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Bacila IA, Lawrence NR, Badrinath SG, Balagamage C, Krone NP. Biomarkers in congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2024; 101:300-310. [PMID: 37608608 DOI: 10.1111/cen.14960] [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: 05/09/2023] [Revised: 07/25/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
Monitoring of hormone replacement therapy represents a major challenge in the management of congenital adrenal hyperplasia (CAH). In the absence of clear guidance and standardised monitoring strategies, there is no consensus among clinicians regarding the relevance of various biochemical markers used in practice, leading to wide variability in their application and interpretation. In this review, we summarise the published evidence on biochemical monitoring of CAH. We discuss temporal variations of the most commonly measured biomarkers throughout the day, the interrelationship between different biomarkers, as well as their relationship with different glucocorticoid and mineralocorticoid treatment regimens and clinical outcomes. Our review highlights significant heterogeneity across studies in both aims and methodology. However, we identified key messages for the management of patients with CAH. The approach to hormone replacement therapy should be individualised, based on the individual hormonal profile throughout the day in relation to medication. There are limitations to using 17-hydroxyprogesterone, androstenedione and testosterone, and the role of additional biomarkers such 11-oxygenated androgens which are more disease specific should be further established. Noninvasive monitoring via salivary and urinary steroid measurements is becoming increasingly available and should be considered, especially in the management of children with CAH. Additionally, this review indicates the need for large scale longitudinal studies analysing the interrelation between different monitoring strategies used in clinical practice and health outcomes in children and adults with CAH.
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Affiliation(s)
| | - Neil R Lawrence
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Chamila Balagamage
- Department of Endocrinology, Birmingham Women's & Children's Hospital, Birmingham, UK
- Department of Endocrinology, Sheffield Children's Hospital, Sheffield, UK
| | - Nils P Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Endocrinology, Sheffield Children's Hospital, Sheffield, UK
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2
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Pofi R, Ji X, Krone NP, Tomlinson JW. Long-term health consequences of congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2024; 101:318-331. [PMID: 37680029 DOI: 10.1111/cen.14967] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/16/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023]
Abstract
Congenital adrenal hyperplasia (CAH) caused by 21-hydroxylase deficiency accounts for 95% of all CAH cases and is one of the most common inborn metabolic conditions. The introduction of life-saving glucocorticoid replacement therapy 70 years ago has changed the perception of CAH from a paediatric disorder into a lifelong, chronic condition affecting patients of all age groups. Alongside health problems that can develop during the time of paediatric care, there is an emerging body of evidence suggesting an increased risk of developing co-morbidities during adult life in patients with CAH. The mechanisms that drive the negative long-term outcomes associated with CAH are complex and involve supraphysiological replacement therapies (glucocorticoids and mineralocorticoids), excess adrenal androgens both in the intrauterine and postnatal life, elevated steroid precursors and adrenocorticotropic hormone levels. Alongside a review of mortality outcome, we discuss issues that need to be addressed when caring for the CAH patient including female and male fertility, cardio-metabolic morbidity, bone health and other important long-term outcomes of CAH.
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Affiliation(s)
- Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Xiaochen Ji
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Endocrinology and Metabolism Department, The Second Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Nils P Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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3
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Auchus RJ, Hamidi O, Pivonello R, Bancos I, Russo G, Witchel SF, Isidori AM, Rodien P, Srirangalingam U, Kiefer FW, Falhammar H, Merke DP, Reisch N, Sarafoglou K, Cutler GB, Sturgeon J, Roberts E, Lin VH, Chan JL, Farber RH. Phase 3 Trial of Crinecerfont in Adult Congenital Adrenal Hyperplasia. N Engl J Med 2024; 391:504-514. [PMID: 38828955 PMCID: PMC11309900 DOI: 10.1056/nejmoa2404656] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND Adrenal insufficiency in patients with classic 21-hydroxylase deficiency congenital adrenal hyperplasia (CAH) is treated with glucocorticoid replacement therapy. Control of adrenal-derived androgen excess usually requires supraphysiologic glucocorticoid dosing, which predisposes patients to glucocorticoid-related complications. Crinecerfont, an oral corticotropin-releasing factor type 1 receptor antagonist, lowered androstenedione levels in phase 2 trials involving patients with CAH. METHODS In this phase 3 trial, we randomly assigned adults with CAH in a 2:1 ratio to receive crinecerfont or placebo for 24 weeks. Glucocorticoid treatment was maintained at a stable level for 4 weeks to evaluate androstenedione values, followed by glucocorticoid dose reduction and optimization over 20 weeks to achieve the lowest glucocorticoid dose that maintained androstenedione control (≤120% of the baseline value or within the reference range). The primary efficacy end point was the percent change in the daily glucocorticoid dose from baseline to week 24 with maintenance of androstenedione control. RESULTS All 182 patients who underwent randomization (122 to the crinecerfont group and 60 to the placebo group) were included in the 24-week analysis, with imputation of missing values; 176 patients (97%) remained in the trial at week 24. The mean glucocorticoid dose at baseline was 17.6 mg per square meter of body-surface area per day of hydrocortisone equivalents; the mean androstenedione level was elevated at 620 ng per deciliter. At week 24, the change in the glucocorticoid dose (with androstenedione control) was -27.3% in the crinecerfont group and -10.3% in the placebo group (least-squares mean difference, -17.0 percentage points; P<0.001). A physiologic glucocorticoid dose (with androstenedione control) was reported in 63% of the patients in the crinecerfont group and in 18% in the placebo group (P<0.001). At week 4, androstenedione levels decreased with crinecerfont (-299 ng per deciliter) but increased with placebo (45.5 ng per deciliter) (least-squares mean difference, -345 ng per deciliter; P<0.001). Fatigue and headache were the most common adverse events in the two trial groups. CONCLUSIONS Among patients with CAH, the use of crinecerfont resulted in a greater decrease from baseline in the mean daily glucocorticoid dose, including a reduction to the physiologic range, than placebo following evaluation of adrenal androgen levels. (Funded by Neurocrine Biosciences; CAHtalyst ClinicalTrials.gov number, NCT04490915.).
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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, Michigan, USA
- Endocrinology & Metabolism Section, Medicine Service, LTC Charles S. Kettles Veterans Affairs Medical Center, Fuller Road, Ann Arbor, Michigan, USA
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - Irina Bancos
- Division of Endocrinology and Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gianni Russo
- Department of Pediatrics, Endocrine Unit, IRCCS San Raffaele Scientific Institute, Endo-ERN Center for Rare Endocrine Conditions, Milan, Italy
| | - Selma F. Witchel
- Division of Pediatric Endocrinology, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Andrea M. Isidori
- Department of Experimental Medicine; Sapienza University of Rome, Rome, Italy
| | - Patrice Rodien
- Department of Endocrinology, Diabetology and Nutrition, Endo-ERN Center for Rare Endocrine Conditions, CHU d’Angers and Laboratoire MITOVASC, Université d’Angers, Angers, France
| | - Umasuthan Srirangalingam
- Departments of Endocrinology and Diabetes, University College London Hospital, London, United Kingdom
| | - Florian W. Kiefer
- Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Deborah P. Merke
- National Institutes of Health Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Nicole Reisch
- Department of Endocrinology, Internal Medicine IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Kyriakie Sarafoglou
- Departments of Pediatrics and Experimental and Clinical Pharmacology, Divisions of Endocrinology and Genetics and Metabolism, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | | | - Julia Sturgeon
- Neurocrine Biosciences, Inc., San Diego, California, USA
| | - Eiry Roberts
- Neurocrine Biosciences, Inc., San Diego, California, USA
| | - Vivian H. Lin
- Neurocrine Biosciences, Inc., San Diego, California, USA
| | - Jean L. Chan
- Neurocrine Biosciences, Inc., San Diego, California, USA
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Sun X, Wu Y, Lu L, Xia W, Zhang L, Chen S, Nie M, Zheng G, Su W, Zhu H, Lu Z. Bone Microarchitecture and Volumetric Mineral Density Assessed by HR-pQCT in Patients with 21- and 17α-Hydroxylase Deficiency. Calcif Tissue Int 2023; 113:515-525. [PMID: 37812222 DOI: 10.1007/s00223-023-01132-w] [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: 05/01/2023] [Accepted: 08/16/2023] [Indexed: 10/10/2023]
Abstract
Due to disturbances in hormones and long-term glucocorticoid replacement therapy (GRT), congenital adrenocortical hyperplasia (CAH) patients are at risk of impaired bone structure and metabolism. This cross-sectional, case-control study aims to investigate for the first time bone microarchitecture features in 21-hydroxylase deficiency (21OHD; N = 38) and 17α-hydroxylase deficiency (17OHD; N = 16) patients using high-resolution peripheral quantitative computed tomography (HR-pQCT) by matching the same sex and similar age [21OHD vs. control: 29.5 (24.0-34.3) vs. 29.6 (25.9-35.2) years; 17OHD vs. controls: 29.0 (21.5-35.0) vs. 29.7 (24.6-35.3) years] with healthy controls (1:3). All patients underwent HR-pQCT scans of the nondominant radius and tibia, and had received GRT. Compared with corresponding controls, 17OHD cases had higher height (P < 0.001), weight (P = 0.013) and similar body mass index (BMI), while 21OHD had lower height (P < 0.001), similar weight and higher BMI (P < 0.001). 17OHD and 21OHD patients demonstrated various significant bone differences in most HR-pQCT indices, suggesting abnormalities in bone microarchitectures from healthy people. Further correlation analyses revealed that some characteristics, such as height and hormones, may contribute to the bone differences in HR-pQCT indices between two diseases. However, treatment dosage and time were not correlated, indicating that the current glucocorticoid doses may be within safety limits for bone impairment. Overall, our study for the first time revealed changes of bone microarchitecture in CAH patients and their potential relations with clinical characteristics. Further longitudinal researches are required to confirm these findings.
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Affiliation(s)
- Xu Sun
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yijun Wu
- Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Lin Lu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Weibo Xia
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Li Zhang
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Shi Chen
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Min Nie
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Guangyao Zheng
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
- School of Clinical Medicine, Weifang Medical University, Weifang, 261053, Shandong, China
| | - Wan Su
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Zhaolin Lu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
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5
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Zwayne N, Chawla R, van Leeuwen K. Caring for Patients With Congenital Adrenal Hyperplasia Throughout the Lifespan. Obstet Gynecol 2023; 142:257-268. [PMID: 37473408 DOI: 10.1097/aog.0000000000005263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/30/2023] [Indexed: 07/22/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder affecting cortisol and aldosterone biosynthesis, which can lead to virilization in fetuses with a 46,XX karyotype. 21-hydroxylase deficiency is the most common cause of CAH, accounting for 90-99% of all patients with the condition. The management of patients with CAH should be done with a multidisciplinary team, which would address all of the complex components of their care throughout their lifespans. Many multidisciplinary teams have adopted shared decision-making approaches to genital surgery in which parents and patients can be part of the decision-making process. Continued research is needed to best serve these patients throughout their lifespans.
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Affiliation(s)
- Noor Zwayne
- Division of Pediatric and Adolescent Gynecology, Women's Health Department, University of Texas at Austin, Dell Medical School, Austin, Texas; and the Division of Pediatric Endocrinology and the Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
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6
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Lee DH, Kong SH, Jang HN, Ahn CH, Lim SG, Lee YA, Kim SW, Kim JH. Association of androgen excess and bone mineral density in women with classical congenital adrenal hyperplasia with 21-hydroxylase deficiency. Arch Osteoporos 2022; 17:45. [PMID: 35258698 DOI: 10.1007/s11657-022-01090-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/26/2022] [Indexed: 02/03/2023]
Abstract
The relationship between androgen excess and bone health in patients with congenital adrenal hyperplasia (CAH) with 21-hydroxylase (21-OH) deficiency is not fully understood. This study demonstrated positive correlations between androgen hormones and bone mineral density (BMD) in CAH women with 21-OH deficiency. PURPOSE This study aims to assess BMD and its association with androgen excess in women with CAH. METHODS We enrolled 92 women with CAH with 21-OH deficiency and retrospectively reviewed their clinical features, hormone concentrations, body composition, glucocorticoid (GC) dose, and BMD. RESULTS BMD was not different according to the subtypes of CAH. BMD at the lumbar spine was lower in women with CAH with regular menstruation than those with irregular menstruation (1.081 vs. 1.165 g/cm2, P < 0.05). BMD was lower in women with CAH with 17-hydroxyprogesterone (17-OHP) < 10 ng/mL than in those with ≥ 10 ng/mL (lumbar spine, 1.019 vs. 1.150 g/cm2; femur neck, 0.806 vs. 0.899 g/cm2; total hip, 0.795 vs. 0.943 g/cm2; all P < 0.05). After adjusting for age and BMI in correlation analyses, testosterone concentrations were positively correlated with lumbar spine, femur neck, and total hip BMD (r = 0.46, r = 0.38, and r = 0.35, respectively; all P < 0.05), while 17-OHP was positively correlated with lumbar spine BMD (r = 0.38, P < 0.01). In subgroup analysis, 17-OHP was positively correlated with BMD (lumbar spine, r = 0.22; femur neck, r = 0.22; total hip, r = 0.24; all P < 0.05) only in the group with a total cumulative dose of GC ≥ 156.0 g/m2. CONCLUSION Androgen excess may have a protective effect on BMD in women with classic CAH and high cumulative doses of GC.
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Affiliation(s)
- Dong Ho Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea
| | - Sung Hye Kong
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Han Na Jang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea
| | - Chang Ho Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Seung Gyun Lim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea.,Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea. .,Department of Internal Medicine, Seoul National University College of Medicine, 101 Dae-hak ro, Jongno gu, Seoul, 03080, Korea.
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7
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 176] [Impact Index Per Article: 88.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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8
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Adriaansen BPH, Schröder MAM, Span PN, Sweep FCGJ, van Herwaarden AE, Claahsen-van der Grinten HL. Challenges in treatment of patients with non-classic congenital adrenal hyperplasia. Front Endocrinol (Lausanne) 2022; 13:1064024. [PMID: 36578966 PMCID: PMC9791115 DOI: 10.3389/fendo.2022.1064024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) due to 21α-hydroxylase deficiency (21OHD) or 11β-hydroxylase deficiency (11OHD) are congenital conditions with affected adrenal steroidogenesis. Patients with classic 21OHD and 11OHD have a (nearly) complete enzyme deficiency resulting in impaired cortisol synthesis. Elevated precursor steroids are shunted into the unaffected adrenal androgen synthesis pathway leading to elevated adrenal androgen concentrations in these patients. Classic patients are treated with glucocorticoid substitution to compensate for the low cortisol levels and to decrease elevated adrenal androgens levels via negative feedback on the pituitary gland. On the contrary, non-classic CAH (NCCAH) patients have more residual enzymatic activity and do generally not suffer from clinically relevant glucocorticoid deficiency. However, these patients may develop symptoms due to elevated adrenal androgen levels, which are most often less elevated compared to classic patients. Although glucocorticoid treatment can lower adrenal androgen production, the supraphysiological dosages also may have a negative impact on the cardiovascular system and bone health. Therefore, the benefit of glucocorticoid treatment is questionable. An individualized treatment plan is desirable as patients can present with various symptoms or may be asymptomatic. In this review, we discuss the advantages and disadvantages of different treatment options used in patients with NCCAH due to 21OHD and 11OHD.
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Affiliation(s)
- Bas P. H. Adriaansen
- Radboud Institute of Health Sciences, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Pediatric Endocrinology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Mariska A. M. Schröder
- Department of Pediatric Endocrinology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Paul N. Span
- Radiotherapy & OncoImmunology Laboratory, Radboud Institute of Molecular Life Sciences, Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Fred C. G. J. Sweep
- Radboud Institute of Health Sciences, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Antonius E. van Herwaarden
- Radboud Institute of Health Sciences, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hedi L. Claahsen-van der Grinten
- Department of Pediatric Endocrinology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Hedi L. Claahsen-van der Grinten,
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9
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Gao Y, Wang O, Guan W, Wu X, Mao J, Wang X, Yu W, Nie M. Bone mineral density and trabecular bone score in patients with 21-hydroxylase deficiency after glucocorticoid treatment. Clin Endocrinol (Oxf) 2021; 94:765-773. [PMID: 33301636 DOI: 10.1111/cen.14391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/28/2020] [Accepted: 12/02/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Patients with 21-hydroxylase deficiency (21-OHD) are at risk of reduced bone mineral density (BMD) and fracture due to long-term glucocorticoid treatment. Trabecular bone score (TBS) is complementary to conventional BMD as a marker for bone quality in patients with glucocorticoid-induced osteoporosis. The purpose of this study is to evaluate the BMD and TBS in a cohort of patients with 21-OHD and analyse factors related to TBS. DESIGN An observational study. PATIENTS A total of 46 21-OHD adult patients treated with glucocorticoid for over 10 years who visited Peking Union Medical College Hospital between 2015 and 2019 were recruited. Eight male patients included in this study were all under 50 years old, and 38 female patients were all premenopausal. MEASUREMENTS Diagnosis was confirmed by multiplex ligation-dependent probe amplification combined with sequencing. Data were collected on physical characteristics, serum hormones and glucocorticoid treatment. Skeletal quality was evaluated by BMD and TBS, and factors related to TBS were analysed. RESULTS Among the 46 patients, 2 (4.3%) had low BMD (Z-score ≤ -2), while 11 (23.9%) patients had low TBS (degraded or partially degraded microarchitecture). The proportion of bone abnormality evaluated by TBS was higher than that by BMD (p < .001). Patients with lower TBS had significantly higher daily hydrocortisone dosage (p = .009 for males; p = .019 for females). TBS value was negatively correlated with daily hydrocortisone dosage (r = -.317, p = .026), and positively correlated with BMI in female patients (r = .345, p = .034). And there was a negative correlation between TBS value and the current age in male patients (r = -.741, p = .036). The distribution of genotypes (p = 1.000 for male; p = .567 for female) or phenotypes (p = .486 for male; p = .075 for female) had no statistical difference in patients with normal or abnormal TBS. CONCLUSIONS Approximately 24% of patients with 21-OHD had abnormal microarchitecture of their bone in our study, and TBS score was negatively correlated with daily glucocorticoid dosage in patients. TBS may be used alongside conventional BMD as a complementary marker for bone evaluation in 21-OHD patients.
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Affiliation(s)
- Yinjie Gao
- NHC Key Laboratory of Endocrinology (Peking Union Medical College Hospital), Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Ou Wang
- NHC Key Laboratory of Endocrinology (Peking Union Medical College Hospital), Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wenmin Guan
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xueyan Wu
- NHC Key Laboratory of Endocrinology (Peking Union Medical College Hospital), Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiangfeng Mao
- NHC Key Laboratory of Endocrinology (Peking Union Medical College Hospital), Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xi Wang
- NHC Key Laboratory of Endocrinology (Peking Union Medical College Hospital), Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Yu
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Min Nie
- NHC Key Laboratory of Endocrinology (Peking Union Medical College Hospital), Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Riehl G, Reisch N, Roehle R, Claahsen van der Grinten H, Falhammar H, Quinkler M. Bone mineral density and fractures in congenital adrenal hyperplasia: Findings from the dsd-LIFE study. Clin Endocrinol (Oxf) 2020; 92:284-294. [PMID: 31886890 DOI: 10.1111/cen.14149] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/26/2019] [Accepted: 12/28/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND In patients with congenital adrenal hyperplasia (CAH) type and doses of glucocorticoids used as well as sex hormone secretion during puberty have important actions on bone mineral density (BMD) in adulthood. AIM To evaluate BMD in adult CAH patients depending on current glucocorticoid therapy and on androgen levels in adulthood and at age 16 years. METHODS We included 244 CAH patients from the dsd-LIFE cohort (women n = 147, men n = 97; salt-wasting n = 148, simple-virilizing n = 71, nonclassical n = 25) in which BMD and bloods were available. Clinical and hormonal data at age 16years were retrieved from patients' files. RESULTS Simple-virilizing women showed lower BMD compared to salt-wasting women at trochanter (0.65 ± 0.12 vs 0.75 ± 0.15 g/cm2 ; P < .050), whole femur T-score (-0.87 ± 1.08 vs -0.16 ± 1.24; P < .05) and lumbar T-score (-0.81 ± 1.34 vs 0.09 ± 1.3; P < .050). Fracture prevalence did not differ significantly between the CAH groups. Prednisolone vs. hydrocortisone only therapy caused worse trochanter Z-score (-1.38 ± 1.46 vs -0.47 ± 1.16; P < .050). In women lumbar spine, BMD correlated negatively with hydrocortisone-equivalent dose per body surface (r2 = 0.695, P < .001). Furthermore, BMI at age 16years correlated positively with lumbar spine T-score (r2 = 0.439, P = .003) and BMD (r2 = 0.420, P = .002) in women. The androstenedione/testosterone ratio at age 16years correlated positively with lumbar spine Z-score in women (r2 = 0.284, P = .024) and trochanter Z-score in men (r2 = 0.600, P = .025). CONCLUSION Higher glucocorticoid doses seemed to cause lower BMD especially in women. Prednisolone appeared to have more detrimental effects on BMD than hydrocortisone. Higher glucocorticoid doses (lower androstenedione/testosterone ratio) during adolescence may cause lower BMD in adulthood.
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Affiliation(s)
| | - Nicole Reisch
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität, Munich, Germany
| | - Robert Roehle
- Charité Universitätsmedizin Berlin, Coordinating Center for Clinical Studies, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Hedi Claahsen van der Grinten
- Department of Pediatric Endocrinology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
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11
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Rangaswamaiah S, Gangathimmaiah V, Nordenstrom A, Falhammar H. Bone Mineral Density in Adults With Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2020; 11:493. [PMID: 32903805 PMCID: PMC7438951 DOI: 10.3389/fendo.2020.00493] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
Background: Decreased bone mineral density (BMD) is a concern in patients with congenital adrenal hyperplasia (CAH) due to lifelong glucocorticoid replacement. Studies till date have yielded conflicting results. We wanted to systematically evaluate the available evidence regarding BMD in adult patients with CAH. Methods: We searched Medline, Embase and Cochrane Central Register of Controlled Trials to identify eligible studies. Studies comparing BMD in CAH patients with age- and sex-matched controls were included. Age <16 years and absence of controls were exclusion criteria. Two authors independently reviewed abstracts, read full-text articles, extracted data, assessed risk of bias using Newcastle-Ottawa scale, and determined level of evidence using Grading of Recommendations Assessment, Development, and Evaluation methodology. Results: Nine case-control studies with a total sample of 598 (cases n = 254, controls n = 344) met eligibility criteria. Median age was 31 years (IQR 23.9-37) and 65.7% were female. Total body BMD (Mean Difference [MD]-0.06; 95%CI -0.07, -0.04), lumbar spine BMD (MD -0.05; 95%CI -0.07, -0.03) and femoral neck BMD (MD -0.07; 95%CI -0.10, -0.05) was lower in cases compared to controls. Lumbar spine T-scores (MD -0.86; 95%CI -1.16, -0.56) and Z-scores (MD -0.66; 95%CI -0.99, -0.32) and femoral neck T-scores (MD -0.75 95%CI -0.95, -0.56) and Z-scores (MD -0.27 95%CI -0.58, 0.04) were lower in cases. Conclusion: BMD in adult patients with CAH was lower compared to controls. Although insufficient data precludes a dose-response relationship between glucocorticoid dose and BMD, it would be prudent to avoid overtreatment with glucocorticoids.
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Affiliation(s)
- Swetha Rangaswamaiah
- Department of Diabetes and Endocrinology, The Townsville University Hospital, Townsville, QLD, Australia
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- *Correspondence: Swetha Rangaswamaiah
| | - Vinay Gangathimmaiah
- Department of Emergency Medicine, The Townsville University Hospital, Townsville, QLD, Australia
| | - Anna Nordenstrom
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Wellbeing and Chronic Preventable Diseases Division, Menzies School of Health Research, Darwin, NT, Australia
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12
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Improda N, Barbieri F, Ciccarelli GP, Capalbo D, Salerno M. Cardiovascular Health in Children and Adolescents With Congenital Adrenal Hyperplasia Due to 21-Hydroxilase Deficiency. Front Endocrinol (Lausanne) 2019; 10:212. [PMID: 31031703 PMCID: PMC6470198 DOI: 10.3389/fendo.2019.00212] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/18/2019] [Indexed: 12/18/2022] Open
Abstract
Increasing evidence indicates that adults with Congenital Adrenal Hyperplasia (CAH) may have a cluster of cardiovascular (CV) risk factors. In addition, ongoing research has highlighted that children and adolescents with CAH are also prone to developing unfavorable metabolic changes, such as obesity, hypertension, insulin resistance, and increased intima-media thickness, which places them at a higher risk of developing CV disease in adulthood. Moreover, CAH adolescents may exhibit subclinical left ventricular diastolic dysfunction and impaired exercise performance, with possible negative consequences on their quality of life. The therapeutic management of patients with CAH remains a challenge and current treatment regimens do not always allow optimal biochemical control. Indeed, overexposure to glucocorticoids and mineralocorticoids, as well as to androgen excess, may contribute to the development of unfavorable metabolic and CV abnormalities. Long-term prospective studies on large cohorts of patients will help to clarify the pathophysiology of metabolic alterations associated with CAH. Meanwhile, further efforts should be made to optimize treatment and identify new therapeutic approaches to prevent metabolic derangement and improve long-term health outcomes of CAH patients.
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Affiliation(s)
- Nicola Improda
- Pediatric Section, Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Flavia Barbieri
- Pediatric Section, Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Gian Paolo Ciccarelli
- Pediatric Section, Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Donatella Capalbo
- Department of Pediatrics, Federico II University of Naples, Naples, Italy
| | - Mariacarolina Salerno
- Pediatric Section, Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
- *Correspondence: Mariacarolina Salerno
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13
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Macut D, Zdravković V, Bjekić-Macut J, Mastorakos G, Pignatelli D. Metabolic Perspectives for Non-classical Congenital Adrenal Hyperplasia With Relation to the Classical Form of the Disease. Front Endocrinol (Lausanne) 2019; 10:681. [PMID: 31632355 PMCID: PMC6783496 DOI: 10.3389/fendo.2019.00681] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 09/19/2019] [Indexed: 12/17/2022] Open
Abstract
Non-classical congenital adrenal hyperplasia (NC-CAH) represents mild form of CAH with the prevalence of 0. 6 to 9% in women with androgen excess. Clinical and hormonal findings in females with NC-CAH are overlapping with other hyperandrogenic entities such as polycystic ovary syndrome hence causing difficulties in diagnostic approach. Metabolic consequences in subjects with NC-CAH are relatively unknown. We are lacking longitudinal follow of these patients regarding natural course of the disease or the therapeutic effects of the different drug regiments. Patients with NC-CAH similarly to those with classical form are characterized with deteriorated cardiovascular risk factors that are probably translated into cardiometabolic diseases and events. An increased preponderance of obesity and insulin resistance in patients with NC-CAH begin at young age could result in increased rates of metabolic sequelae and cardiovascular disease later during adulthood in both sexes. On the other hand, growth disorder was not proven in patients with NC-CAH in comparison to CAH patients of both gender characterized with reduced final adult height. Similarly, decreased bone mineral density and osteoporosis are not constant findings in patients with NC-CAH and could depend on the sex, and type or dose of corticosteroids applied. It could be concluded that NC-CAH represent a particular form of CAH that is characterized with specificities in clinical presentation, diagnosis, therapeutic approach and metabolic outcomes.
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Affiliation(s)
- Djuro Macut
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- *Correspondence: Djuro Macut
| | - Vera Zdravković
- Division of Endocrinology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jelica Bjekić-Macut
- Department of Endocrinology, UMC Bežanijska kosa, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - George Mastorakos
- Unit of Endocrine Diseases, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Duarte Pignatelli
- Faculty of Medicine, Instituto de Patologia e Imunologia Molecular da Universidade do Porto/I3S Research Institute, Hospital S João, University of Porto, Porto, Portugal
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14
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Frey KR, Kienitz T, Schulz J, Ventz M, Zopf K, Quinkler M. Prednisolone is associated with a worse bone mineral density in primary adrenal insufficiency. Endocr Connect 2018; 7:811-818. [PMID: 29720511 PMCID: PMC5987359 DOI: 10.1530/ec-18-0160] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 12/30/2022]
Abstract
CONTEXT Patients with primary adrenal insufficiency (PAI) or congenital adrenal hyperplasia (CAH) receive life-long glucocorticoid (GC) therapy. Daily GC doses are often above the physiological cortisol production rate and can cause long-term morbidities such as osteoporosis. No prospective trial has investigated the long-term effect of different GC therapies on bone mineral density (BMD) in those patients. OBJECTIVES To determine if patients on hydrocortisone (HC) or prednisolone show changes in BMD after follow-up of 5.5 years. To investigate if BMD is altered after switching from immediate- to modified-release HC. DESIGN AND PATIENTS Prospective, observational, longitudinal study with evaluation of BMD by DXA at visit1, after 2.2 ± 0.4 (visit2) and after 5.5 ± 0.8 years (visit3) included 36 PAI and 8 CAH patients. Thirteen patients received prednisolone (age 52.5 ± 14.8 years; 8 women) and 31 patients received immediate-release HC (age 48.9 ± 15.8 years; 22 women). Twelve patients on immediate-release switched to modified-release HC at visit2. RESULTS Prednisolone showed significantly lower Z-scores compared to HC at femoral neck (-0.85 ± 0.80 vs -0.25 ± 1.16, P < 0.05), trochanter (-0.96 ± 0.62 vs 0.51 ± 1.07, P < 0.05) and total hip (-0.78 ± 0.55 vs 0.36 ± 1.04, P < 0.05), but not at lumbar spine, throughout the study. Prednisolone dose decreased by 8% over study time, but no significant effect was seen on BMD. BMD did not change significantly after switching from immediate- to modified-release HC. CONCLUSIONS The use of prednisolone as hormone replacement therapy results in significantly lower BMD compared to HC. Patients on low-dose HC replacement therapy showed unchanged Z-scores within the normal reference range during the study period.
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Affiliation(s)
- Kathrin R Frey
- Department of Medicine IEndocrine and Diabetes Unit, University Hospital, University of Würzburg, Würzburg, Germany
| | - Tina Kienitz
- Charité - Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Julia Schulz
- Charité - Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Manfred Ventz
- Charité - Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Kathrin Zopf
- Charité - Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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15
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Mooij CF, Webb EA, Claahsen van der Grinten HL, Krone N. Cardiovascular health, growth and gonadal function in children and adolescents with congenital adrenal hyperplasia. Arch Dis Child 2017; 102:578-584. [PMID: 27974295 DOI: 10.1136/archdischild-2016-311910] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/21/2016] [Indexed: 11/04/2022]
Abstract
After the introduction of replacement therapy with glucocorticoids and mineralocorticoids in the 1950s, congenital adrenal hyperplasia (CAH) is no longer a life-limiting condition. However, due to the successful introduction of medical steroid hormone replacement, CAH has become a chronic condition, with associated comorbidities and long-term health implications. The aim of treatment is the replacement of mineralocorticoids and glucocorticoids and the normalisation of elevated androgen concentrations. Long-term consequences of the condition and current treatment regimens include unfavourable changes in the cardiovascular risk profile, impaired growth, testicular adrenal rest tumours (TART) in male and subfertility in both male and female patients with CAH. Optimising replacement therapy in patients with CAH remains challenging. On one hand, treatment with supraphysiological doses of glucocorticoids might be required to normalise androgen concentrations and decrease size or presence of TARTs. On the other hand, treatment with supraphysiological doses of glucocorticoids is associated with an increased prevalence of unfavourable cardiovascular and metabolic risk profiles as well as impaired longitudinal growth and gonadal function. Therefore, treatment of children and adults with CAH requires an individualised approach. Careful monitoring for early signs of complications is already warranted during paediatric healthcare provision to prevent and reduce the impact of comorbidities in later life.
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Affiliation(s)
- Christiaan F Mooij
- Institute of Metabolism and Systems Research, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK.,Department of Paediatric Endocrinology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Emma A Webb
- Institute of Metabolism and Systems Research, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK
| | - Hedi L Claahsen van der Grinten
- Department of Paediatric Endocrinology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nils Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield Children's Hospital, Sheffield, UK
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16
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Ariyawatkul K, Tepmongkol S, Aroonparkmongkol S, Sahakitrungruang T. Cardio-metabolic risk factors in youth with classical 21-hydroxylase deficiency. Eur J Pediatr 2017; 176:537-545. [PMID: 28224294 DOI: 10.1007/s00431-017-2875-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 11/28/2022]
Abstract
UNLABELLED Patients with congenital adrenal hyperplasia (CAH) appear to have adverse cardiovascular risk profile and other long-term health problems in adult life, but there are limited data in young CAH patients. We aim to evaluate the cardio-metabolic risk factors in adolescents and young adults with classical 21-hydroxylase deficiency (21-OHD). We performed a cross-sectional study of 21 patients (17 females) with classic CAH detected clinically and not through newborn screening, aged 15.2 ± 5.8 years, and 21 healthy matched controls. Anthropometric, biochemical, inflammatory markers, and body composition using dual-energy X-ray absorptiometry were measured. Obesity was observed in 33% of the CAH patients. The waist/hip ratio and waist/height ratio were significantly higher in CAH patients. Five out of 21 patients (24%) had elevated blood pressure. Silent diabetes was diagnosed in one patient (4.8%), but none in the control group. Serum leptin and interleukin-6 levels were not different between groups, but hs-CRP levels tended to be higher in CAH patients. Other metabolic profiles and body composition were similar in CAH and controls. CONCLUSION Adolescents and young adults with CAH appear to have an increased risk of obesity and cardio-metabolic risk factors. Close monitoring, early identification, and secondary prevention should be implemented during pediatric care to improve the long-term health outcomes in CAH patients. What is Known: • Lifelong glucocorticoid (GC) replacement is the main treatment modality in patients with congenital adrenal hyperplasia which predispose to an adverse metabolic profile. • Adult CAH patients have adverse cardiovascular risk profile and other long-term health problems. What is New: • Adolescents and young adults with CAH appear to have an increased risk of obesity and cardio-metabolic risk factors.
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Affiliation(s)
- Kansuda Ariyawatkul
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Supatporn Tepmongkol
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Suphab Aroonparkmongkol
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Taninee Sahakitrungruang
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.
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Bulsari K, Falhammar H. Clinical perspectives in congenital adrenal hyperplasia due to 11β-hydroxylase deficiency. Endocrine 2017; 55:19-36. [PMID: 27928728 DOI: 10.1007/s12020-016-1189-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
Abstract
Congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency is a rare autosomal recessive genetic disorder. It is caused by reduced or absent activity of 11β-hydroxylase (CYP11B1) enzyme and the resultant defects in adrenal steroidogenesis. The most common clinical features of 11 beta-hydroxylase deficiency are ambiguous genitalia, accelerated skeletal maturation and resultant short stature, peripheral precocious puberty and hyporeninemic hypokalemic hypertension. The biochemical diagnosis is based on raised serum 11-deoxycortisol and 11-deoxycorticosterone levels together with increased adrenal androgens. More than 100 mutations in CYP11B1 gene have been reported to date. The level of in-vivo activity of CYP11B1 relates to the degree of severity of 11 beta-hydroxylase deficiency. Clinical management of 11 beta-hydroxylase deficiency can pose a challenge to maintain adequate glucocorticoid dosing to suppress adrenal androgen excess while avoiding glucocorticoid-induced side effects. The long-term outcomes of clinical and surgical management are not well studied. This review article aims to collate the current available data about 11 beta-hydroxylase deficiency and its management.
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Affiliation(s)
- Krupali Bulsari
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia.
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, NT, Australia
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Chiodini I, Vainicher CE, Morelli V, Palmieri S, Cairoli E, Salcuni AS, Copetti M, Scillitani A. MECHANISMS IN ENDOCRINOLOGY: Endogenous subclinical hypercortisolism and bone: a clinical review. Eur J Endocrinol 2016; 175:R265-R282. [PMID: 27412441 DOI: 10.1530/eje-16-0289] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/13/2016] [Indexed: 01/11/2023]
Abstract
In recent years, the condition of subclinical hypercortisolism (SH) has become a topic of growing interest. This is due to the fact that SH prevalence is not negligible (0.8-2% in the general population) and that, although asymptomatic, this subtle cortisol excess is not harmless, being associated with an increased risk of complications, in particular of osteoporosis and fragility fractures. As specific symptoms of hypercortisolism are absent in SH, the SH diagnosis relies only on biochemical tests and it is a challenge for physicians. As a consequence, even the indications for the evaluation of bone involvement in SH patients are debatable and guidelines are not available. Finally, the relative importance of bone density, bone quality and glucocorticoid sensitivity in SH is a recent field of research. On the other hand, SH prevalence seems to be increased in osteoporotic patients, in whom a vertebral fracture may be the presenting symptom of an otherwise asymptomatic cortisol excess. Therefore, the issue of who and how to screen for SH among the osteoporotic patients is widely debated. The present review will summarize the available data regarding the bone turnover, bone mineral density, bone quality and risk of fracture in patients with endogenous SH. In addition, the role of the individual glucocorticoid sensitivity in SH-related bone damage and the problem of diagnosing and managing the bone consequences of SH will be reviewed. Finally, the issue of suspecting and screening for SH patients with apparent primary osteoporosis will be addressed.
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Affiliation(s)
- I Chiodini
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - C Eller Vainicher
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - V Morelli
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - S Palmieri
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - E Cairoli
- Unit of Endocrinology and Metabolic DiseasesFondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy Department of Clinical Sciences and Community HealthUniversity of Milan, Milan, Italy
| | - A S Salcuni
- Endocrine UnitDepartment of Medical Sciences, University of Cagliari, Cagliari, Italy
| | | | - A Scillitani
- Unit of Endocrinology"Casa Sollievo della Sofferenza", IRCCS, San Giovanni Rotondo, Foggia, Italy
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Ceccato F, Barbot M, Albiger N, Zilio M, De Toni P, Luisetto G, Zaninotto M, Greggio NA, Boscaro M, Scaroni C, Camozzi V. Long-term glucocorticoid effect on bone mineral density in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Eur J Endocrinol 2016; 175:101-6. [PMID: 27185866 DOI: 10.1530/eje-16-0104] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/16/2016] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Patients with 21-hydroxylase deficiency (21OHD) assume a lifelong glucocorticoid (GC) therapy. Excessive GC treatment increases the risk of osteoporosis and bone fractures, even though the role of substitutive therapy is not fully established: we analyzed the effect of GC dose on bone metabolism and bone mineral density (BMD) over time in patients with 21OHD. METHODS We studied bone metabolism markers and BMD in 38 adult patients with 21OHD (19-47 years, 24 females and 14 males) and 38 matched healthy control. In 15 patients, BMD data were available at both baseline and after a long-term follow-up. RESULTS BMD was lower in patients than in controls at lumbar spine (0.961±0.1g/cm(2) vs 1.02±0.113g/cm(2), P=0.014) and femur neck (0.736±0.128g/cm(2) vs 0.828±0.103g/cm(2), P=0.02); otherwise, after height correction, only femoral neck BMD was lower in patients (0.458±0.081g/cm(2) vs 0.498±0.063g/cm(2), P=0.028). In those 21OHD subjects with at least 10 years follow-up, we observed an increase in lumbar BMD (P=0.0429) and a decrease in femur neck BMD values (P=0.004). Cumulative GC dose was not related to bone metabolism or BMD. No patient experienced clinical fragility fractures. CONCLUSIONS BMD values are decreased in patients with 21OHD, which are in part explained by decreased height, but not by the dose of glucocorticoids. Nevertheless, bone status should be carefully monitored in patients with 21OHD.
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Affiliation(s)
- Filippo Ceccato
- Endocrinology UnitUniversity-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Endocrinology UnitUniversity-Hospital of Padova, Padova, Italy
| | - Nora Albiger
- Endocrinology UnitUniversity-Hospital of Padova, Padova, Italy
| | | | - Pietro De Toni
- Geriatric ClinicUniversity-Hospital of Padova, Padova, Italy
| | | | - Martina Zaninotto
- Laboratory Medicine UnitUniversity-Hospital of Padova, Padova, Italy
| | - Nella Augusta Greggio
- Pediatrics Endocrinology and Adolescence UnitDepartment of Woman and Child Health, University-Hospital of Padova, Padova, Italy
| | - Marco Boscaro
- Endocrinology UnitUniversity-Hospital of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology UnitUniversity-Hospital of Padova, Padova, Italy
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Schulz J, Frey KR, Cooper MS, Zopf K, Ventz M, Diederich S, Quinkler M. Reduction in daily hydrocortisone dose improves bone health in primary adrenal insufficiency. Eur J Endocrinol 2016; 174:531-8. [PMID: 26811406 DOI: 10.1530/eje-15-1096] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 01/25/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Individuals with primary adrenal insufficiency (PAI) or congenital adrenal hyperplasia (CAH) receive life-long glucocorticoid (GC) replacement therapy. Current daily GC doses are still higher than the reported adrenal cortisol production rate. This GC excess could result in long-term morbidities such as osteoporosis. No prospective trials have investigated the long-term effect of GC dose changes in PAI and CAH patients. METHODS This is a prospective and longitudinal study including 57 subjects with PAI (42 women) and 33 with CAH (21 women). Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry at baseline and after 2 years. Subjects were divided into three groups (similar baseline characteristics) depending on changes in daily hydrocortisone equivalent dose (group 1: unchanged 25.2±8.2 mg (mean±S.D., n=50); group 2: increased 18.7±10.3 to 25.9±12.0 mg (n=13); group 3: decreased 30.8±8.5 to 21.4±7.2 mg (n=27)). RESULTS Subjects in group 1 showed normal lumbar and femoral Z-scores which were unchanged over time. Group 2 subjects showed a significant decrease in femoral neck Z-scores over time (-0.15±1.1 to -0.37±1.0 (P<0.05)), whereas group 3 subjects showed a significant increase in lumbar spine and hip Z-scores (L1-L4: -0.93±1.2 to -0.65±1.5 (P<0.05); total hip: -0.40±1.0 to -0.28±1.0 (P<0.05)). No changes in BMI over time were seen within any group. Reduction in GC dose did not increase the risk of adrenal crisis. CONCLUSION This study demonstrates for the first time that cautious reduction in hydrocortisone equivalent doses leads to increases in BMD, whereas dose increments reduced BMD. These data emphasize the need for the lowest possible GC replacement dose in AI patients to maintain health and avoid long-term adverse effects.
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Affiliation(s)
- Julia Schulz
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Kathrin R Frey
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Mark S Cooper
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Kathrin Zopf
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Manfred Ventz
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Sven Diederich
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
| | - Marcus Quinkler
- Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany Department of Clinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyEndocrine and Diabetes UnitDepartment of Medicine I, University Hospital, University of Würzburg, Würzburg, GermanyAdrenal Steroid GroupANZAC Research Institute, Concord Repatriation General Hospital, Hospital Road, Concord Hospital, Concord, New South Wales 2139, AustraliaEndokrinologikumBerlin, GermanyEndocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, Germany
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Raizada N, Jyotsna VP, Upadhyay AD, Gupta N. Bone mineral density in young adult women with congenital adrenal hyperplasia. Indian J Endocrinol Metab 2016; 20:62-66. [PMID: 26904470 PMCID: PMC4743386 DOI: 10.4103/2230-8210.172283] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There is equipoise regarding the status of bone mineral density (BMD) in patients with congenital adrenal hyperplasia (CAH), where patients need to be on long-term low-dose steroids. OBJECTIVE We aimed to evaluate BMD at the hip, spine and forearm in women with CAH and compare it to healthy young adult women of the same age range. SUBJECTS AND METHODS Fifteen adult women with CAH with age ranging from 18 to 40 years (mean ± standard deviation = 27.5 ± 6.2 years) underwent dual-energy X-ray absorptiometry along with laboratory evaluation. BMD at lumbar spine, hip, forearm along with T-scores were measured. Serum total calcium, phosphate, alkaline phosphatase, 25 hydroxy Vitamin D, intact parathyroid hormone, total testosterone, and dehydroepiandrosterone were assayed. History of any fractures in the past was taken. Fifteen healthy women in the same age range were taken as controls for comparison. RESULTS The BMD at hip (0.85 ± 0.02 g/cm(2)) in CAH was significantly lower as compared with controls (0.92 ± 0.03 g/cm(2), P = 0.029). BMD at lumbar spine was also reduced (0.96 ± 0.02 vs. 1.03 ± 0.03, P = 0.057). The BMD at forearm was not significantly different between CAH and controls. The mean Vitamin D was 9.8 ng/ml (deficient range). There was no history of fractures in CAH. CONCLUSION Young adult CAH women had lower BMD at spine and hip than healthy young adult women of the same age range. The forearm BMD was not different from controls. No change in fracture frequency was present. Patients with CAH being treated with steroids are at increased risk of osteopenia, and their bone health needs to be monitored.
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Affiliation(s)
- Nishant Raizada
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Viveka P. Jyotsna
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Datt Upadhyay
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Nandita Gupta
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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22
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Falhammar H, Nordenström A. Nonclassic congenital adrenal hyperplasia due to 21-hydroxylase deficiency: clinical presentation, diagnosis, treatment, and outcome. Endocrine 2015; 50:32-50. [PMID: 26082286 DOI: 10.1007/s12020-015-0656-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/03/2015] [Indexed: 01/14/2023]
Abstract
Nonclassic congenital adrenal hyperplasia (NCAH) is one of the most frequent autosomal recessive disorders in man with a prevalence ranging from 0.1 % in Caucasians up to a few percent in certain ethnic groups. Most cases are never diagnosed due to very mild symptoms, misdiagnosing as polycystic ovary syndrome, or ignorance. In contrast to classic CAH, patients with NCAH present with mild partial cortisol insufficiency and hyperandrogenism and will survive without any treatment. Undiagnosed NCAH may result in infertility, miscarriages, oligomenorrhea, hirsutism, acne, premature pubarche, testicular adrenal rest tumors, adrenal tumors, and voice problems among other symptoms. A baseline measurement of 17-hydroxyprogesterone can be used for diagnosis, but the ACTH stimulation test with measurement of 17-hydroxyprogesterone is regarded as the golden standard. The diagnosis can be verified by CYP21A2 mutation analysis. Treatment is symptomatic and usually with glucocorticoids alone. The lowest possible glucocorticoid dose should be used. Long-term treatment with glucocorticoids will improve the symptoms but will also result in iatrogenic cortisol insufficiency and may also lead to long-term complications such as obesity, insulin resistance, hypertension, osteoporosis, and fractures. Although the complications seen in NCAH patients have been assumed to be related to the glucocorticoid treatment, some may, in fact, be associated with prolonged hyperandrogenism. Different risk factors and negative consequences should be monitored regularly in an attempt to improve the clinical outcome. More research is needed in this relatively common disorder.
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, D2:04, Karolinska University Hospital, 171 76, Stockholm, Sweden,
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23
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Bachelot A, Golmard JL, Dulon J, Dahmoune N, Leban M, Bouvattier C, Cabrol S, Leger J, Polak M, Touraine P. Determining clinical and biological indicators for health outcomes in adult patients with childhood onset of congenital adrenal hyperplasia. Eur J Endocrinol 2015; 173:175-84. [PMID: 25947139 DOI: 10.1530/eje-14-0978] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 05/06/2015] [Indexed: 11/08/2022]
Abstract
AIM Adverse outcomes in adult congenital adrenal hyperplasia (CAH) patients are frequent. The determinants of them have not yet been established. OBJECTIVE To establish the prevalence of adverse outcomes and to find determining factors for each of them. DESIGN, PATIENTS, AND METHODS Cross-sectional monocentric study of 104 patients with childhood onset of CAH (71 women, 33 men). Analysis established first the determinants of clinical, hormonal, genetic variables and second a composite criterion for some of the outcomes and determinants. RESULTS BMI was above 25 kg/m(2) in 44% of the cohort, adrenal hyperplasia and/or nodules were present in 45% of the patients, and irregular menstrual cycles and hyperandrogenism were found in 50 and 35% of the women respectively. In univariate analysis, the determinants of these outcomes were all linked to disease control, especially 17-hydroxyprogesterone (17OHP) and androstenedione concentrations. Low weight was a determinant of abnormal bone mineral density (BMD) (60% of the cohort). Multivariate analysis confirmed these data. A classic form (CF) of CAH was a determinant of testicular adrenal rest tumors (TARTs) (36% of the men). Total cumulative glucocorticoid dose was a determinant of BMI and TART, whereas fludrocortisone dose was a determinant of TART (P=0.03). In men, the composite criterion was associated with androstenedione concentration and CF. In women, the composite criterion was associated with total testosterone concentration. CONCLUSION The present study confirms the high prevalence of adverse outcomes in CAH patients. These are, most often, related to disease control. The impaired health status of adults with CAH could therefore be improved through the modification of treatment.
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Affiliation(s)
- Anne Bachelot
- Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France
| | - Jean Louis Golmard
- Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France
| | - Jérôme Dulon
- Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France
| | - Nora Dahmoune
- Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France
| | - Monique Leban
- Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France
| | - Claire Bouvattier
- Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France
| | - Sylvie Cabrol
- Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France
| | - Juliane Leger
- Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France
| | - Michel Polak
- Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France
| | - Philippe Touraine
- Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France Department of Endocrinology and Reproductive MedicineCentre de Référence des Maladies Endocriniennes Rares de la Croissance, AP-HP, IE3M, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75013 Paris, FranceUPMC Univ Paris 06Paris, FranceClinical Research UnitAP-HP, Hôpital Pitié-Salpêtrière, Paris, FranceDepartment of Hormonal BiochemistryAP-HP, Hôpital Pitié-Salpêtrière, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Bicêtre, Le Kremlin Bicêtre, FranceFaculté de Médecine Paris-SudUniversité Paris-Sud 11, Le Kremlin-Bicêtre F-94276, FrancePediatric EndocrinologyAP-HP, Hôpital Trousseau, Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Robert Debré, Paris, FranceUniversité Paris Diderot Paris 07Paris, FrancePediatric EndocrinologyAP-HP, Hôpital Necker Enfants-Malades, Paris, FranceUniversité Paris Descartes Paris 05Paris, France
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Webb EA, Krone N. Current and novel approaches to children and young people with congenital adrenal hyperplasia and adrenal insufficiency. Best Pract Res Clin Endocrinol Metab 2015; 29:449-68. [PMID: 26051302 DOI: 10.1016/j.beem.2015.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Congenital adrenal hyperplasia (CAH) represents a group of autosomal recessive conditions leading to glucocorticoid deficiency. CAH is the most common cause of adrenal insufficiency (AI) in the paediatric population. The majority of the other forms of primary and secondary adrenal insufficiency are rare conditions. It is critical to establish the underlying aetiology of each specific condition as a wide range of additional health problems specific to the underlying disorder can be found. Following the introduction of life-saving glucocorticoid replacement sixty years ago, steroid hormone replacement regimes have been refined leading to significant reductions in glucocorticoid doses over the last two decades. These adjustments are made with the aim both of improving the current management of children and young persons and of reducing future health problems in adult life. However despite optimisation of existing glucocorticoid replacement regimens fail to mimic the physiologic circadian rhythm of glucocorticoid secretion, current efforts therefore focus on optimising replacement strategies. In addition, in recent years novel experimental therapies have been developed which target adrenal sex steroid synthesis in patients with CAH aiming to reduce co-morbidities associated with sex steroid excess. These developments will hopefully improve the health status and long-term outcomes in patients with congenital adrenal hyperplasia and adrenal insufficiency.
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Affiliation(s)
- Emma A Webb
- School of Clinical & Experimental Medicine, University of Birmingham, Institute of Biomedical Research, Birmingham B15 2TT, UK.
| | - Nils Krone
- School of Clinical & Experimental Medicine, University of Birmingham, Institute of Biomedical Research, Birmingham B15 2TT, UK.
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25
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El-Maouche D, Collier S, Prasad M, Reynolds JC, Merke DP. Cortical bone mineral density in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Clin Endocrinol (Oxf) 2015; 82:330-7. [PMID: 24862755 PMCID: PMC4242797 DOI: 10.1111/cen.12507] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 03/26/2014] [Accepted: 05/16/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Prior studies reveal that bone mineral density (BMD) in congenital adrenal hyperplasia (CAH) is mostly in the osteopaenic range and is associated with lifetime glucocorticoid dose. The forearm, a measure of cortical bone density, has not been evaluated. OBJECTIVE We aimed to evaluate BMD at various sites, including the forearm, and the factors associated with low BMD in CAH patients. METHODS Eighty CAH adults (47 classic, 33 nonclassic) underwent dual-energy-x-ray absorptiometry and laboratory and clinical evaluation. BMD Z-scores at the AP spine, total hip, femoral neck, forearm and whole body were examined in relation to phenotype, body mass index, current glucocorticoid dose, average 5-year glucocorticoid dose, vitamin D, 17-hydroxyprogesterone, androstenedione, testosterone, dehydroepiandrosterone and dehydroepiandrosterone sulphate (DHEAS). RESULTS Reduced BMD (T-score <-1 at hip, spine, or forearm) was present in 52% and was more common in classic than nonclassic patients (P = 0·005), with the greatest difference observed at the forearm (P = 0·01). Patients with classic compared to nonclassic CAH, had higher 17-hydroxyprogesterone (P = 0·005), lower DHEAS (P = 0·0002) and higher non-traumatic fracture rate (P = 0·0005). In a multivariate analysis after adjusting for age, gender, height standard deviation, phenotype and cumulative glucocorticoid exposure, higher DHEAS was independently associated with higher BMD at the spine, radius and whole body. CONCLUSION Classic CAH patients have lower BMD than nonclassic patients, with the most affected area being the forearm. This first study of forearm BMD in CAH patients suggests that low DHEAS may be associated with weak cortical bone independent of glucocorticoid exposure.
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Affiliation(s)
- Diala El-Maouche
- National Institute of Dental and Craniofacial Research, National Institutes of Health (NIH), Bethesda, Maryland
- National Institutes of Health (NIH) Clinical Center, Bethesda, Maryland
| | - Suzanne Collier
- National Institutes of Health (NIH) Clinical Center, Bethesda, Maryland
| | - Mala Prasad
- Radiology and Imaging Sciences Department, Warren G. Magnuson Clinical Center, National Institutes of Health (NIH), Bethesda, Maryland
| | - James C Reynolds
- Radiology and Imaging Sciences Department, Warren G. Magnuson Clinical Center, National Institutes of Health (NIH), Bethesda, Maryland
| | - Deborah P. Merke
- National Institutes of Health (NIH) Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda, Maryland
- Corresponding Author: National Institutes of Health Clinical Center, Building 10, Clinical Research Center, Room 1-2740, 10 Center Drive, Mail Stop Code 1932, Bethesda, Maryland, 20892-1932.
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26
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Wilson MK, Collyar D, Chingos DT, Friedlander M, Ho TW, Karakasis K, Kaye S, Parmar MKB, Sydes MR, Tannock IF, Oza AM. Outcomes and endpoints in cancer trials: bridging the divide. Lancet Oncol 2015; 16:e43-52. [PMID: 25638556 DOI: 10.1016/s1470-2045(14)70380-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cancer is not one disease. Outcomes and endpoints in trials should incorporate the therapeutic modality and cancer type because these factors affect clinician and patient expectations. In this Review, we discuss how to: define the importance of endpoints; make endpoints understandable to patients; improve the use of patient-reported outcomes; advance endpoints to parallel changes in trial design and therapeutic interventions; and integrate these improvements into trials and practice. Endpoints need to reflect benefit to patients, and show that changes in tumour size either in absolute terms (response and progression) or relative to control (progression) are clinically relevant. Improvements in trial design should be accompanied by improvements in available endpoints. Stakeholders need to come together to determine the best approach for research that ensures accountability and optimises the use of available resources.
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Affiliation(s)
- Michelle K Wilson
- University of Toronto Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | | | - Michael Friedlander
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Tony W Ho
- AstraZeneca, Wilmington DE 19850-5437, USA
| | | | - Stan Kaye
- Drug Development Unit and Gynaecology Unit, Royal Marsden Hospital and Institute of Cancer Research, London, UK
| | | | - Matthew R Sydes
- MRC Clinical Trials Unit, University College London, London, UK
| | - Ian F Tannock
- University of Toronto Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Amit M Oza
- University of Toronto Princess Margaret Cancer Centre, Toronto, ON, Canada.
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27
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Martín S, Muñoz L, Pérez A, Sobrero G, Picotto G, Ochetti M, Carpentieri A, Silvano L, de Barboza GD, Signorino M, Rupérez C, Bertolotto P, Ulla MR, Pellizas C, Montesinos M, Tolosa de Talamoni N, Miras M. Clinical and molecular studies related to bone metabolism in patients with congenital adrenal hyperplasia. J Pediatr Endocrinol Metab 2014; 27:1161-6. [PMID: 25026125 DOI: 10.1515/jpem-2014-0104] [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] [Received: 02/27/2014] [Accepted: 06/13/2014] [Indexed: 11/15/2022]
Abstract
Patients with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency need glucocorticoid (GC) therapy, which alters bone mineral metabolism. We analyze clinical and biochemical parameters and different polymorphisms of candidate genes associated with bone mineral density (BMD) in CAH patients. The CAH patients treated with GC and healthy controls were studied. Anthropometric parameters, biochemical markers of bone turnover, and BMD were evaluated. Polymerase chain reaction technique was used to genotype different candidate genes. The 192-192 genotype frequency (IGF-I) was lower in poorly controlled patients than that from controls. In CAH patients, FF genotype (vitamin D receptor, VDR) correlated with lower lumbar spine BMD and there was a significant association between the 0-0 genotype (IGF-I) and high values of β-CrossLaps and a low total BMD. This study contributes to understanding of the association of genetic determinants of BMD with the variable response to GC treatment in CAH patients and demonstrates the usefulness of these genetic polymorphisms.
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28
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Gonçalves EM, Sewaybricker LE, Baptista F, Silva AM, Carvalho WRG, Santos AO, de Mello MP, Lemos-Marini SHV, Guerra G. Performance of phalangeal quantitative ultrasound parameters in the evaluation of reduced bone mineral density assessed by DX in patients with 21 hydroxylase deficiency. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:1414-1419. [PMID: 24726797 DOI: 10.1016/j.ultrasmedbio.2013.12.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 12/12/2013] [Accepted: 12/29/2013] [Indexed: 06/03/2023]
Abstract
The purpose of this study was to verify the performance of quantitative ultrasound (QUS) parameters of proximal phalanges in the evaluation of reduced bone mineral density (BMD) in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency (21 OHD). Seventy patients with 21 OHD (41 females and 29 males), aged between 6-27 y were assessed. The QUS measurements, amplitude-dependent speed of sound (AD-SoS), bone transmission time (BTT), and ultrasound bone profile index (UBPI) were obtained using the BMD Sonic device (IGEA, Carpi, Italy) on the last four proximal phalanges in the non-dominant hand. BMD was determined by dual energy X-ray (DXA) across the total body and lumbar spine (LS). Total body and LS BMD were positively correlated to UBPI, BTT and AD-SoS (correlation coefficients ranged from 0.59-0.72, p < 0.001). In contrast, when comparing patients with normal and low (Z-score < -2) BMD, no differences were found in the QUS parameters. Furthermore, UBPI, BTT and AD-SoS measurements were not effective for diagnosing patients with reduced BMD by receiver operator characteristic curve parameters. Although the AD-SoS, BTT and UBPI showed significant correlations with the data obtained by DXA, they were not effective for diagnosing reduced bone mass in patients with 21 OHD.
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Affiliation(s)
- Ezequiel M Gonçalves
- Growth and Development Lab-Center for Investigation in Pediatrics (CIPED), Faculty of Medical Sciences, University of Campinas, Campinas, SP, Brazil.
| | - Leticia E Sewaybricker
- Growth and Development Lab-Center for Investigation in Pediatrics (CIPED), Faculty of Medical Sciences, University of Campinas, Campinas, SP, Brazil; Pediatric Endocrinology Unit, Pediatrics Department, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil; PhD Student Program in Child and Adolescent Health
| | - Fatima Baptista
- Exercise and Health Laboratory, CIPER, Fac Motricidade Humana, Univ Lisboa, Cruz-Quebrada, Portugal
| | - Analiza M Silva
- Exercise and Health Laboratory, CIPER, Fac Motricidade Humana, Univ Lisboa, Cruz-Quebrada, Portugal
| | - Wellington R G Carvalho
- Growth and Development Lab-Center for Investigation in Pediatrics (CIPED), Faculty of Medical Sciences, University of Campinas, Campinas, SP, Brazil; Physical Education Department, Center of Health and Biology Sciences, Federal University of Maranhão, São Luis, MA, Brazil
| | - Allan O Santos
- Nuclear Medicine Division, Clinical Hospital, University of Campinas, Campinas, SP, Brazil
| | - Maricilda P de Mello
- Center of Molecular Biology and Genetic Engineering, University of Campinas, Campinas, SP, Brazil
| | - Sofia H V Lemos-Marini
- Pediatric Endocrinology Unit, Pediatrics Department, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
| | - Gil Guerra
- Growth and Development Lab-Center for Investigation in Pediatrics (CIPED), Faculty of Medical Sciences, University of Campinas, Campinas, SP, Brazil; Pediatric Endocrinology Unit, Pediatrics Department, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
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29
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Costa-Barbosa FA, Telles-Silveira M, Kater CE. [Congenital adrenal hyperplasia in the adult women: management of old and new challenges]. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2014; 58:124-131. [PMID: 24830589 DOI: 10.1590/0004-2730000002987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 11/25/2013] [Indexed: 06/03/2023]
Abstract
Due to major improvements in the management and therapy of patients with congenital adrenal hyperplasia owing to 21-hydroxylase deficiency (21OHD) along childhood and adolescence, affected women are able to reach adulthood. Therefore, management throughout adult life became even more complex, leading to new challenges. Both the protracted use of corticosteroids (sometimes in supraphysiologic doses), and excess androgen (due to irregular treatment and/or inadequate dosage) may impair the quality of life and health outcomes in affected adult women, causing osteoporosis, metabolic disturbances with high cardiovascular risk, cosmetic damage, infertility, and psychosocial and psychosexual changes. However, long-term follow-up studies with 21OHD adult women are still required. In this review, we discuss some important and controversial aspects of the follow-up of adult women with 21OHD, and recommend the use of a customized multi-disciplinary therapeutic approach while further studies with these patients do not provide distinct understanding and well-defined attitudes towards better quality of life.
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Affiliation(s)
- Flávia A Costa-Barbosa
- Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Mariana Telles-Silveira
- Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Claudio E Kater
- Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Garcia Alves Junior PA, Schueftan DLG, de Mendonça LMC, Farias MLF, Beserra ICR. Bone mineral density in children and adolescents with congenital adrenal hyperplasia. Int J Endocrinol 2014; 2014:806895. [PMID: 24734045 PMCID: PMC3966416 DOI: 10.1155/2014/806895] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 01/22/2014] [Accepted: 01/23/2014] [Indexed: 11/18/2022] Open
Abstract
Chronic glucocorticoid therapy is associated with reduced bone mineral density. In paediatric patients with congenital adrenal hyperplasia, increased levels of androgens could not only counteract this effect, but could also advance bone age, with interference in the evaluation of densitometry. We evaluate bone mineral density in paediatric patients with classic congenital adrenal hyperplasia taking into account chronological and bone ages at the time of the measurement. Patients aged between 5 and 19 years underwent radiography of the hand and wrist followed by total body and lumbar spine densitometry. Chronological and bone ages were used in the scans interpretation. In fourteen patients, mean bone mineral density Z-score of total body to bone age was -0.76 and of lumbar spine to bone age was -0.26, lower than those related to chronological age (+0.03 and +0.62, resp.). Mean Z-score differences were statistically significant (P = 0.004 for total body and P = 0.003 for lumbar spine). One patient was classified as having low bone mineral density only when assessed by bone age. We conclude that there was a reduction in the bone mineral density Z-score in classic congenital adrenal hyperplasia paediatric patients when bone age was taken into account instead of chronological age.
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Affiliation(s)
- Paulo Alonso Garcia Alves Junior
- Universidade Federal do Rio de Janeiro (UFRJ), 21941-901 Rio de Janeiro, RJ, Brazil
- Ambulatório de Endocrinologia, Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG), UFRJ, Rua Bruno Lobo No. 50, 21941-912 Rio de Janeiro, RJ, Brazil
- *Paulo Alonso Garcia Alves Junior:
| | - Daniel Luis Gilban Schueftan
- Universidade Federal do Rio de Janeiro (UFRJ), 21941-901 Rio de Janeiro, RJ, Brazil
- Ambulatório de Endocrinologia, Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG), UFRJ, Rua Bruno Lobo No. 50, 21941-912 Rio de Janeiro, RJ, Brazil
| | | | | | - Izabel Calland Ricarte Beserra
- Universidade Federal do Rio de Janeiro (UFRJ), 21941-901 Rio de Janeiro, RJ, Brazil
- Ambulatório de Endocrinologia, Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG), UFRJ, Rua Bruno Lobo No. 50, 21941-912 Rio de Janeiro, RJ, Brazil
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31
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Abstract
The management of congenital adrenal hyperplasia involves suppression of adrenal androgen production, in addition to treatment of adrenal insufficiency. Management of adolescents with congenital adrenal hyperplasia is especially challenging because changes in the hormonal milieu during puberty can lead to inadequate suppression of adrenal androgens, psychosocial issues often affect adherence to medical therapy, and sexual function plays a major part in adolescence and young adulthood. For these reasons, treatment regimen reassessment is indicated during adolescence. Patients with non-classic congenital adrenal hyperplasia require reassessment regarding the need for glucocorticoid drug treatment. No clinical trials have compared various regimens for classic congenital adrenal hyperplasia in adults, thus therapy is individualised and based on the prevention of adverse outcomes. Extensive patient education is key during transition from paediatric care to adult care and should include education of females with classic congenital adrenal hyperplasia regarding their genital anatomy and surgical history. Common issues for these patients include urinary incontinence, vaginal stenosis, clitoral pain, and cosmetic concerns; for males with classic congenital adrenal hyperplasia, common issues include testicular adrenal rest tumours. Transition from paediatric to adult care is most successful when phased over many years. Education of health-care providers on how to successfully transition patients is greatly needed.
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Affiliation(s)
- Deborah P Merke
- National Institutes of Health Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
| | - Dix P Poppas
- the Institute for Pediatric Urology, Comprehensive Center for Congenital Adrenal Hyperplasia, Komansky Center for Children's Health, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
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32
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Brunetti G, Faienza MF, Piacente L, Ventura A, Oranger A, Carbone C, Benedetto AD, Colaianni G, Gigante M, Mori G, Gesualdo L, Colucci S, Cavallo L, Grano M. High dickkopf-1 levels in sera and leukocytes from children with 21-hydroxylase deficiency on chronic glucocorticoid treatment. Am J Physiol Endocrinol Metab 2013; 304:E546-54. [PMID: 23299503 DOI: 10.1152/ajpendo.00535.2012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Children with 21-hydroxylase deficiency (21-OHD) need chronic glucocorticoid (cGC) therapy to replace congenital deficit of cortisol synthesis, and this therapy is the most frequent and severe form of drug-induced osteoporosis. In this study, we enrolled 18 patients (9 females) and 18 sex- and age-matched controls. We found in 21-OHD patients high serum and leukocyte levels of dickkopf-1 (DKK1), a secreted antagonist of the Wnt/β-catenin signaling pathway known to be a key regulator of bone mass. In particular, we demonstrated by flow cytometry, confocal microscopy, and real-time PCR that monocytes, T lymphocytes, and neutrophils from patients expressed high levels of DKK1, which may be related to the cGC therapy. In fact, we showed that dexamethasone treatment markedly induced the expression of DKK1 in a dose- and time-dependent manner in leukocytes. The serum from patients containing elevated levels of DKK1 can directly inhibit in vitro osteoblast differentiation and receptor activator of NF-κB ligand (RANKL) expression. We also found a correlation between both DKK1 and RANKL or COOH-terminal telopeptides of type I collagen (CTX) serum levels in 21-OHD patients on cGC treatment. Our data indicated that DKK1, produced by leukocytes, may contribute to the alteration of bone remodeling in 21-OHD patients on cGC treatment.
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Affiliation(s)
- Giacomina Brunetti
- Dept. of Basic Medical Sciences, Neuroscience, and Sense Organs, Section of Human Anatomy and Histology, Univ. of Bari, Piazza Giulio Cesare, 11 70124 Bari, Italy.
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Falhammar H, Filipsson Nyström H, Wedell A, Brismar K, Thorén M. Bone mineral density, bone markers, and fractures in adult males with congenital adrenal hyperplasia. Eur J Endocrinol 2013; 168:331-41. [PMID: 23211577 DOI: 10.1530/eje-12-0865] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The aim of this study was to determine bone mineral density (BMD), markers of bone metabolism, fractures, and steroids reflecting hormonal control in adult males with congenital adrenal hyperplasia (CAH). SUBJECTS, METHODS, AND DESIGN: We compared CAH males with 21-hydroxylase deficiency (n=30), 19-67 years old, with age- and sex-matched controls (n=32). Subgroups of CYP21A2 genotypes, age, glucocorticoid preparation, poor control vs overtreatment, and early vs late (>36 months) diagnosis were studied. BMD measured by dual energy X-ray absorptiometry and markers of bone metabolism and androgens/17-hydroxyprogesterone levels were investigated. RESULTS All, including older (>30 years), CAH patients had lower BMD in all measured sites compared with control subjects. The null group demonstrated lower BMD in more locations than the other groups. Osteoporosis/osteopenia was present in 81% of CAH patients compared with 32% in controls (≥30 years). Fracture frequency was similar, osteocalcin was lower, and fewer patients than controls had vitamin D insufficiency. IGF1 was elevated in the milder genotypes. In patients, total body BMD was positively correlated to weight, BMI, total lean body mass, and triglycerides, and negatively to prolactin. Patients on prednisolone had lower BMD and osteocalcin levels than those on hydrocortisone/cortisone acetate. Patients with poor control had higher femoral neck BMD. There were no differences in BMD between patients with an early vs late diagnosis. CONCLUSIONS CAH males have low BMD and bone formation markers. BMD should be monitored, adequate prophylaxis and treatment established, and glucocorticoid doses optimized to minimize the risk of future fractures.
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, D02:04, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
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Janin C, Pascal Vigneron V, Weryha G, Leheup B. Clinical audit concerning the quality of management in patients with classic form of congenital adrenal hyperplasia. ANNALES D'ENDOCRINOLOGIE 2013; 74:13-26. [PMID: 23357572 DOI: 10.1016/j.ando.2012.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Accepted: 10/16/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE High Authority for Health (HAS) edited in April 2011 a national program of care and diagnostic (PNDS) concerning congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency in agreement with the international recommendation 2002 and 2010. To reduce long-term complications and improve the quality of life to our patients, we had tested our professional practices. PATIENTS All patients aged more than 18 years with classic CAH of the adult endocrine units in the Nancy's University Hospital Center. METHODS We have made a clinical audit. We checked all medical records to see whether the recommendation were applied or not between the last consultation before (Tour 1; T1) and after (Tour 2; T2) the introduction of the national guidelines. RESULTS Twenty-seven medicals records with classic CAH were analyzed. The collection of clinical data must be more systematic because if the weight appeared in 89% of cases, body mass index missed (26% only in T1), the measure of the blood pressure remained insufficient (74% in T2). Concerning the therapeutic balance, 17-hydroxyprogestérone, testosterone, renin were correctly prescribed (>80%), Delta4-androstènedione in improvement (from 67% to 100%) some in defect (stable with 68% sodium and potassium). The evaluation of the fertility considerably progressed on the other hand the markers of bone metabolism were still often too much lacking. CONCLUSIONS Change in compliance since national guidelines is a slow process.
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Affiliation(s)
- Cécile Janin
- Service d'endocrinologie adulte, CHU Brabois, 11, rue du morvan, 54500 Vandœuvre-lès-Nancy, France.
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Glucocorticoid-induced osteoporosis in children with 21-hydroxylase deficiency. BIOMED RESEARCH INTERNATIONAL 2013; 2013:250462. [PMID: 23484098 PMCID: PMC3581245 DOI: 10.1155/2013/250462] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 10/04/2012] [Indexed: 02/07/2023]
Abstract
21-Hydroxylase deficiency (21-OHD) is the most common cause of congenital adrenal hyperplasia (CAH), resulting from deletions or mutations of the P450 21-hydroxylase gene (CYP21A2). Children with 21-OHD need chronic glucocorticoid (cGC) therapy, both to replace congenital deficit in cortisol synthesis and to reduce androgen secretion by adrenal cortex. GC-induced osteoporosis (GIO) is the most common form of secondary osteoporosis that results in an early, transient increase in bone resorption accompanied by a decrease in bone formation, maintained for the duration of GC therapy. Despite the conflicting results in the literature about the bone status on GC-treated patients with 21-OHD, many reports consider these subjects to be at risk for osteoporosis and fractures. In bone cells, at the molecular level, GCs regulate various functions including osteoblastogenesis, osteoclastogenesis, and the apoptosis of osteoblasts and osteocytes. In this paper, we focus on the physiology and biosynthesis of endogenous steroid hormones as well as on the effects of GCs on bone cells, highlighting the pathogenetic mechanism of GIO in children with 21-OHD.
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Schober J, Nordenström A, Hoebeke P, Lee P, Houk C, Looijenga L, Manzoni G, Reiner W, Woodhouse C. Disorders of sex development: summaries of long-term outcome studies. J Pediatr Urol 2012. [PMID: 23182771 DOI: 10.1016/j.jpurol.2012.08.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Existing outcomes for DSD individuals are inadequate because reports are based upon information collected retrospectively. This paper is presented to review existing data emphasizing information needed to lead to better future care, is based on presentations and discussions at a multi-disciplinary meeting on DSD held in Annecy in 2012, and is not intended to define the present status of management of each of the various DSD diagnoses. Rather it is intended to provide information needed to do studies regarding outcome data from the treatment of children with DSD by providing a summary of recommendations of 'patient-centered' topics that need investigation. The hope is that by being concerned with what is not known, new protocols will be developed for improving both early management and transition to adult life.
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Finkielstain GP, Kim MS, Sinaii N, Nishitani M, Van Ryzin C, Hill SC, Reynolds JC, Hanna RM, Merke DP. Clinical characteristics of a cohort of 244 patients with congenital adrenal hyperplasia. J Clin Endocrinol Metab 2012; 97:4429-38. [PMID: 22990093 PMCID: PMC3513542 DOI: 10.1210/jc.2012-2102] [Citation(s) in RCA: 196] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 08/23/2012] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with congenital adrenal hyperplasia (CAH) often suffer from long-term complications secondary to chronic glucocorticoid therapy and suboptimal treatment regimens. OBJECTIVE The aim of the study was to describe clinical characteristics of a large cohort of pediatric and adult CAH patients. DESIGN AND SETTING We conducted a cross-sectional study of 244 CAH patients [183 classic, 61 nonclassic (NC)] included in a Natural History Study at the National Institutes of Health. MAIN OUTCOME MEASURE(S) Outcome variables of interest were height sd score, obesity, hypertensive blood pressure (BP), insulin resistance, metabolic syndrome, bone mineral density, hirsutism (females), and testicular adrenal rest (TART). RESULTS The majority had elevated or suppressed androgens, with varied treatment regimens. Mean adult height SD score was -1.0 ± 1.1 for classic vs. -0.4 ± 0.9 for NC patients (P = 0.015). Obesity was present in approximately one third of patients, across phenotypes. Elevated BP was more common in classic than NC patients (P ≤ 0.01); pediatric hypertensive BP was associated with suppressed plasma renin activity (P = 0.001). Insulin resistance was common in classic children (27%) and adults (38% classic, 20% NC); 18% of adults had metabolic syndrome. The majority (61%) had low vitamin D; 37% of adults had low bone mineral density. Hirsutism was common (32% classic; 59% NC women). TART was found in classic males (33% boys; 44% men). CONCLUSIONS Poor hormonal control and adverse outcomes are common in CAH, necessitating new treatments. Routine monitoring of classic children should include measuring BP and plasma renin activity. Osteoporosis prophylaxis and TART screening should begin during childhood. A longitudinal study is under way.
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Affiliation(s)
- Gabriela P Finkielstain
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda, Maryland 20892, USA
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Mnif MF, Kamoun M, Mnif F, Charfi N, Naceur BB, Kallel N, Rekik N, Mnif Z, Sfar MH, Sfar MT, Hachicha M, Abid M. Metabolic profile and cardiovascular risk factors in adult patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Indian J Endocrinol Metab 2012; 16:939-946. [PMID: 23226639 PMCID: PMC3510964 DOI: 10.4103/2230-8210.102995] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND In congenital adrenal hyperplasia (CAH), long-term glucocorticoid treatment coupled with increased androgens may lead to undesirable metabolic effects. The aim of our report was to determine the prevalence of metabolic abnormalities and cardiovascular risk factors in a population of adult patients with CAH due to 21 hydroxylase deficiency. MATERIALS AND METHODS Twenty-six patients (11 males and 15 females, mean age ± SD=27.4±8.2 years) were recruited. Anthropometry, body composition, metabolic parameters and cardiovascular risk factors were studied. RESULTS Obesity (overweight included) was noted in 16 patients (61.5%), with android distribution in all cases. Bioelectrical impedance showed increased body fat mass in 12 patients (46.1%). Lipid profile alterations and carbohydrate metabolism disorders were detected in seven (26.9%) and five (19.2%) patients respectively. Moderate hepatic cytolysis, associated with hepatic steatosis, was found in one patient. Seven patients (27%) had insulin resistance. Ambulatory blood pressure monitoring showed abnormalities in six patients (23%). Increased carotid intima media thickness was found in 14 patients (53.8%). CONCLUSION Adult CAH patients tend to have altered metabolic parameters and a higher prevalence of cardiovascular risk factors. Lifelong follow-up, lifestyle modifications, and attempts to adjust and reduce the glucocorticoid doses seem important.
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Affiliation(s)
- Mouna Feki Mnif
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Mahdi Kamoun
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Fatma Mnif
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Nadia Charfi
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Basma Ben Naceur
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Nozha Kallel
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Nabila Rekik
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Zainab Mnif
- Department of Radiology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Mohamed Habib Sfar
- Department of Endocrinology and Internal Medicine, Tahar Sfar Hospital, 5111 Mahdia, Tunisia
| | | | - Mongia Hachicha
- Department of Pediatric, Hedi Chaker Hospital, 3029 Sfax, Tunisia
| | - Mohamed Abid
- Department of Endocrinology, Hedi Chaker Hospital, 3029 Sfax, Tunisia
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Falhammar H, Thorén M. Clinical outcomes in the management of congenital adrenal hyperplasia. Endocrine 2012; 41:355-73. [PMID: 22228497 DOI: 10.1007/s12020-011-9591-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 12/20/2011] [Indexed: 01/09/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of disorders affecting adrenal steroid synthesis. The most common form, 21-hydroxylase deficiency, leads to decreased production of cortisol and aldosterone with increased androgen secretion. In classic CAH glucocorticoid treatment can be life-saving, and provides symptom control, but must be given in an unphysiological manner with the risk of negative long-term outcomes. A late diagnosis or a severe phenotype or genotype has also a negative impact. These factors can result in impaired quality of life (QoL), increased cardiometabolic risk, short stature, osteoporosis and fractures, benign tumors, decreased fertility, and vocal problems. The prognosis has improved during the last decades, thanks to better clinical management and nowadays the most affected patients seem to have a good QoL. Very few patients above the age of 60 years have, however, been studied. Classifying patients according to genotype may give additional useful clinical information. The introduction of neonatal CAH screening may enhance long-term results. Monitoring of different risk factors and negative consequences should be done regularly in an attempt to improve clinical outcomes further.
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, D2:04, 17176 Stockholm, Sweden,
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40
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Nimkarn S, Lin-Su K, New MI. Steroid 21 hydroxylase deficiency congenital adrenal hyperplasia. Pediatr Clin North Am 2011; 58:1281-300, xii. [PMID: 21981961 DOI: 10.1016/j.pcl.2011.07.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Steroid 21 hydroxylase deficiency is the most common form of congenital adrenal hyperplasia (CAH). The severity of this disorder depends on the extent of impaired enzymatic activity, which is caused by various mutations of the 21 hydroxylase gene. This article reviews adrenal steroidogenesis and the pathophysiology of 21 hydroxylase deficiency. The three forms of CAH are then discussed in terms of clinical presentation, diagnosis and treatment, and genetic basis. Prenatal diagnosis and treatment are also reviewed. The goal of therapy is to correct the deficiency in cortisol secretion and suppress androgen overproduction. Glucocorticoid replacement has been the mainstay of treatment for CAH, but new treatment strategies continue to be developed and studied.
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Affiliation(s)
- Saroj Nimkarn
- Adrenal Steroid Disorders Program, Division of Pediatric Endocrinology, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1198, New York, NY 10029, USA
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Cetinkaya S, Kara C. The effect of glucocorticoid replacement therapy on bone mineral density in children with congenital adrenal hyperplasia. J Pediatr Endocrinol Metab 2011; 24:265-9. [PMID: 21823521 DOI: 10.1515/jpem.2011.189] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES 1) To evaluate the effects of glucocorticoid (GC) doses on bone mineral density (BMD) in children with congenital adrenal hyperplasia (CAH), 2) Investigate other factors influencing BMD. METHODS Twenty-six children with CAH and 11 healthy controls included in the study. All of the patients were examined with dual-energy X-ray absorptiometry (DXA) using a Hologic QDR 1000/W densitometer. The metabolic control state, age at diagnosis GC dose (mg/m2/day), pubertal status, 17 hydroxyprogesterone (17 OHP) levels, bone age (BA), and lumber BMD were evaluated in all cases. BMD (g/cm2), BMD z-score corrected to National Standards (cNS-BMD z-score), BMD z-score corrected to BA (cBABMD), bone mineral content (BMC), BMC corrected to puberty (cPBMC), and bone area (BAR) values were determined. Patients were grouped according to mean on-therapy serum 17 OHP levels as tight control (17 OHP<10 nmol/L) (n:13) and poor control (17 OHP>10 nmol/L) (n:13). All groups were compared with each other. RESULTS The age range was 2.1-15.7 years and the mean age (+/- SD) 9.3 (+/- 3.5) years. There were no significant differences between the groups in terms of GC doses, lumbar BMD values [BMD (g/cm2), BMD z-score corrected to National Standards (cNS-BMD z-score), BMD z-score corrected to BA (cBABMD), bone mineral content (BMC), BMC corrected to puberty (cPBMC), and bone area (BAR)]. However, the BMI value was higher in children with CAH than normal healthy controls. The BA of the poor control, late diagnosed groups and male patients were higher than tight control, early diagnosed group and female patients, respectively. BMC and BA were lower than the control group in tight control with early diagnosed patients. The cBABMD z-score was lower in males with poor control than males with tight control. There were no similar results in female patients. CONCLUSIONS Although GC treatment seems not to influence BMD in CAH patients in our study, further studies are needed to additionally evaluate daily calcium (Ca) intake, polymorphism of vitamin D receptor, ethnic factors (strict Islamic dress, etc.), socioeconomic status, and 24-h urinary free cortisol level.
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Affiliation(s)
- Semra Cetinkaya
- Dr. Sami Ulus Obstetrics and Gynecology, Children's Health and Disease Training and Research Hospital, Ankara, Turkey.
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Bone health should be an important concern in the care of patients affected by 21 hydroxylase deficiency. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010. [PMID: 20936142 PMCID: PMC2948879 DOI: 10.1155/2010/326275] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 07/08/2010] [Indexed: 12/04/2022]
Abstract
Osteoporosis has been an understandable concern for children and adult patients with congenital adrenal hyperplasia (CAH) who may receive or have received supraphysiological doses of glucocorticoids. Some previous reports on bone mineral density (BMD) in adult CAH patients showed no significant differences in BMD between patients with CAH and controls, but others have found lower BMD in CAH patients. In reports documenting the BMD reduction, this outcome has been attributed to an accumulated effect of prolonged exposure to excess glucocorticoids during infancy and childhood. We recently conducted a trial to establish the role of the total cumulative glucocorticoid dose on BMD. We established for the first time that there was a negative relationship between total cumulative glucocorticoid dose and lumbar and femoral BMD. Women might benefit from the preserving effect of estrogens compared to men. BMI (Body Mass Index) also appeared to protect patients from bone loss. In light of this, physicians should bear in mind the potential consequences of glucocorticoids on bone and therefore adjust the treatment and improve clinical and biological surveillance from infancy. Furthermore, preventive measures against corticosteroid-induced osteoporosis should be discussed right from the beginning of glucocorticoid therapy.
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43
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Adrenal gland and bone. Arch Biochem Biophys 2010; 503:137-45. [PMID: 20542010 DOI: 10.1016/j.abb.2010.06.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 06/05/2010] [Accepted: 06/08/2010] [Indexed: 02/06/2023]
Abstract
The adrenal gland synthesizes steroid hormones from the adrenal cortex and catecholamines from the adrenal medulla. Both cortisol and adrenal androgens can have powerful effects on bone. The overproduction of cortisol in Cushing's disease leads to a dramatic reduction in bone density and an increase risk of fracture. Overproduction of adrenal androgens in congenital adrenal hyperplasia (CAH) leads to marked changes in bone growth and development with early growth acceleration but ultimately a significant reduction in final adult height. The role of more physiological levels of glucocorticoids and androgens on bone metabolism is less clear. Cortisol levels measured in elderly individuals show a weak correlation with measures of bone density and change in bone density over time with a high cortisol level associated with lower bone density and more rapid bone loss. Cortisol levels and the dynamics of cortisol secretion change with age which could also explain some age related changes in bone physiology. It is also now clear that adrenal steroids can be metabolized within bone tissue itself. Local synthesis of cortisol within bone from its inactive precursor cortisone has been demonstrated and the amount of cortisol produced within osteoblasts appears to increase with age. With regard to adrenal androgens there is a dramatic reduction in levels with aging and several studies have examined the impact that restoration of these levels back to those seen in younger individuals has on bone health. Most of these studies show small positive effects in women, not men, but the skeletal sites where benefits are seen varies from study to study.
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Schaeffer TL, Tryggestad JB, Mallappa A, Hanna AE, Krishnan S, Chernausek SD, Chalmers LJ, Reiner WG, Kropp BP, Wisniewski AB. An Evidence-Based Model of Multidisciplinary Care for Patients and Families Affected by Classical Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:692439. [PMID: 20339513 PMCID: PMC2842898 DOI: 10.1155/2010/692439] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Accepted: 01/19/2010] [Indexed: 11/18/2022]
Abstract
In 2002 a consensus statement pertaining to the management of classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency was jointly produced by the Lawson Wilkins Pediatric Endocrine Society and the European Society of Pediatric Endocrinology. One of the recommendations of this consensus was that centers should maintain multidisciplinary teams for providing care and support to these patients and their families. However, the specifics for how this should be accomplished were not addressed in the original consensus statement. Here we interpret and translate the 2002 consensus statement recommendations into medical, surgical and mental health protocols. Additionally, we provide preliminary evidence that such protocols result in improved care and support for patients and families.
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Affiliation(s)
- Traci L. Schaeffer
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Jeanie B. Tryggestad
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Ashwini Mallappa
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Adam E. Hanna
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Sowmya Krishnan
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Steven D. Chernausek
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Laura J. Chalmers
- Pediatric Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - William G. Reiner
- Pediatric Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Brad P. Kropp
- Pediatric Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Amy B. Wisniewski
- Pediatric Endocrinology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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Bachelot A, Chakhtoura Z, Samara-Boustani D, Dulon J, Touraine P, Polak M. Bone Health Should Be an Important Concern in the Care of Patients Affected by 21 Hydroxylase Deficiency. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-326275] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Loechner KJ, Patel S, Fordham L, McLaughlin JT. Decreased bone mineral density and vertebral compression fractures in a young adult male with 21-hydroxylase deficiency congenital adrenal hyperplasia (CAH): is CAH an unrecognized population at risk for glucocorticoid-induced osteoporosis? J Pediatr Endocrinol Metab 2010; 23:179-87. [PMID: 20432821 DOI: 10.1515/jpem.2010.23.1-2.179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND CAH, most often due to a molecular defect in the 21-OH enzyme, results in inadequate cortisol production and subsequent life-long GC replacement. AIMS To heighten awareness for risk of GIO in children with CAH including (1) ongoing assessment of GC dosing, (2) screening for bone health, and (3) prophylactic measures/early intervention once GIO is identified. PATIENT 23 year-old male with 21OHD CAH referred for osteopenia. METHODS Chart review; radiological, serological and urine assessment. RESULTS Patient has old vertebral compression fractures and diminished BMD, the onset of which likely corresponds to excessive GC dosing during adolescence. CONCLUSION As with other GC-dependent conditions, children with CAH may represent a previously unrecognized population at risk for GIO. Physicians need to be cognizant of the consequences of excessive GC dosing on bone health, especially during infancy and adolescence, critical periods for both linear growth as well as bone accretion.
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Affiliation(s)
- Karen J Loechner
- Division of Pediatric Endocrinology, University of North Carolina, Chapel Hill, NC, USA.
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47
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Schaeffer T, Tryggestad J, Mallappa A, Hanna A, Krishnan S, Chernausek S, Chalmers L, Reiner W, Kropp B, Wisniewski A. An Evidence-Based Model of Multidisciplinary Care for Patients and Families Affected by Classical Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-692439] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Nimkarn S, Lin-Su K, New MI. Steroid 21 hydroxylase deficiency congenital adrenal hyperplasia. Endocrinol Metab Clin North Am 2009; 38:699-718. [PMID: 19944288 DOI: 10.1016/j.ecl.2009.08.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Steroid 21 hydroxylase deficiency is the most common form of congenital adrenal hyperplasia (CAH). The severity of this disorder depends on the extent of impaired enzymatic activity, which is caused by various mutations of the 21 hydroxylase gene. This article reviews adrenal steroidogenesis and the pathophysiology of 21 hydroxylase deficiency. The three forms of CAH are then discussed in terms of clinical presentation, diagnosis and treatment, and genetic basis. Prenatal diagnosis and treatment are also reviewed. The goal of therapy is to correct the deficiency in cortisol secretion and suppress androgen overproduction. Glucocorticoid replacement has been the mainstay of treatment for CAH, but new treatment strategies continue to be developed and studied.
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Affiliation(s)
- Saroj Nimkarn
- Mount Sinai School of Medicine, New York, NY 10029, USA
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Zimmermann A, Sido PG, Schulze E, Al Khzouz C, Lazea C, Coldea C, Weber MM. Bone mineral density and bone turnover in Romanian children and young adults with classical 21-hydroxylase deficiency are influenced by glucocorticoid replacement therapy. Clin Endocrinol (Oxf) 2009; 71:477-84. [PMID: 19170706 DOI: 10.1111/j.1365-2265.2008.03518.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE It remains controversial if glucocorticoid replacement therapy impairs bone mineral density (BMD) in young patients with 21-hydroxylase deficiency. We aimed to analyze the impact of treatment variables, phenotype and genotype on BMD and bone metabolism in these patients. DESIGN Cross-sectional study. MEASUREMENTS Twenty-eight Caucasian patients with classical 21-hydroxylase deficiency (5-39 years). Clinical parameters, hormonal status, osteocalcin (OC), C-terminal telopeptide of type I collagen (CTX), genotype and lumbar BMD (Z-scores) were assessed. Cumulative and mean hydrocortisone equivalent doses were calculated for the entire treatment period. RESULTS Patients with severely reduced BMD Z-scores (< or = -2.5 SD) had significantly higher mean/cumulative glucocorticoid doses compared to patients with moderately reduced (P = 0.003/P = 0.026) and normal Z-scores (> -1 SD) (P = 0.005/P = 0.011). Mean hydrocortisone equivalent doses > 20 mg/m(2)/day led to significantly lower lumbar BMD Z-scores (-2.16 +/- 1.4 SD) vs. doses </= 20 mg/m(2)/day (-0.59 +/- 1.25 SD) (P = 0.008). BMD correlated negatively with mean/cumulative glucocorticoid doses and treatment duration. OC (86.45 +/- 37.45 ng/ml) and CTX (1.45 +/- 0.43 ng/ml) were significantly increased compared to an age- and sex-matched control group in patients with active growth; only CTX was slightly increased in patients who completed growth. CONCLUSIONS High cumulative and mean glucocorticoid doses negatively impact on BMD in children and young adults with classical 21-hydroxylase deficiency. Substitution therapy should be adapted particularly at this life period to prevent bone loss.
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Affiliation(s)
- Anca Zimmermann
- 1st Medical Clinic, Department of Endocrinology and Metabolic Diseases, Johannes Gutenberg University of Mainz, Langenbeckstrasse 1, Mainz, Germany.
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Faienza MF, Brunetti G, Colucci S, Piacente L, Ciccarelli M, Giordani L, Del Vecchio GC, D'Amore M, Albanese L, Cavallo L, Grano M. Osteoclastogenesis in children with 21-hydroxylase deficiency on long-term glucocorticoid therapy: the role of receptor activator of nuclear factor-kappaB ligand/osteoprotegerin imbalance. J Clin Endocrinol Metab 2009; 94:2269-76. [PMID: 19401376 DOI: 10.1210/jc.2008-2446] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Children with 21-hydroxylase deficiency (21-OHD) need chronic glucocorticoid (cGC) therapy to replace congenital deficit of cortisol synthesis. cGC therapy is the most frequent and severe form of drug-induced osteoporosis, and different mechanisms have been proposed to explain its pathogenesis. OBJECTIVE We investigated the osteoclastogenic potential of peripheral blood mononuclear cells (PBMCs) from 18 children with 21-OHD on cGC therapy and 25 controls who never received GCs. We also evaluated the presence of circulating osteoclast precursors (OCPs) and the role of T cells in osteoclast formation. RESULTS Spontaneous osteoclastogenesis, without adding macrophage-colony stimulating factor and receptor activator of nuclear factor-kappaB ligand (RANKL), and significantly higher osteoclasts resorption activity occurred in 21-OHD patients. Conversely, macrophage-colony stimulating factor and RANKL were essential to trigger and sustain osteoclastogenesis in controls. Furthermore, in 21-OHD patients, we identified a significant percentage of CD11b-CD51/CD61 and CD51/61-RANK-positive cells, which are OCPs strongly committed. Additionally, we demonstrated a T cell-dependent osteoclastogenesis from 21-OHD patients' PBMCs. T cells from patients expressed high levels of RANKL and low levels of osteoprotegerin (OPG) with respect to controls. Moreover, 21-OHD patients had higher soluble RANKL and lower OPG serum levels compared with controls; thus, soluble RANKL to OPG ratio was significantly higher in patients than controls. CONCLUSIONS The present study showed for the first time a high osteoclastogenic potential of PBMCs from 21-OHD patients on cGC therapy. This spontaneous osteoclastogenesis seems to be supported by both the presence of circulating OCPs and factors released by T cells.
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Affiliation(s)
- Maria Felicia Faienza
- Department of Biomedicine of Developmental Age, University of Bari, Bari, Italy, Piazza G. Cesare, 11, 70100 Bari, Italy.
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