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Bilginer MC, Tam AA, Faki S, Bestepe N, Dellal FD, Ozdemir D, Topaloglu O, Ersoy R, Cakir B. Evaluation of Adrenal Reserve in Patients with Differentiated Thyroid Cancer Receiving Thyroid Hormone Suppression Therapy- case-control Comparative Study. Endocr Res 2023; 48:9-15. [PMID: 36524715 DOI: 10.1080/07435800.2022.2158338] [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] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with differentiated thyroid cancer (DTC) are exposed to subclinical exogenous hyperthyroidism for the suppression of thyroid-stimulating hormone (TSH). In this study, we aimed to evaluate the adrenal reserve in DTC patients receiving suppression therapy. MATERIALS AND METHODS The study included 55 DTC patients on suppression therapy and 32 healthy volunteers. Basal serum cortisol of all participants and adrenocorticotropic hormone (ACTH) of the patient group were measured. A standard-dose ACTH test (0.25 mg) was performed in patients with a basal cortisol <14.5 mcg/dL. RESULTS In the patient group, TSH was lower, free thyroxine (fT4) was higher, and free triiodothyronine (fT3) was similar to those of the control group (p < .01, p < .01, p = .140, respectively). The serum cortisol of the patient group was significantly lower than the control group (12.14 ± 5.12 mcg/dL vs 18.00 ± 5.56 mcg/dL, p < .001). A total of 34 (61.8%) patients with DTC had a basal cortisol <14.5 mcg/dL. Prolonged TSH suppression (≥5 years vs <5 years) was associated with lower basal cortisol (7.46 ± 2.63 mcg/dL vs 9.48 ± 2.65 mcg/dL, p = .022). The ACTH stimulation test showed that 2 (5.8%) patients had a cortisol response <18 mcg/dL. The rate of adrenal insufficiency was 3.6% in DTC patients. A moderate negative correlation was found between ACTH and fT3 of patients with low basal cortisol (r = -0.358, p = .038). CONCLUSION Patients with DTC receiving TSH suppression therapy are at risk for adrenal insufficiency. The duration and severity of suppression might increase this possibility. Dynamic testing with synthetic ACTH can be used to reveal insufficient cortisol response in case of clinical suspicion.
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Affiliation(s)
- Muhammet Cuneyt Bilginer
- Faculty of Medicine, Department of Endocrinology and Metabolism, Karadeniz Technical University, Trabzon, Turkey
| | - Abbas Ali Tam
- Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Sevgul Faki
- Department of Endocrinology and Metabolism, University of Health Sciences Turkey, Ankara City Hospital, Ankara, Turkey
| | - Nagihan Bestepe
- Department of Endocrinology and Metabolism, University of Health Sciences Turkey, Ankara City Hospital, Ankara, Turkey
| | - Fatma Dilek Dellal
- Department of Endocrinology and Metabolism, University of Health Sciences Turkey, Ankara City Hospital, Ankara, Turkey
| | - Didem Ozdemir
- Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Oya Topaloglu
- Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Reyhan Ersoy
- Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Bekir Cakir
- Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara Yıldırım Beyazıt University, Ankara, Turkey
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De Almeida R, McCalmon S, Cabandugama PK. Clinical Review and Update on the Management of Thyroid Storm. MISSOURI MEDICINE 2022; 119:366-371. [PMID: 36118802 PMCID: PMC9462913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Thyroid storm is a severe manifestation of thyrotoxicosis. Thyroid storm is diagnosed as a combination of thyroid function studies showing low to undetectable thyroid stimulating hormone (TSH) (<0.01mU/L) with elevated free thyroxine (T4) and/or triiodothyronine (T3), positive thyroid receptor antibody (TRab) (if Graves' disease is the underlying etiology), and with clinical signs and symptoms of end organ damage. Treatment involves bridging to a euthyroid state prior to total thyroidectomy or radioactive iodine ablation to limit surgical complications such as excessive bleeding from highly vascular hyperthyroid tissue or exacerbation of thyrotoxicosis. The purpose of this article is a clinical review of the various treatments and methodologies to achieve a euthyroid state in patients with thyroid storm prior to definitive therapy.
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Affiliation(s)
- Reuben De Almeida
- Internal Medicine Resident, University of Missouri-Kansas City-School of Medicine (UMKC-SOM), Kansas City, Missouri
| | - Sean McCalmon
- Endocrinology Fellow at UMKC-SOM, Kansas City, Missouri
| | - Peminda K Cabandugama
- Assistant Professor of Medicine and Faculty Member of the Endocrinology Fellowship Program at the UMKC-SOM, Kansas City, Missouri
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Zhao H, Ruan Y. Relative Adrenocortical Insufficiency Following Radioactive Iodine Therapy for Graves' Disease: A Report of Two Cases. Int J Gen Med 2021; 14:1641-1646. [PMID: 33976564 PMCID: PMC8104983 DOI: 10.2147/ijgm.s305454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/06/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction In recent years, radioactive iodine (RAI) therapy has become a main choice for Graves' disease. The rapid release of thyroid hormones following RAI may on occasion trigger severe events, such as thyroid storm or heart block. This study presents two cases of possible acute adrenocortical insufficiency precipitated by radioiodine therapy. Case Presentation Two females aged 65 and 19 years with long-standing Graves' disease underwent radioiodine treatment at our clinical center. Both patients suffered nausea, fatigue, aggravated palpitation, and relative hypotension thereafter. Laboratory data showed severe thyrotoxicosis with free thyroxine higher than three times the upper limit, while basal serum cortisol (8 AM) was below the lower limit (5.08 μg/dL and 2.08 μg/dL respectively) under stress, indicating a potential relative adrenocortical insufficiency. There was then full recovery after adequate hydrocortisone therapy. As thyrotoxicosis resolved, the levels of basal cortisol were subsequently raised to normal. Conclusion Post-RAI adrenocortical insufficiency might occur in patients with severe Graves' disease. Basal serum cortisol might be a cost-effective parameter for the identification of potential patients.
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Affiliation(s)
- Hanxin Zhao
- Department of Endocrinology and Metabolism, Zhejiang University Affiliated Sir Run Run Shaw Hospital, School of Medicine, Hangzhou, People's Republic of China
| | - Yu Ruan
- Department of Endocrinology and Metabolism, Zhejiang University Affiliated Sir Run Run Shaw Hospital, School of Medicine, Hangzhou, People's Republic of China
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Neuroendocrine manifestations of Erdheim-Chester disease. HANDBOOK OF CLINICAL NEUROLOGY 2021; 181:137-147. [PMID: 34238453 DOI: 10.1016/b978-0-12-820683-6.00010-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Neuroendocrine manifestations are common in Erdheim-Chester disease (ECD) patients. ECD is a rare non-Langerhans form of histiocytosis with multisystemic infiltration. The involvement of the hypothalamo-pituitary axis is common and central diabetes insipidus (CDI) is one of the most common endocrine manifestations in ECD patients. CDI is the first manifestation of ECD in 25%-48% of the cases. Suprasellar region extension, due to the infiltration of ECD lesions, can cause neurologic manifestations by mass effects, such as headache, visual disturbance, and cranial nerve palsies. Recent studies have revealed that disorders affecting anterior pituitary hormones are common in ECD patients. Secondary adrenal insufficiency, secondary hypothyroidism, (adult) growth hormone deficiency, hypogonadotropic hypogonadism, hyperprolactinemia, and hypoprolactinemia can develop as the neuroendocrine manifestations of ECD. Since the symptoms of anterior pituitary hormone deficiencies tend to be nonspecific, the diagnosis of anterior pituitary hormone dysfunctions can be delayed. Some anterior pituitary dysfunctions such as adrenocorticotropic hormone and/or thyroid-stimulating hormone deficiencies can be life-threatening without adequate hormone supplementation therapies. An endocrinological evaluation of the function of the pituitary gland should be performed at the initial diagnosis of ECD. It is important to recognize that endocrine dysfunctions can develop later during the follow-up of ECD.
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Holmberg MO, Malmgren H, Berglund P, Bunketorp-Käll L, Heckemann RA, Johansson B, Klasson N, Olsson E, Skau S, Nystrom Filipsson H. Structural brain changes in hyperthyroid Graves' disease: protocol for an ongoing longitudinal, case-controlled study in Göteborg, Sweden-the CogThy project. BMJ Open 2019; 9:e031168. [PMID: 31685507 PMCID: PMC6858258 DOI: 10.1136/bmjopen-2019-031168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 10/06/2019] [Accepted: 10/08/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Cognitive impairment and reduced well-being are common manifestations of Graves' disease (GD). These symptoms are not only prevalent during the active phase of the disease but also often prevail for a long time after hyperthyroidism is considered cured. The pathogenic mechanisms involved in these brain-derived symptoms are currently unknown. The overall aim of the CogThy study is to identify the mechanism behind cognitive impairment to be able to recognise GD patients at risk. METHODS AND ANALYSIS The study is a longitudinal, single-centre, case-controlled study conducted in Göteborg, Sweden on premenopausal women with newly diagnosed GD. The subjects are examined: at referral, at inclusion and then every 3.25 months until 15 months. Examinations include: laboratory measurements; eye evaluation; neuropsychiatric and neuropsychological testing; structural MRI of the whole brain, orbits and medial temporal lobe structures; functional near-infrared spectroscopy of the cerebral prefrontal cortex and self-assessed quality of life questionnaires. The primary outcome measure is the change in medial temporal lobe structure volume. Secondary outcome measures include neuropsychological, neuropsychiatric, hormonal and autoantibody variables. The study opened for inclusion in September 2012 and close for inclusion in October 2019. It will provide novel information on the effect of GD on medial temporal lobe structures and cerebral cortex functionality as well as whether these changes are associated with cognitive and affective impairment, hormonal levels and/or autoantibody levels. It should lead to a broader understanding of the underlying pathogenesis and future treatment perspectives. ETHICS AND DISSEMINATION The study has been reviewed and approved by the Regional Ethical Review Board in Göteborg, Sweden. The results will be actively disseminated through peer-reviewed journals, national and international conference presentations and among patient organisations after an appropriate embargo time. TRIAL REGISTRATION NUMBER 44321 at the public project database for research and development in Västra Götaland County, Sweden (https://www.researchweb.org/is/vgr/project/44321).
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Affiliation(s)
- Mats Olof Holmberg
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Institute of Medicine, University of Gothenburg, Sahlgrenska Academy, Göteborg, Sweden
| | - Helge Malmgren
- Institute of Medicine, University of Gothenburg, Sahlgrenska Academy, Göteborg, Sweden
- MedTech West, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Peter Berglund
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Göteborg, Sweden
| | - Lina Bunketorp-Käll
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Göteborg, Sweden
| | - Rolf A Heckemann
- Division of Brain Sciences, Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy, Göteborg, Sweden
| | - Birgitta Johansson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Göteborg, Sweden
| | - Niklas Klasson
- MedTech West, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Göteborg, Sweden
| | - Erik Olsson
- Institute of Medicine, University of Gothenburg, Sahlgrenska Academy, Göteborg, Sweden
| | - Simon Skau
- MedTech West, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Göteborg, Sweden
| | - Helena Nystrom Filipsson
- Institute of Medicine, University of Gothenburg, Sahlgrenska Academy, Göteborg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
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Al Mushref M, Caldwell M, Harris E. Adrenal Crisis Triggered by Endogenous Thyrotoxicosis: Case Series. AACE Clin Case Rep 2018. [DOI: 10.4158/accr-2018-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Suwansaksri N, Preechasuk L, Kunavisarut T. Nonthionamide Drugs for the Treatment of Hyperthyroidism: From Present to Future. Int J Endocrinol 2018; 2018:5794054. [PMID: 29849619 PMCID: PMC5937426 DOI: 10.1155/2018/5794054] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 03/11/2018] [Indexed: 12/20/2022] Open
Abstract
Hyperthyroidism is a common endocrine disease. Although thionamide antithyroid drugs are the cornerstone of hyperthyroidism treatment, some patients cannot tolerate this drug class because of its serious side effects including agranulocytosis, hepatotoxicity, and vasculitis. Therefore, nonthionamide antithyroid drugs (NTADs) still have an important role in controlling hyperthyroidism in clinical practice. Furthermore, some situations such as thyroid storm or preoperative preparation require a rapid decrease in thyroid hormone by combination treatment with multiple classes of antithyroid drugs. NTADs include iodine-containing compounds, lithium carbonate, perchlorate, glucocorticoid, and cholestyramine. In this narrative review, we summarize the mechanisms of action, indications, dosages, and side effects of currently used NTADs for the treatment of hyperthyroidism. In addition, we also describe the state-of-the-art in future drugs under development including rituximab, small-molecule ligands (SMLs), and monoclonal antibodies with a thyroid-stimulating hormone receptor (TSHR) antagonist effect.
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Affiliation(s)
| | - Lukana Preechasuk
- Siriraj Diabetes Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tada Kunavisarut
- Division of Endocrine and Metabolism, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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8
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Paik J, Kang JH, Chang D, Yang MP. Cardiogenic Pulmonary Edema in a Dog Following Initiation of Therapy for Concurrent Hypoadrenocorticism and Hypothyroidism. J Am Anim Hosp Assoc 2016; 52:378-384. [PMID: 27685367 DOI: 10.5326/jaaha-ms-6225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 5 yr old intact female cocker spaniel dog weighing 7.8 kg was referred with anorexia, vomiting, and depression. At referral, the dog was diagnosed initially with typical hypoadrenocorticism, and 2 d later, concurrent primary hypothyroidism was detected. Hormonal replacement therapies, including fludrocortisone, prednisolone, and levothyroxine, were initiated, but a few days later the dog became abruptly tachypneic, and thoracic radiographs indicated the development of pulmonary edema. Echocardiography showed that there were abnormalities indicating impaired left ventricular function, although the heart valves were normal. Following treatment with pimobendan and furosemide, the pulmonary edema resolved. The dog had no recurrence of the clinical signs after 10 mo of follow-up, despite being off all cardiac medications; consequently, the cardiac failure was transient or reversible in this dog. The case report describes the stepwise diagnosis and successful treatment of cardiogenic pulmonary edema after initiation of hormonal replacement therapy for concurrent hypoadrenocorticism and hypothyroidism in a dog.
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Affiliation(s)
- Jooyae Paik
- From the Chungbuk National University College of Veterinary Medicine, Cheongju, South Korea
| | - Ji-Houn Kang
- From the Chungbuk National University College of Veterinary Medicine, Cheongju, South Korea
| | - Dongwoo Chang
- From the Chungbuk National University College of Veterinary Medicine, Cheongju, South Korea
| | - Mhan-Pyo Yang
- From the Chungbuk National University College of Veterinary Medicine, Cheongju, South Korea
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9
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Dušková M, Šimůnková K, Vítků J, Sosvorová L, Jandíková H, Pospíšilová H, Šrámková M, Kosák M, Kršek M, Hána V, Žánová M, Springer D, Stárka L. A Comparison of Salivary Steroid Levels during Diagnostic Tests for Adrenal Insufficiency. Prague Med Rep 2016; 117:18-33. [PMID: 26995200 DOI: 10.14712/23362936.2016.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Numerous diagnostic tests are used to evaluate the hypothalamic-pituitary-adrenal axis (HPA axis). The gold standard is still considered the insulin tolerance test (ITT), but this test has many limitations. Current guidelines therefore recommend the Synacthen test first when an HPA axis insufficiency is suspected. However, the dose of Synacthen that is diagnostically most accurate and sensitive is still a matter of debate. We investigated 15 healthy men with mean/median age 27.4/26 (SD±4.8) years, and mean/median BMI (body mass index) 25.38/24.82 (SD±3.2) kg/m2. All subjects underwent 4 dynamic tests of the HPA axis, specifically 1 μg, 10 μg, and 250 μg Synacthen (ACTH) tests and an ITT. Salivary cortisol, cortisone, pregnenolone, and DHEA (dehydroepiandrosterone) were analysed using liquid chromatography-tandem mass spectrometry. During the ITT maximum salivary cortisol levels over 12.5 nmol/l were found at 60 minutes. Maximum cortisol levels in all of the Synacthen tests were higher than this; however, demonstrating that sufficient stimulation of the adrenal glands was achieved. Cortisone reacted similarly as cortisol, i.e. we did not find any change in the ratio of cortisol to cortisone. Pregnenolone and DHEA were higher during the ITT, and their peaks preceded the cortisol peak. There was no increase of pregnenolone or DHEA in any of the Synacthen tests. We demonstrate that the 10 μg Synacthen dose is sufficient stimulus for testing the HPA axis and is also a safe and cost-effective alternative. This dose also largely eliminates both false negative and false positive results.
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Affiliation(s)
| | - Kateřina Šimůnková
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Jana Vítků
- Institute of Endocrinology, Prague, Czech Republic
| | | | | | | | | | - Mikuláš Kosák
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Michal Kršek
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Václav Hána
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Magdaléna Žánová
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Drahomíra Springer
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
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Auchus RJ, Yu MK, Nguyen S, Mundle SD. Use of prednisone with abiraterone acetate in metastatic castration-resistant prostate cancer. Oncologist 2014; 19:1231-40. [PMID: 25361624 DOI: 10.1634/theoncologist.2014-0167] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Abiraterone acetate, a prodrug of the CYP17A1 inhibitor abiraterone that blocks androgen biosynthesis, is approved for treatment of patients with metastatic castration-resistant prostate cancer (mCRPC) in combination with prednisone or prednisolone 5 mg twice daily. This review evaluates the basis for the effects of prednisone on mineralocorticoid-related adverse events that arise because of CYP17A1 inhibition with abiraterone. Coadministration with the recommended dose of glucocorticoid compensates for abiraterone-induced reductions in serum cortisol and blocks the compensatory increase in adrenocorticotropic hormone seen with abiraterone. Consequently, 5 mg prednisone twice daily serves as a glucocorticoid replacement therapy when coadministered with abiraterone acetate, analogous to use of glucocorticoid replacement therapy for certain endocrine disorders. We searched PubMed to identify safety concerns regarding glucocorticoid use, placing a focus on longitudinal studies in autoimmune and inflammatory diseases and cancer. In general, glucocorticoid-related adverse events, including bone loss, immunosuppression, hyperglycemia, mood and cognitive alterations, and myopathy, appear dose related and tend to occur at doses and/or treatment durations greater than the low dose of glucocorticoid approved in combination with abiraterone acetate for the treatment of mCRPC. Although glucocorticoids are often used to manage tumor-related symptoms or to prevent treatment-related toxicity, available evidence suggests that prednisone and dexamethasone might also offer modest therapeutic benefit in mCRPC. Given recent improvements in survival achieved for mCRPC with novel agents in combination with prednisone, the risks of these recommended glucocorticoid doses must be balanced with the benefits shown for these regimens.
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Affiliation(s)
- Richard J Auchus
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA; Janssen Research & Development, Los Angeles, California, USA; Janssen Scientific Affairs LLC, Johnson & Johnson, Horsham, Pennsylvania, USA; Department of Biochemistry, Rush University Medical Center, Chicago, Illinois, USA
| | - Margaret K Yu
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA; Janssen Research & Development, Los Angeles, California, USA; Janssen Scientific Affairs LLC, Johnson & Johnson, Horsham, Pennsylvania, USA; Department of Biochemistry, Rush University Medical Center, Chicago, Illinois, USA
| | - Suzanne Nguyen
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA; Janssen Research & Development, Los Angeles, California, USA; Janssen Scientific Affairs LLC, Johnson & Johnson, Horsham, Pennsylvania, USA; Department of Biochemistry, Rush University Medical Center, Chicago, Illinois, USA
| | - Suneel D Mundle
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA; Janssen Research & Development, Los Angeles, California, USA; Janssen Scientific Affairs LLC, Johnson & Johnson, Horsham, Pennsylvania, USA; Department of Biochemistry, Rush University Medical Center, Chicago, Illinois, USA
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Abstract
Adrenal insufficiency is the clinical manifestation of deficient production or action of glucocorticoids, with or without deficiency also in mineralocorticoids and adrenal androgens. It is a life-threatening disorder that can result from primary adrenal failure or secondary adrenal disease due to impairment of the hypothalamic-pituitary axis. Prompt diagnosis and management are essential. The clinical manifestations of primary adrenal insufficiency result from deficiency of all adrenocortical hormones, but they can also include signs of other concurrent autoimmune conditions. In secondary or tertiary adrenal insufficiency, the clinical picture results from glucocorticoid deficiency only, but manifestations of the primary pathological disorder can also be present. The diagnostic investigation, although well established, can be challenging, especially in patients with secondary or tertiary adrenal insufficiency. We summarise knowledge at this time on the epidemiology, causal mechanisms, pathophysiology, clinical manifestations, diagnosis, and management of this disorder.
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Affiliation(s)
- Evangelia Charmandari
- Division of Endocrinology, Metabolism, and Diabetes, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece; Division of Endocrinology and Metabolism, Clinical Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.
| | - Nicolas C Nicolaides
- Division of Endocrinology, Metabolism, and Diabetes, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece; Division of Endocrinology and Metabolism, Clinical Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - George P Chrousos
- Division of Endocrinology, Metabolism, and Diabetes, First Department of Pediatrics, University of Athens Medical School, Aghia Sophia Children's Hospital, Athens, Greece; Division of Endocrinology and Metabolism, Clinical Research Center, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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12
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Abstract
Explicit data regarding the changes in adrenocortical reserves during hyperthyroidism do not exist. We aimed to document the capability (response) of adrenal gland to secrete cortisol and DHEA-S during hyperthyroidism compared to euthyroidism, and to describe factors associated with these responses. A standard-dose (0.25 mg/i.v.) ACTH stimulation test was performed to the same patients before hyperthyroidism treatment, and after attainment of euthyroidism. Baseline cortisol (Cor(0)), DHEA-S (DHEA-S(0)), cortisol binding globulin (CBG), ACTH, calculated free cortisol (by Coolen's equation = CFC), free cortisol index (FCI), 60-min cortisol (Cor(60)), and DHEA-S (DHEA-S(60)), delta cortisol (ΔCor), delta DHEA-S (ΔDHEA-S) responses were evaluated. Forty-one patients [22 females, 49.5 ± 15.2 years old, 32 Graves disease, nine toxic nodular goiter] had similar Cor(0), DHEA-S(0), CFC, FCI, and DHEA-S(60) in hyperthyroid and euthyroid states. Cor(60), ΔCor, and ΔDHEA-S were lower in hyperthyroidism. In four (10 %) patients the peak ACTH-stimulated cortisol values were lower than 18 μg/dL. When the test repeated after attainment of euthyroidism, all of the patients had normal cortisol response. Regression analysis demonstrated an independent association of Cor(60) with free T3 in hyperthyroidism. However, the predictors of CFC, FCI, and DHEA-S levels were serum creatinine levels in hyperthyroidism, and both creatinine and transaminase levels in euthyroidism. ACTH-stimulated peak cortisol, delta cortisol, and delta DHEA-S levels are decreased during hyperthyroidism, probably due to increased turnover. Since about 10 % of the subjects with hyperthyroidism are at risk for adrenal insufficiency, clinicians dealing with Graves' disease should be alert to the possibility of adrenal insufficiency during hyperthyroid stage.
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Affiliation(s)
- Kemal Agbaht
- Department of Endocrinology and Metabolic Diseases, Faculty of Medicine, Ibn-i Sina Hospital, Ankara University, Sihhiye, Ankara, Turkey,
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13
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Price SA, Thondam S, Bondugulapati LNR, Kamath C, Adlan M, Premawardhana LD. Significant attenuation of stimulated cortisol in early Graves disease without adrenal autoimmunity. Endocr Pract 2013; 18:924-30. [PMID: 22982787 DOI: 10.4158/ep12002.or] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate cortisol responses to adrenocorticotropic hormone during thyrotoxic (G1) and euthyroid (G2) phases in patients with Graves disease (GD) who were without adrenal autoimmunity. METHODS Fifteen patients with GD, who were thyrotropin receptor antibody positive and 21-hydroxylase antibody negative, were recruited to this prospective pilot study. A modified short Synacthen test (SST) was performed, in which cortisol was measured every 30 minutes for 2 hours during G1 and G2. RESULTS The median times to SST were 3 weeks (G1) and 27 weeks (G2) after diagnosis of GD. Integrated stimulated cortisol levels were significantly lower at G1 in comparison with G2: mean ± standard error of the mean for area under the curve was 78,091.6 ± 4,462.1 nmol/L (G1) versus 89,055 ± 4,434 nmol/L at 120 minutes (G2), P = .017; and for delta area under the curve was 36,309.9 ± 3,526 nmol/L (G1) versus 44,041.7 ± 2,147 nmol/L at 120 minutes (G2), P = .039. Mean cortisol levels were significantly lower for G1 versus G2 at 60, 90, and 120 minutes of the SST (P = .001 to .013). The cortisol level was abnormal in 2 patients (13%) at 30 minutes during G1 but in none during G2. There was no correlation of integrated cortisol with free thyroxine or thyrotropin receptor antibody. There was no significant difference in median adrenocorticotropic hormone level (17 versus 20.4 ng/mL at G1 and G2, respectively; P = .14). CONCLUSION Significant attenuation of stimulated cortisol occurs in the early thyrotoxic phase in comparison with the euthyroid phase in patients with GD without adrenal autoimmunity. Clinicians treating patients with GD should have a low threshold for investigating symptoms suggestive of hypoadrenalism at times of "stress."
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Affiliation(s)
- Sally A Price
- Section of Diabetes and Endocrinology, Caerphilly Miners' Hospital, Caerphilly, UK
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Ramspott S, Hartmann K, Sauter-Louis C, Weber K, Wehner A. Adrenal function in cats with hyperthyroidism. J Feline Med Surg 2012; 14:262-6. [PMID: 22373912 PMCID: PMC10822515 DOI: 10.1177/1098612x11435893] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2011] [Indexed: 07/10/2024]
Abstract
Adrenal function may be altered in animals with hyperthyroidism. The aim of the study was to assess adrenal function of hyperthyroid cats (n = 17) compared to healthy cats (n = 18) and cats with chronic diseases (n = 18). Adrenal function was evaluated by adrenocorticotropic hormone (ACTH) stimulation test and the urinary cortisol to creatinine ratio (UCCR) was determined. Length and width of both adrenal glands were measured via ultrasound. Hyperthyroid cats had significantly higher cortisol levels before and after stimulation with ACTH than the other groups. However, the UCCR was not elevated in hyperthyroid cats. The size of the adrenal glands of hyperthyroid cats was not significantly different from the size of those of healthy cats. The results indicate that cats with hyperthyroidism have a higher cortisol secretory capacity in a hospital setting. The normal size of the adrenal glands suggests that cortisol levels may not be increased permanently.
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Affiliation(s)
- Sabine Ramspott
- Clinic of Small Animal Medicine, LMU University of Munich, Veterinaerstrasse 13, Munich, Germany
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15
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Molica P, Nascif SO, Correa-Silva SR, de Sá LBPC, Vieira JGH, Lengyel AMJ. Effects of ghrelin, GH-releasing peptide-6 (GHRP-6) and GHRH on GH, ACTH and cortisol release in hyperthyroidism before and after treatment. Pituitary 2010; 13:315-23. [PMID: 20602173 DOI: 10.1007/s11102-010-0238-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In thyrotoxicosis GH responses to stimuli are diminished and the hypothalamic-pituitary-adrenal axis is hyperactive. There are no data on ghrelin or GHRP-6-induced GH, ACTH and cortisol release in treated hyperthyroidism. We, therefore, evaluated these responses in 10 thyrotoxic patients before treatment and in 7 of them after treatment. GHRH-induced GH release was also studied. Peak GH (μg/L; mean ± SE) values after ghrelin (22.6 ± 3.9), GHRP-6 (13.8 ± 2.3) and GHRH (4.9 ± 0.9) were lower in hyperthyroidism before treatment compared to controls (ghrelin: 67.6 ± 19.3; GHRP-6: 25.4 ± 2.7; GHRH: 12.2 ± 2.8) and did not change after 6 months of euthyroidism (ghrelin: 32.7 ± 4.7; GHRP-6: 15.6 ± 3.6; GHRH: 7.4 ± 2.3), although GH responses to all peptides increased in ~50% of the patients. In thyrotoxicosis before treatment ACTH response to ghrelin was two fold higher (107.4 ± 26.3) than those of controls (54.9 ± 10.3), although not significantly. ACTH response to GHRP-6 was similar in both groups (hyperthyroid: 44.7 ± 9.0; controls: 31.3 ± 7.9). There was a trend to a decreased ACTH response to ghrelin after 3 months of euthyroidism (35.6 ± 5.3; P = 0.052), but after 6 months this decrease was non-significant (50.7 ± 14.0). After 3 months ACTH response to GHRP-6 decreased significantly (20.4 ± 4.2), with no further changes. In hyperthyroidism before treatment, peak cortisol (μg/dL) responses to ghrelin (18.2 ± 1.2) and GHRP-6 (15.9 ± 1.4) were comparable to controls (ghrelin: 16.4 ± 1.6; GHRP-6: 13.5 ± 0.9) and no changes were seen after treatment. Our results suggest that the pathways of GH release after ghrelin/GHRP-6 and GHRH are similarly affected by thyroid hormone excess and hypothalamic mechanisms of ACTH release modulated by ghrelin/GHSs may be activated in this situation.
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Affiliation(s)
- Patricia Molica
- Division of Endocrinology, Universidade Federal de São Paulo, UNIFESP-EPM, Rua Pedro de Toledo 910, 04039-002, São Paulo, Brazil.
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16
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O'Neal P, Alamdari N, Smith I, Poylin V, Menconi M, Hasselgren PO. Experimental hyperthyroidism in rats increases the expression of the ubiquitin ligases atrogin-1 and MuRF1 and stimulates multiple proteolytic pathways in skeletal muscle. J Cell Biochem 2010; 108:963-73. [PMID: 19777444 DOI: 10.1002/jcb.22329] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Muscle wasting is commonly seen in patients with hyperthyroidism and is mainly caused by stimulated muscle proteolysis. Loss of muscle mass in several catabolic conditions is associated with increased expression of the muscle-specific ubiquitin ligases atrogin-1 and MuRF1 but it is not known if atrogin-1 and MuRF1 are upregulated in hyperthyroidism. In addition, it is not known if thyroid hormone increases the activity of proteolytic mechanisms other than the ubiquitin-proteasome pathway. We tested the hypotheses that experimental hyperthyroidism in rats, induced by daily intraperitoneal injections of 100 microg/100 g body weight of triiodothyronine (T3), upregulates the expression of atrogin-1 and MuRF1 in skeletal muscle and stimulates lysosomal, including cathepsin L, calpain-, and caspase-3-dependent protein breakdown in addition to proteasome-dependent protein breakdown. Treatment of rats with T3 for 3 days resulted in an approximately twofold increase in atrogin-1 and MuRF1 mRNA levels. The same treatment increased proteasome-, cathepsin L-, and calpain-dependent proteolytic rates by approximately 40% but did not influence caspase-3-dependent proteolysis. The expression of atrogin-1 and MuRF1 remained elevated during a more prolonged period (7 days) of T3 treatment. The results provide support for a role of the ubiquitin-proteasome pathway in muscle wasting during hyperthyroidism and suggest that other proteolytic pathways as well may be activated in the hyperthyroid state.
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Affiliation(s)
- Patrick O'Neal
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA
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17
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Nascif SO, Molica P, Correa-Silva SR, Silva MR, Lengyel AMJ. Ghrelin and GHRP-6-induced ACTH and cortisol release in thyrotoxicosis. Pituitary 2009; 12:315-21. [PMID: 19396632 DOI: 10.1007/s11102-009-0181-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Accepted: 04/14/2009] [Indexed: 11/29/2022]
Abstract
Thyrotoxicosis might alter the hypothalamic-pituitary-adrenal (HPA) axis. We evaluated the effects of ghrelin and GHRP-6 on the HPA axis in 20 hyperthyroid patients and in 9 controls. Mean basal cortisol (microg/dl) and ACTH (pg/ml) levels were higher in hyperthyroidism (cortisol: 10.7 +/- 0.7; ACTH: 21.5 +/- 2.9) compared to controls (cortisol: 8.1 +/- 0.7; ACTH: 13.5 +/- 1.8). In thyrotoxicosis Delta AUC cortisol values (microg/dl.90 min) after ghrelin (484 +/- 80) and GHRP-6 (115 +/- 63) were similar to controls (ghrelin: 524 +/- 107; GHRP-6: 192 +/- 73). A significant increase in Delta AUC ACTH (pg/ml x 90 min) after ghrelin was observed in thyrotoxicosis (4,189 +/- 1,202) compared to controls (1,499 +/- 338). Delta AUC ACTH values after GHRP-6 were also higher, although not significantly (patients: 927 +/- 330; controls: 539 +/- 237). In summary, our results suggest that ghrelin-mediated pathways of ACTH release might be activated by thyroid hormone excess, but adrenocortical reserve is maintained.
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Affiliation(s)
- Sergio Oliva Nascif
- Division of Endocrinology, Federal University of São Paulo, UNIFESP/EPM, Pedro de Toledo Street, 910, São Paulo, SP, 04039-002, Brazil,
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Tan R, Davies S, Crisman M, Coyle L, Daniel G. Propylthiouracil for Treatment of Hyperthyroidism in a Horse. J Vet Intern Med 2008; 22:1253-8. [DOI: 10.1111/j.1939-1676.2008.0169.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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19
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Bibliography. Current world literature. Adrenal cortex. Curr Opin Endocrinol Diabetes Obes 2008; 15:284-299. [PMID: 18438178 DOI: 10.1097/med.0b013e3283040e80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
This paper outlines the interferences of the most widely used drugs with hypothalamo-pituitary-adrenal function and the related laboratory parameters, with the purpose of providing practical help to clinicians during testing for hypo- or hypercortisolemic states.
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