buccal area is the most affected location; other sites are palatine arches, lips, gums, and tongue. Pigmented oral lesions are patchy or diffuse; mostly asymptomatic; and occasionally accompanied by pain, itchiness, and burn-like lesions. Pigmented lingual patches are isolated or multiple, located on dorsal and lateral areas; fungiform pigmented papillae are also reported in AD individuals. Dermoscopy examination is particularly indicated for fungal etiology; yet, it is not routinely performed. AD’s comorbidity burden includes the cluster of autoimmune polyglandular syndrome (APS) type 1 underlying AIRE gene malfunction. Chronic cutaneomucosal candidiasis (CMC), including oral CMC, represents the first sign of APS1 in 70–80% of cases, displaying autoantibodies against interleukin (IL)-17A, IL-17F ± IL-22, and probably a high mucosal concentration of interferon (IFN)-γ. CMC is prone to systemic candidiasis, representing a procarcinogenic status due to Th17 cell anomalies. In APS1, the first cause of mortality is infections (24%), followed by oral and esophageal cancers (15%). Autoimmune hypoparathyroidism (HyP) is the earliest endocrine element in APS1; a combination of CMC by the age of 5 years and dental enamel hypoplasia (the most frequent dental complication of pediatric HyP) by the age of 15 is an indication for HyP assessment. Children with HyP might experience short dental roots, enamel opacities, hypodontia, and eruption dysfunctions. Copresence of APS-related type 1 diabetes mellitus (DM) enhances the risk of CMC, as well as periodontal disease (PD). Anemia-related mucosal pallor is related to DM, hypothyroidism, hypogonadism, corresponding gastroenterological diseases (Crohn’s disease also presents oral ulceration (OU), mucogingivitis, and a 2–3 times higher risk of PD; Biermer anemia might cause hyperpigmentation by itself), and rheumatologic diseases (lupus induces OU, honeycomb plaques, keratotic plaques, angular cheilitis, buccal petechial lesions, and PD). In more than half of the patients, associated vitiligo involves depigmentation of oral mucosa at different levels (palatal, gingival, alveolar, buccal mucosa, and lips). Celiac disease may manifest xerostomia, dry lips, OU, sialadenitis, recurrent aphthous stomatitis and dental enamel defects in children, a higher prevalence of caries and dentin sensitivity, and gingival bleeding. Oral pigmented lesions might provide a useful index of suspicion for AD in apparently healthy individuals, and thus an adrenocorticotropic hormone (ACTH) stimulation is useful. The spectrum of autoimmune AD comorbidities massively complicates the overall picture of oral manifestations.
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Affiliation(s)
- Narcis Mihăiţă Bugălă
- Department of Medical Informatics and Biostatistics, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- C.I. Parhon National Institute of Endocrinology, Aviatorilor Ave. 34–38, Sector 1, 011683 Bucharest, Romania
- Correspondence: ; Tel.: +40-744851934
| | - Loredana Elena Stoica
- Department of Dermatology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Dana Maria Albulescu
- Department of Anatomy, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mihaela Jana Ţuculină
- Department of Odontology, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Smaranda Adelina Preda
- Department of Odontology, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Ancuta-Ramona Boicea
- Department of Occupational Medicine, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Dragoș Ovidiu Alexandru
- Department of Medical Informatics and Biostatistics, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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13
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Mineralocorticoid Receptor Activation in Vascular Insulin Resistance and Dysfunction. Int J Mol Sci 2022; 23:ijms23168954. [PMID: 36012219 PMCID: PMC9409140 DOI: 10.3390/ijms23168954] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 11/25/2022] Open
Abstract
Systemic insulin resistance is characterized by reduced insulin metabolic signaling and glucose intolerance. Mineralocorticoid receptors (MRs), the principal receptors for the hormone aldosterone, play an important role in regulating renal sodium handling and blood pressure. Recent studies suggest that MRs also exist in tissues outside the kidney, including vascular endothelial cells, smooth muscle cells, fibroblasts, perivascular adipose tissue, and immune cells. Risk factors, including excessive salt intake/salt sensitivity, hypertension, and obesity, can lead to the activation of vascular MRs to promote inflammation, oxidative stress, remodeling, and fibrosis, as well as cardiovascular stiffening and microcirculatory impairment. These pathophysiological changes are associated with a diminished ability of insulin to initiate appropriate intracellular signaling events, resulting in a reduced glucose uptake within the microcirculation and related vascular insulin resistance. Therefore, the pharmacological inhibition of MR activation provides a potential therapeutic option for improving vascular function, glucose uptake, and vascular insulin sensitivity. This review highlights recent experimental and clinical data that support the contribution of abnormal MR activation to the development of vascular insulin resistance and dysfunction.
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14
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Smolensky MH, Hermida RC, Sackett-Lundeen L, Hermida-Ayala RG, Geng YJ. Does Patient-Applied Testosterone Replacement Therapy Pose Risk for Blood Pressure Elevation? Circadian Medicine Perspectives. Compr Physiol 2022; 12:4165-4184. [PMID: 35950658 DOI: 10.1002/cphy.c220014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We reviewed medication package inserts, US Food and Drug Administration (FDA) reports, and journal publications concerning the 10 nonbiosimilar patient-applied (PA) testosterone (T) replacement therapies (TRTs) for intraday serum T patterning and blood pressure (BP) effects. Blood T concentration is circadian rhythmic in young adult eugonadal males, being highest around awakening and lowest before bedtime. T level and 24 h variation are blunted in primary and secondary hypogonadism. Utilized as recommended, most PA-TRTs achieve nonphysiologic T 24 h patterning. Only Androderm® , an evening PA transdermal patch, closely replicates the normal T circadian rhythmicity. Accurate determination of risk for BP elevation and hypertension (HTN) by PA-TRTs is difficult due to limitations of office BP measurements (OBPM) and suboptimal methods and endpoints of ambulatory BP monitoring (ABPM). OBPM is subject to "White Coat" pressor effect resulting in unrepresentative BP values plus masked normotension and masked HTN, causing misclassification of approximately 45% of trial participants, both before and during treatment. Change in guideline-recommended diagnostic thresholds over time causes misclassification of an additional approximately 15% of participants. ABPM is improperly incorporated into TRT safety trials. It is done for 24 h rather than preferred 48 h; BP is oversampled during wakefulness, biasing derived 24 h mean values; 24 h mean systolic and diastolic BP (SBP, DBP) are inappropriate primary outcomes, because of not being best predictors of risk for major acute cardiovascular events (MACE); "daytime" and "nighttime" BP means referenced to clock time are reported rather than biologically relevant wake-time and sleep-time BP means; most importantly, asleep SBP mean and dipping, strongest predictors of MACE, are disregarded. © 2022 American Physiological Society. Compr Physiol 12: 1-20, 2022.
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Affiliation(s)
- Michael H Smolensky
- Department of Biomedical Engineering, Cockrell School of Engineering, The University of Texas at Austin, Austin, Texas, USA.,The Center for Cardiovascular Biology and Atherosclerosis Research, Division of Cardiovascular Medicine, Department of Internal Medicine, McGovern School of Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ramon C Hermida
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Telecommunication Technologies (atlanTTic), University of Vigo, Vigo, Spain
| | - Linda Sackett-Lundeen
- American Association for Medical Chronobiology and Chronotherapeutics, Roseville, Minnesota, USA
| | - Ramon G Hermida-Ayala
- Circadian Ambulatory Technology & Diagnostics (CAT&D), Santiago de Compostela, Spain
| | - Yong-Jian Geng
- The Center for Cardiovascular Biology and Atherosclerosis Research, Division of Cardiovascular Medicine, Department of Internal Medicine, McGovern School of Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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15
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Abstract
Adrenal insufficiency (AI), first described by Thomas Addison in 1855, is characterised by inadequate hormonal production by the adrenal gland, which could either be primary, due to destruction of the adrenal cortex, or secondary/tertiary, due to lack of adrenocorticotropic hormone or its stimulation by corticotropin-releasing hormone. This was an invariably fatal condition in Addison's days with most patients dying within a few years of diagnosis. However, discovery of cortisone in the 1940s not only improved the life expectancy of these patients but also had a dramatic effect on their overall quality of life. The diagnosis, easily confirmed by demonstrating inappropriately low cortisol secretion, is often delayed by months, and many patients present with acute adrenal crisis. Sudden withdrawal from chronic glucocorticoid therapy is the most common cause of AI. Currently, there remains a wide variation in the management of this condition across Europe. As primary AI is a relatively rare condition, most medical specialists will only manage a handful of these patients in their career. Despite many advances in recent years, there is currently no curative option, and modern cortisol replacement regimens fail to adequately mimic physiological cortisol rhythm. A number of new approaches including allograft of adrenocortical tissue and stem cell therapy are being tried but remain largely experimental.
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Affiliation(s)
- Rajeev Kumar
- Diabetes and Endocrinology, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - W S Wassif
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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16
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Abstract
Congenital hypopituitarism is the deficiency in 1 or more hormones produced by the anterior pituitary or released by the posterior pituitary and has an estimated incidence of 1 in 4,000 to 10,000. Due to the critical role the pituitary plays in growth, metabolic, and reproductive processes, early diagnosis is essential to prevent devastating and often preventable outcomes. However, in neonates with congenital hypopituitarism, symptoms are often nonspecific and tend to overlap with other disease processes, making diagnosis extremely challenging in the neonatal period. This review highlights the embryology and organogenesis of the pituitary gland, genetic causes of hypopituitarism, clinical presentations in the neonatal period, and methods to diagnose and treat select deficiencies with a focus on anterior pituitary hormones.
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Affiliation(s)
- Geoanna Bautista
- Department of Pediatrics, Division of Neonatology, University of California, Davis Children's Hospital, Sacramento, CA
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17
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Long-Term Follow-Up of Three Family Members with a Novel NNT Pathogenic Variant Causing Primary Adrenal Insufficiency. Genes (Basel) 2022; 13:genes13050717. [PMID: 35627102 PMCID: PMC9140979 DOI: 10.3390/genes13050717] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/14/2022] [Accepted: 04/18/2022] [Indexed: 11/16/2022] Open
Abstract
Nicotinamide nucleotide transhydrogenase (NNT) deficiency causes primary adrenal insufficiency (PAI) and possibly some extra-adrenal manifestations. A limited number of these patients were previously described. We present the clinical and genetic characteristics of three family members with a biallelic novel pathogenic variant in the NNT gene. The patients were followed until the ages of 21.6, 20.2, and 4.2 years. PAI was diagnosed in the eldest two brothers after an Addisonian crisis and the third was diagnosed at the age of 4.5 months in the asymptomatic stage due to the genetic screening of family members. Whole exome sequencing with a targeted interpretation of variants in genes related to PAI was performed in all the patients. The urinary steroid metabolome was determined by gas chromatography–mass spectrometry in the asymptomatic patient. The three patients, who were homozygous for c.1575dup in the NNT gene, developed isolated glucocorticoid deficiency. The urinary steroid metabolome showed normal excretion of cortisol metabolites. The adolescent patients had slow pubertal progression with low–normal testicular volume, while testicular endocrine function was normal. Bone mineral density was in the range for osteopenia in both grown-up siblings. Echocardiography revealed no structural or functional heart abnormalities. This article is among the first with a comprehensive and chronologically-detailed description of patients with NNT deficiency.
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18
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Stachanow V, Neumann U, Blankenstein O, Bindellini D, Melin J, Ross R, Whitaker MJ, Huisinga W, Michelet R, Kloft C. Exploring Dried Blood Spot Cortisol Concentrations as an Alternative for Monitoring Pediatric Adrenal Insufficiency Patients: A Model-Based Analysis. Front Pharmacol 2022; 13:819590. [PMID: 35370666 PMCID: PMC8968419 DOI: 10.3389/fphar.2022.819590] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) is the most common form of adrenal insufficiency in childhood; it requires cortisol replacement therapy with hydrocortisone (HC, synthetic cortisol) from birth and therapy monitoring for successful treatment. In children, the less invasive dried blood spot (DBS) sampling with whole blood including red blood cells (RBCs) provides an advantageous alternative to plasma sampling. Potential differences in binding/association processes between plasma and DBS however need to be considered to correctly interpret DBS measurements for therapy monitoring. While capillary DBS samples would be used in clinical practice, venous cortisol DBS samples from children with adrenal insufficiency were analyzed due to data availability and to directly compare and thus understand potential differences between venous DBS and plasma. A previously published HC plasma pharmacokinetic (PK) model was extended by leveraging these DBS concentrations. In addition to previously characterized binding of cortisol to albumin (linear process) and corticosteroid-binding globulin (CBG; saturable process), DBS data enabled the characterization of a linear cortisol association with RBCs, and thereby providing a quantitative link between DBS and plasma cortisol concentrations. The ratio between the observed cortisol plasma and DBS concentrations varies highly from 2 to 8. Deterministic simulations of the different cortisol binding/association fractions demonstrated that with higher blood cortisol concentrations, saturation of cortisol binding to CBG was observed, leading to an increase in all other cortisol binding fractions. In conclusion, a mathematical PK model was developed which links DBS measurements to plasma exposure and thus allows for quantitative interpretation of measurements of DBS samples.
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Affiliation(s)
- Viktoria Stachanow
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Uta Neumann
- Pediatric Endocrinology, Charité-Universitätsmedizin, Berlin, Germany
| | - Oliver Blankenstein
- Pediatric Endocrinology, Charité-Universitätsmedizin, Berlin, Germany.,Labor Berlin, Charité Vivantes GmbH, Berlin, Germany
| | - Davide Bindellini
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Johanna Melin
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin, Germany
| | | | | | | | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
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19
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Auchus RJ, Courtillot C, Dobs A, El-Maouche D, Falhammar H, Lacroix A, Farrar M, O’Donoghue C, Anatchkova M, Cutts K, Taylor N, Yonan C, Lamotte M, Touraine P. Treatment patterns and unmet needs in adults with classic congenital adrenal hyperplasia: A modified Delphi consensus study. Front Endocrinol (Lausanne) 2022; 13:1005963. [PMID: 36465641 PMCID: PMC9717438 DOI: 10.3389/fendo.2022.1005963] [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: 07/28/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is a rare autosomal recessive condition characterized by cortisol deficiency and excess androgen production. The current standard of care is glucocorticoid (GC) therapy, and sometimes mineralocorticoids, to replace endogenous cortisol deficiency; however, supraphysiologic GC doses are usually needed to reduce excess androgen production. Monitoring/titrating GC treatment remains a major challenge, and there is no agreement on assessment of treatment adequacy. This study surveyed expert opinions on current treatment practices and unmet needs in adults with classic CAH. METHODS A modified two-round Delphi process with adult endocrinologists was conducted via online questionnaire. Survey questions were organized into three categories: practice characteristics/CAH experience, GC management, and unmet needs/complications. Anonymized aggregate data from Round 1 were provided as feedback for Round 2. Responses from both rounds were analyzed using descriptive statistics. Consensus was defined a priori as: full consensus (100%, n=9/9); near consensus (78% to <100%, n=7/9 or 8/9); no consensus (<78%, n<7/9). RESULTS The same nine panelists participated in both survey rounds; five (56%) were based in North America and four (44%) in Europe. Most panelists (78%) used hydrocortisone in the majority of patients, but two (22%) preferred prednisone/prednisolone. Panelists agreed (89%) that adequate control is best evaluated using a balance of clinical presentation and androgen/precursor laboratory values; no consensus was reached on optimal timing of collecting samples for androgen testing or laboratory values indicating good control. Despite lack of consensus on many aspects of CAH management, panelists agreed on the importance of many disease- and GC-related complications, and that there is a large unmet need for new treatments. With currently available treatments, panelists reported that 46% of classic CAH patients did not have optimized androgen levels, regardless of GC dose. CONCLUSIONS The limited areas of consensus obtained in this study reflect the variability in treatment practices for adults with classic CAH, even among clinicians with expertise in treating this population. However, all panelists agreed on the need for new treatments for classic CAH and the importance of many disease- and GC-related complications, which are difficult to manage with currently available treatments.
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Affiliation(s)
- Richard J. Auchus
- Departments of Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI, United States
- *Correspondence: Richard J. Auchus,
| | - Carine Courtillot
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine and Gynecological Disorders, Groupe Hospitalier Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Adrian Dobs
- Department of Medicine, Division of Endocrinology and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Diala El-Maouche
- Division of Endocrinology and Metabolism, George Washington University, Washington, DC, United States
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Andre Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
| | - Mallory Farrar
- Neurocrine Biosciences, Inc., Health Economics and Outcomes Research, San Diego, CA, United States
| | - Conor O’Donoghue
- Neurocrine Biosciences, Inc., New Product Commercialization, San Diego, CA, United States
| | | | - Katelyn Cutts
- Evidera, Patient-Centered Research, Bethesda, MD, United States
| | - Natalie Taylor
- Evidera, Patient-Centered Research, Bethesda, MD, United States
| | - Chuck Yonan
- Neurocrine Biosciences, Inc., Health Economics and Outcomes Research, San Diego, CA, United States
| | - Mark Lamotte
- IQVIA, Global Health Economics and Outcomes Research (HEOR), Zaventem, Belgium
| | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine and Gynecological Disorders, Groupe Hospitalier Pitié-Salpêtrière, Sorbonne Université, Paris, France
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20
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Yoo HW. Diverse etiologies, diagnostic approach, and management of primary adrenal insufficiency in pediatric age. Ann Pediatr Endocrinol Metab 2021; 26:149-157. [PMID: 34610702 PMCID: PMC8505038 DOI: 10.6065/apem.2142150.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/11/2021] [Indexed: 12/02/2022] Open
Abstract
Primary adrenal insufficiency (PAI) in pediatric age is a rare, but potentially fatal condition caused by diverse etiologies including biochemical defects of steroid biosynthesis, developmental abnormalities of the adrenal gland, or reduced responsiveness to adrenocorticotropic hormone. Compared to adult PAI, pediatric PAI is more often the result of genetic (monogenic, syndromic disorders) than acquired conditions. During the past decade, rare monogenic disorders associated with PAI have helped unravel the underlying novel molecular genetic mechanism. The diagnosis of adrenal insufficiency in children and young infancy is often challenging, usually based on clinical suspicion and endocrine laboratory findings. Pediatric endocrinologists sometimes encounter therapeutic difficulty in finding the balance between undertreatment and overtreatment, determining how to optimize the dose over the patient's lifetime, and maximizing mimicry of normal cortisol secretion with glucocorticoid replacement therapy.
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Affiliation(s)
- Han-Wook Yoo
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea,Address for correspondence: Han-Wook Yoo Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympicro 43-gil, Songpa-gu, Seoul 05505, Korea
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21
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Saito J, Yoshikawa N, Hanawa T, Ozawa A, Matsumoto T, Harada T, Iwahashi K, Nakamura H, Yamatani A. Stability of Hydrocortisone in Oral Powder Form Compounded for Pediatric Patients in Japan. Pharmaceutics 2021; 13:pharmaceutics13081267. [PMID: 34452228 PMCID: PMC8400744 DOI: 10.3390/pharmaceutics13081267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 12/20/2022] Open
Abstract
Hydrocortisone has been utilized in the management of adrenal insufficiency. For pediatric patients, the commercially available enteral form of hydrocortisone tablets (Cortoril®) is administered in powder form after being compounded by a pharmacist. However, the stability and quality of compounded hydrocortisone powder have not been verified. In this study, we formulated a 20 mg/g oral hydrocortisone powder by adding lactose monohydrate to crushed and filtered hydrocortisone tablets and assessed the stability and physical properties of this compounded product in polycarbonate amber bottles or coated paper packages laminated with cellophane and polyethylene. Stability was examined over 120 days in three storage conditions: closed bottle, in-use bottle, and laminated paper. Drug dissolution and powder X-ray diffraction analysis were conducted to assess its physicochemical stabilities. Validated liquid chromatography-diode array detection was used to detect and quantify hydrocortisone and its degradation products. Although impurity B (cortisone) and G (hydrocortisone-21-aldehyde) were found after 120 days of storage, no crystallographic and dissolution changes were noted. Hydrocortisone content was maintained between 90% and 110% of initial contents for 120 days at 25 ± 2 °C and 60 ± 5% relative humidity in all packaging conditions.
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Affiliation(s)
- Jumpei Saito
- Department of Pharmacy, National Center for Child Health and Development, Setagaya-ku, Tokyo 157-0054, Japan; (N.Y.); (K.I.); (A.Y.)
- Division of Clinical Pharmacology and Oral Formulation Development, National Center for Child Health and Development, Tokyo 157-0054, Japan
- Correspondence: ; Tel.: +81-(0)3-3416-0181
| | - Nozomi Yoshikawa
- Department of Pharmacy, National Center for Child Health and Development, Setagaya-ku, Tokyo 157-0054, Japan; (N.Y.); (K.I.); (A.Y.)
| | - Takehisa Hanawa
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, Chiba 278-8510, Japan; (T.H.); (A.O.)
| | - Ayuna Ozawa
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, Chiba 278-8510, Japan; (T.H.); (A.O.)
| | | | - Tsutomu Harada
- Division of Pharmaceutics, School of Pharmacy, Showa University, Tokyo 142-8555, Japan;
| | - Kana Iwahashi
- Department of Pharmacy, National Center for Child Health and Development, Setagaya-ku, Tokyo 157-0054, Japan; (N.Y.); (K.I.); (A.Y.)
- Division of Clinical Pharmacology and Oral Formulation Development, National Center for Child Health and Development, Tokyo 157-0054, Japan
| | - Hidefumi Nakamura
- Department of Research and Development Supervision, National Center for Child Health and Development, Tokyo 157-0054, Japan;
| | - Akimasa Yamatani
- Department of Pharmacy, National Center for Child Health and Development, Setagaya-ku, Tokyo 157-0054, Japan; (N.Y.); (K.I.); (A.Y.)
- Division of Clinical Pharmacology and Oral Formulation Development, National Center for Child Health and Development, Tokyo 157-0054, Japan
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22
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Van Wyngene L, Vanderhaeghen T, Petta I, Timmermans S, Corbeels K, Van der Schueren B, Vandewalle J, Van Looveren K, Wallaeys C, Eggermont M, Dewaele S, Catrysse L, van Loo G, Beyaert R, Vangoitsenhoven R, Nakayama T, Tavernier J, De Bosscher K, Libert C. ZBTB32 performs crosstalk with the glucocorticoid receptor and is crucial in glucocorticoid responses to starvation. iScience 2021; 24:102790. [PMID: 34337361 PMCID: PMC8324811 DOI: 10.1016/j.isci.2021.102790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 03/25/2021] [Accepted: 06/24/2021] [Indexed: 12/15/2022] Open
Abstract
The hypothalamic-pituitary-adrenal (HPA) axis forms a complex neuroendocrine system that regulates the body’s response to stress such as starvation. In contrast with the glucocorticoid receptor (GR), Zinc finger and BTB domain containing 32 (ZBTB32) is a transcription factor with poorly described functional relevance in physiology. This study shows that ZBTB32 is essential for the production of glucocorticoids (GCs) in response to starvation, since ZBTB32−/− mice fail to increase their GC production in the absence of nutrients. In terms of mechanism, GR-mediated upregulation of adrenal Scarb1 gene expression was absent in ZBTB32−/− mice, implicating defective cholesterol import as the cause of the poor GC synthesis. These lower GC levels are further associated with aberrations in the metabolic adaptation to starvation, which could explain the progressive weight gain of ZBTB32−/− mice. In conclusion, ZBTB32 performs a crosstalk with the GR in the metabolic adaptation to starvation via regulation of adrenal GC production. ZBTB32 is involved in the glucocorticoid production in response to starvation GR-mediated upregulation of adrenal Scarb1 regulates cholesterol import The weight gain of ZBTB32−/− mice is associated with aberrant metabolic adaptations
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Affiliation(s)
- Lise Van Wyngene
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Tineke Vanderhaeghen
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Ioanna Petta
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Ghent Gut Inflammation Group (GGIG), Ghent University, 9000 Ghent, Belgium.,Department of Rheumatology, Ghent University, 9000 Ghent, Belgium
| | - Steven Timmermans
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Katrien Corbeels
- Department of Chronic Diseases and Metabolism - Endocrinology, KU Leuven, Leuven, Belgium
| | - Bart Van der Schueren
- Department of Chronic Diseases and Metabolism - Endocrinology, KU Leuven, Leuven, Belgium
| | - Jolien Vandewalle
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Kelly Van Looveren
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Charlotte Wallaeys
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Melanie Eggermont
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Sylviane Dewaele
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Leen Catrysse
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Geert van Loo
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium.,Ghent Gut Inflammation Group (GGIG), Ghent University, 9000 Ghent, Belgium
| | - Rudi Beyaert
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium.,Ghent Gut Inflammation Group (GGIG), Ghent University, 9000 Ghent, Belgium
| | - Roman Vangoitsenhoven
- Department of Chronic Diseases and Metabolism - Endocrinology, KU Leuven, Leuven, Belgium
| | - Toshinori Nakayama
- Department of Immunology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Jan Tavernier
- Center for Medical Biotechnology, VIB Center for Medical Biotechnology, 9000 Ghent, Belgium.,Cytokine Receptor Laboratory (CRL), Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, 3 Albert Baertsoenkaai, 9000 Ghent, Belgium
| | - Karolien De Bosscher
- Center for Medical Biotechnology, VIB Center for Medical Biotechnology, 9000 Ghent, Belgium.,Translational Nuclear Receptor Research Lab, Department of Biomolecular Medicine, Faculty of Medicine and Health Sciences, Ghent University, 3 Albert Baertsoenkaai,9000 Ghent, Belgium
| | - Claude Libert
- Center for Inflammation Research, VIB Center for Inflammation Research, 9000 Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium.,Ghent Gut Inflammation Group (GGIG), Ghent University, 9000 Ghent, Belgium
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23
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Ramirez Alcantara J, Halper A. Adrenal insufficiency updates in children. Curr Opin Endocrinol Diabetes Obes 2021; 28:75-81. [PMID: 33278125 DOI: 10.1097/med.0000000000000591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The current article will review the newest diagnostic tools, genetic causes, and treatment of adrenal insufficiency in children. RECENT FINDINGS It is common practice to perform an adrenocorticotropin hormone (ACTH) stimulation test when adrenal insufficiency is suspected. The indications for use of a high-dose or low-dose of synthetic ACTH in children have been refined. In addition, newer studies propose adding 15 and 30-min serum or salivary cortisol levels to the low-dose ACTH stimulation test to correctly identify adrenal insufficiency. Recent identification of genetic mutations in children with non-classic steroidogenic acute regulatory protein and other mutations associated with primary and secondary adrenal insufficiency have expanded the cause and pathophysiology of monogenic adrenal insufficiency. In addition, newer hydrocortisone formulations and delivery methods and medications to use in combination with hydrocortisone are being explored to improve treatment for children with adrenal insufficiency. SUMMARY Improved diagnostic aids, detection of newer genetic mutations, and better treatment options and delivery systems will help correctly identify and manage children with adrenal insufficiency to improve health outcomes and quality of life. VIDEO ABSTRACT http://links.lww.com/COE/A21.
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Affiliation(s)
- Jonanlis Ramirez Alcantara
- Division of Pediatric Endocrinology, Department of Pediatrics, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
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24
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Cui Q, Liu D, Xiang B, Sun Q, Fan L, He M, Wang Y, Zhu X, Ye H. Morning Serum Cortisol as a Predictor for the HPA Axis Recovery in Cushing's Disease. Int J Endocrinol 2021; 2021:4586229. [PMID: 34527048 PMCID: PMC8437621 DOI: 10.1155/2021/4586229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/12/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The suppressed hypothalamic-pituitary-adrenal (HPA) axis after successful surgery for Cushing's disease (CD) will recover in almost all patients. We aimed to identify the predictive factors for HPA axis recovery in CD patients with postoperative remission. Design and Methods. This observational retrospective cross-sectional study enrolled 69 CD patients with postoperative remission in Huashan Hospital from 2015 to 2019. All subjects had a detailed clinical evaluation. The low-dose ACTH stimulation test (LDT) was conducted as the gold standard for assessing the HPA axis function. RESULTS Peak cortisol in LDT was found only to be positively correlative with morning serum cortisol (MSC) (ρ=0.451, p < 0.001). The MSC was higher (p < 0.001), and the median postoperative course was significantly longer (p=0.025) in the patients with the recovered HPA axis function compared with unrecovered patients. The AUC value of MSC for predicting the recovery of the HPA axis was 0.701, and the optimal cutoff was 6.25 μg/dl (sensitivity 85.19% and specificity 47.62%). Other useful cutoff values were 10.74 μg/dl (specificity 100%) and 4.18 μg/dl (sensitivity 100%). Besides, combined with the postoperative course, the AUC values were higher than MSC alone (0.935 vs. 0.701, p < 0.001). CONCLUSIONS MSC is a viable first-step diagnostic predictor for HPA axis recovery in CD patients with postoperative remission. For the patients with cortisol levels between 4.18 and 10.74 μg/dl, a confirmatory test should be conducted. When the MSC level was 10.74 μg/dl or greater, the replacement therapy could be discontinued.
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Affiliation(s)
- Q. Cui
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - D. Liu
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - B. Xiang
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - Q. Sun
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - L. Fan
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - M. He
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - Y. Wang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - X. Zhu
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - H. Ye
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
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25
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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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26
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Shah V, Hoyos-Martinez A, Horne VE. Association of Adrenal Insufficiency With Pediatric Pseudotumor Cerebri Syndrome. JAMA Ophthalmol 2020; 138:1187-1191. [PMID: 32940641 DOI: 10.1001/jamaophthalmol.2020.3322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Pediatric pseudotumor cerebri syndrome pathophysiology is complex and not well delineated. Therefore, it is important to identify potential contributors or targets underlying the primary pathogenesis for its development. Objective To report cases highlighting the association of pediatric pseudotumor cerebri syndrome with adrenal insufficiency. Design, Setting, and Participants This noncontrolled, observational case series included pediatric patients diagnosed with pseudotumor cerebri syndrome and adrenal insufficiency at an urban academic children's hospital in Houston, Texas, from June 2015 to October 2019. Main Outcomes and Measures Monitoring optic nerve edema by clinical examination, fundus photography, and optical coherence topography images of the optic nerve. Results Data were collected from 5 pediatric patients (age range, 5-10 years) diagnosed with pseudotumor cerebri syndrome and adrenal insufficiency. One was a girl; all were White and prepubertal. Three patients had unrecognized glucocorticoid exposure. All patients had bilateral optic nerve edema that was initially treated with acetazolamide or topiramate, but cortisol functional testing by either 8 am cortisol or cosyntropin stimulation tests revealed a diagnosis of central adrenal insufficiency. Treatment with physiological doses of hydrocortisone resulted in resolution of optic nerve edema and clinical symptoms of pseudotumor cerebri syndrome, as well as a shorter time receiving medical therapy. Conclusions and Relevance In this case series, adrenal insufficiency was associated with both primary and secondary prepubertal pediatric pseudotumor cerebri syndrome. As a potential target specific to causative mechanism, physiologic hydrocortisone therapy resolved the condition. To date, there remains a global unawareness among clinicians about the suppressive outcome that glucocorticoids may have on the developing hypothalamic-pituitary-adrenal axis, resulting in adrenal insufficiency and so-called episodic pseudotumor cerebri syndrome in young children. Ophthalmologists and pediatric subspecialists should implement cortisol testing via either 8 am cortisol or cosyntropin stimulation tests at initial evaluation of all children with pseudotumor cerebri syndrome and risk factors for adrenal insufficiency, no predisposing causes, or nonresponse to conventional treatment. Further management and treatment should be in combination with ophthalmology and endocrine services.
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Affiliation(s)
- Veeral Shah
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas.,Abrahamson Pediatric Eye Institute, Division of Pediatric Ophthalmology, Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Ophthalmology, University of Cincinnati, Cincinnati, Ohio
| | - Alfonso Hoyos-Martinez
- Section of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston
| | - Vincent E Horne
- Section of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston
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27
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Chihaoui M, Madhi W, Yazidi M, Hammami B, Oueslati I, Khessairi N, Grira W, Bibi A, Feki M, Chaker F. Salivary cortisol levels during Ramadan fasting in hydrocortisone-treated secondary adrenal insufficiency patients. Endocrine 2020; 70:404-411. [PMID: 32789535 DOI: 10.1007/s12020-020-02452-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Patients with adrenal insufficiency have difficulties in fasting during the month of Ramadan with an increased risk of complications. Cortisol levels are unknown in these patients. The objective of this study was to assess the daily cortisol profile in hydrocortisone-treated patients with secondary adrenal insufficiency (SAI) and healthy controls during a fasting day. METHODS A cross-sectional matched case-control study on 50 hydrocortisone-treated SAI patients and 69 controls who are used to fast. Clinical and therapeutic data were collected. Five salivary samples for cortisol measurement were collected throughout a fasting day of the third week of Ramadan 2019. RESULTS Salivary cortisol levels were significantly higher on awakening, at midnight and before the predawn meal in patients compared with controls. The circadian cortisol rhythm was disrupted in patients. The area under the salivary cortisol level versus time curve (AUC) was lower than the 2.5th percentile of the controls in one patient (2.5%) and higher than the 97.5th percentile in 23 patients (59%) who were considered overtreated. Age ≥ 35 years was independently associated with overtreatment (adjusted odds ratio = 12.0; 95% CI (2.0-70.4); p = 0.006). Seven patients broke their fasting for a complication compared with no one of the controls (p = 0.001). No factor was associated with this risk. CONCLUSIONS Salivary cortisol levels were high in fasting hydrocortisone-treated SAI patients with a disruption of the circadian rhythm.
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Affiliation(s)
- Melika Chihaoui
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Wiem Madhi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Bessem Hammami
- Department of Biochemistry, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Nadia Khessairi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Wafa Grira
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Amina Bibi
- Department of Biochemistry, National Institute of Nutrition, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Moncef Feki
- Department of Biochemistry, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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28
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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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29
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Mofokeng TRP, Beshyah SA, Mahomed F, Ndlovu KCZ, Ross IL. Significant barriers to diagnosis and management of adrenal insufficiency in Africa. Endocr Connect 2020; 9:445-456. [PMID: 32348958 PMCID: PMC7274557 DOI: 10.1530/ec-20-0129] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/28/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND The burden and management of primary adrenal insufficiency (PAI) in Africa have not been well documented. We aimed to identify specific disease characteristics, patient demographics, and patterns of clinical management in established PAI in Africa. METHODS An online survey of physicians' experience relating to PAI. RESULTS There were 1334 responses received, 589 were complete, and 332 respondents reported managing patients with hypoadrenalism. The described responses were related to a calculated pool of 5787 patients with hypoadrenalism (2746 females, 3041 males), of whom 2302 had PAI. The likely causes of PAI in Sub-Saharan Africa (SSA) vs the Middle East and North Africa (MENA) regions included autoimmune disease (20% vs 60.3%; P < 0.001), tuberculosis (34% vs 4.1%; P < 0.001), AIDS (29.8% vs 1%; P < 0.001), malignancy, and genetic conditions. Sixteen percent of AD patients (376/2302) presented in an adrenal crisis. Medical emergency identification was not used by 1233 (83.6%) SSA vs 330 (40.4%) MENA patients (P < 0.001), respectively. Relative non-availability of diagnostic tests across both regions included adrenal antibodies 63% vs 69.6% (P = 0.328), s-cortisol 49.4 % vs 26.7% (P = 0.004), s-ACTH 55.7% vs 53.3% (P = 0.217), and adrenal CT scans 52.4% vs 31.8% (P = 0.017) in the SSA and MENA region, respectively. Across the entire cohort, the overall hydrocortisone use and extrapolated proportion of synacthen use were 59.4% and 50.7%, respectively. CONCLUSIONS Through the perception and practice of healthcare professionals, we identified significant challenges in the diagnosis and management of PAI which may herald high mortality. Differences between regions may reflect the allocation of healthcare resources.
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Affiliation(s)
- Thabiso R P Mofokeng
- Department of Medicine, University of the Free State, Bloemfontein, South Africa
- Correspondence should be addressed to T R P Mofokeng:
| | - Salem A Beshyah
- Department of Medicine, Dubai Medical College, Duabi, United Arab Emirates
- Department of Endocrinology, Mediclinic Airport Road Hospital, Abu Dhabi, United Arab Emirates
| | - Fazleh Mahomed
- Department of Medicine, University of the Free State, Bloemfontein, South Africa
| | - Kwazi C Z Ndlovu
- Department of Medicine, University of the Free State, Bloemfontein, South Africa
| | - Ian L Ross
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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30
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Ashida K, Terada E, Nagayama A, Sakamoto S, Hasuzawa N, Nomura M. Necessity of Utilizing Physiological Glucocorticoids for Managing Familial Mediterranean Fever. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e920983. [PMID: 32203056 PMCID: PMC7117857 DOI: 10.12659/ajcr.920983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Familial Mediterranean fever is an auto-inflammatory disease caused by pyrin mutations. Glucocorticoids inhibit the production and secretion of inflammatory cytokines, including IL-6 and IL-1ß, from inflammatory cells and suppress the activation of nuclear factor-kappaB in the nucleus. However, the functions of physiological glucocorticoids in the disease remain unknown. CASE REPORT We report the case of a Japanese man with familial Mediterranean fever complicated by isolated adrenocorticotropic hormone deficiency. Patient non-compliance with hydrocortisone replacement therapy led to a series of pericarditis and fever episodes. Subsequently, the regular administration of colchicine alone could not prevent auto-inflammation. The clinical course of treatment suggested that the absence of physiological levels of glucocorticoids is crucial for familial Mediterranean fever attacks. Because familial Mediterranean fever is a pyrin abnormality-induced auto-inflammatory disease that subsequently activates cytokines via the nucleotide-binding domain, leucine-rich repeat/pyrin domain-containing 3 inflammasomes and the absence of glucocorticoids can exacerbate the severity of the auto-inflammatory disease. CONCLUSIONS Physiological glucocorticoid levels appear to be essential for the regulation of inflammasome activation via IL-6-negative regulation. However, pharmacological levels of glucocorticoids are not currently used for the prevention of familial Mediterranean fever attacks. Physicians should be aware of adrenal insufficiency as a possible disorder when they encounter cases of refractory familial Mediterranean fever.
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Affiliation(s)
- Kenji Ashida
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka City, Fukuoka, Japan.,Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Eriko Terada
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka City, Fukuoka, Japan
| | - Ayako Nagayama
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Shohei Sakamoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka City, Fukuoka, Japan
| | - Nao Hasuzawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka City, Fukuoka, Japan.,Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Masatoshi Nomura
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka City, Fukuoka, Japan.,Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
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31
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Chihaoui M, Mimita W, Oueslati I, Rejeb O, Ben Amor Z, Grira W, Yazidi M, Chaker F. Prednisolone or hydrocortisone replacement in patients with corticotrope deficiency fasting during Ramadan result in similar risks of complications and quality of life: a randomized double-blind controlled trial. Endocrine 2020; 67:155-160. [PMID: 31552584 DOI: 10.1007/s12020-019-02082-w] [Citation(s) in RCA: 6] [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: 04/25/2019] [Accepted: 09/03/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The aims of the study were to compare the risk of complications and the quality of life in patients with corticotrope deficiency, who fasted during Ramadan. Both hydrocortisone and prednisolone were compared as treatments. METHODS A randomized double-blind crossover clinical trial conducted in the department of Endocrinology of the University Hospital la Rabta in Tunis, during Ramadan 2018, on 53 patients with known corticotrope deficiency treated with hydrocortisone 20 mg per day and who were willing to fast during Ramadan. Patients were randomized into two groups; AB that received hydrocortisone twice daily for 14 days then prednisolone once daily with a placebo for 14 days and group BA that received the two treatments in the reverse order. Patients had to complete a daily follow-up sheet about their eating and sleeping habits, the occurrence of complications and blood glucose monitoring and also to respond to the AddiQoL questionnaire at the end of each treatment period. RESULTS Fifty patients' data were analyzed; 29 men, mean age: 42.4 ± 13.3 years, mean duration of the disease: 8.1 ± 7.6 years. The frequency of complications, mean blood glucose levels and the quality of life did not differ on hydrocortisone compared to prednisolone after adjustment for the sequence of the treatment. CONCLUSIONS the risks of Ramadan fasting in patients with corticotrope deficiency were the same on hydrocortisone or prednisolone.
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Affiliation(s)
- Melika Chihaoui
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Wafa Mimita
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ons Rejeb
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Zohra Ben Amor
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Wafa Grira
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Fatma Chaker
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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32
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Bosch I Ara L, Katugampola H, Dattani MT. Congenital Hypopituitarism During the Neonatal Period: Epidemiology, Pathogenesis, Therapeutic Options, and Outcome. Front Pediatr 2020; 8:600962. [PMID: 33634051 PMCID: PMC7902025 DOI: 10.3389/fped.2020.600962] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/31/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction: Congenital hypopituitarism (CH) is characterized by a deficiency of one or more pituitary hormones. The pituitary gland is a central regulator of growth, metabolism, and reproduction. The anterior pituitary produces and secretes growth hormone (GH), adrenocorticotropic hormone, thyroid-stimulating hormone, follicle-stimulating hormone, luteinizing hormone, and prolactin. The posterior pituitary hormone secretes antidiuretic hormone and oxytocin. Epidemiology: The incidence is 1 in 4,000-1 in 10,000. The majority of CH cases are sporadic; however, a small number of familial cases have been identified. In the latter, a molecular basis has frequently been identified. Between 80-90% of CH cases remain unsolved in terms of molecular genetics. Pathogenesis: Several transcription factors and signaling molecules are involved in the development of the pituitary gland. Mutations in any of these genes may result in CH including HESX1, PROP1, POU1F1, LHX3, LHX4, SOX2, SOX3, OTX2, PAX6, FGFR1, GLI2, and FGF8. Over the last 5 years, several novel genes have been identified in association with CH, but it is likely that many genes remain to be identified, as the majority of patients with CH do not have an identified mutation. Clinical manifestations: Genotype-phenotype correlations are difficult to establish. There is a high phenotypic variability associated with different genetic mutations. The clinical spectrum includes severe midline developmental disorders, hypopituitarism (in isolation or combined with other congenital abnormalities), and isolated hormone deficiencies. Diagnosis and treatment: Key investigations include MRI and baseline and dynamic pituitary function tests. However, dynamic tests of GH secretion cannot be performed in the neonatal period, and a diagnosis of GH deficiency may be based on auxology, MRI findings, and low growth factor concentrations. Once a hormone deficit is confirmed, hormone replacement should be started. If onset is acute with hypoglycaemia, cortisol deficiency should be excluded, and if identified this should be rapidly treated, as should TSH deficiency. This review aims to give an overview of CH including management of this complex condition.
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Affiliation(s)
- Laura Bosch I Ara
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Harshini Katugampola
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Mehul T Dattani
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London, United Kingdom.,Genetics and Genomic Medicine Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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33
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[Supportive therapy and management of side effects in dermato-oncology]. Hautarzt 2019; 70:975-988. [PMID: 31720719 DOI: 10.1007/s00105-019-04496-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: 10/25/2022]
Abstract
In the context of supportive therapy, possible complaints which may be caused by the cancer itself, by the antitumoral therapy or by psychosocial concerns are considered. Due to the introduction of new anticancer drugs in dermato-oncology, clinicians are confronted with a novel spectrum of adverse events. There are a number of inflammatory, immune-mediated side effects caused by immunotherapies, which can affect virtually any organ. Targeted therapies also have specific side effects. Basically, the management of adverse events depends on their severity. Besides treatment breaks and dosage modifications, immunotherapy-related adverse events are treated with systemic immunosuppressants. Supportive symptomatic therapy is offered. The additional consideration of psychosocial problems can improve quality of life of cancer patients.
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34
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Timmermans S, Souffriau J, Libert C. A General Introduction to Glucocorticoid Biology. Front Immunol 2019; 10:1545. [PMID: 31333672 PMCID: PMC6621919 DOI: 10.3389/fimmu.2019.01545] [Citation(s) in RCA: 282] [Impact Index Per Article: 56.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/20/2019] [Indexed: 12/13/2022] Open
Abstract
Glucocorticoids (GCs) are steroid hormones widely used for the treatment of inflammation, autoimmune diseases, and cancer. To exert their broad physiological and therapeutic effects, GCs bind to the GC receptor (GR) which belongs to the nuclear receptor superfamily of transcription factors. Despite their success, GCs are hindered by the occurrence of side effects and glucocorticoid resistance (GCR). Increased knowledge on GC and GR biology together with a better understanding of the molecular mechanisms underlying the GC side effects and GCR are necessary for improved GC therapy development. We here provide a general overview on the current insights in GC biology with a focus on GC synthesis, regulation and physiology, role in inflammation inhibition, and on GR function and plasticity. Furthermore, novel and selective therapeutic strategies are proposed based on recently recognized distinct molecular mechanisms of the GR. We will explain the SEDIGRAM concept, which was launched based on our research results.
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Affiliation(s)
- Steven Timmermans
- Center for Inflammation Research, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - Jolien Souffriau
- Center for Inflammation Research, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - Claude Libert
- Center for Inflammation Research, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
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35
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Ahmet A, Mokashi A, Goldbloom EB, Huot C, Jurencak R, Krishnamoorthy P, Rowan-Legg A, Kim H, Pancer L, Kovesi T. Adrenal suppression from glucocorticoids: preventing an iatrogenic cause of morbidity and mortality in children. BMJ Paediatr Open 2019; 3:e000569. [PMID: 31750407 PMCID: PMC6830460 DOI: 10.1136/bmjpo-2019-000569] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/26/2019] [Accepted: 09/28/2019] [Indexed: 12/18/2022] Open
Abstract
Adrenal suppression (AS) is an important side effect of glucocorticoids (GCs) including inhaled corticosteroids (ICS). AS can often be asymptomatic or associated with non-specific symptoms until a physiological stress such as an illness precipitates an adrenal crisis. Morbidity and death associated with adrenal crisis is preventable but continues to be reported in children. There is a lack of consensus about the management of children at risk of AS. However, healthcare professionals need to develop an awareness and approach to keep these children safe. In this article, current knowledge of the risk factors, diagnosis and management of AS are reviewed while drawing attention to knowledge gaps and areas of controversy. Possible strategies to reduce the morbidity associated with this iatrogenic condition are provided for healthcare professionals.
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Affiliation(s)
- Alexandra Ahmet
- Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Arati Mokashi
- Pediatrics, Division of Endocrinology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Ellen B Goldbloom
- Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Celine Huot
- Pediatrics, Division of Endocrinology, University of Montreal, Montreal, Quebec, Canada.,Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Roman Jurencak
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Division of Rheumatology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Preetha Krishnamoorthy
- Pediatrics, Division of Endocrinology, Montreal Childrens Hospital, Montreal, Quebec, Canada.,Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Anne Rowan-Legg
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Harold Kim
- Department of Medicine, Division of Clinical Immunology and Allergy, St. Joseph's Hospital, London, Ontario, Canada
| | - Larry Pancer
- Pediatrics, Markham Stouffville Hospital, Markham, Ontario, Canada
| | - Tom Kovesi
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Division of Respirology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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