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Esposito D, Tivesten Å, Olivius C, Ragnarsson O, Johannsson G. Androgen deficiency in hypopituitary women: its consequences and management. Rev Endocr Metab Disord 2024; 25:479-488. [PMID: 38240912 PMCID: PMC11162366 DOI: 10.1007/s11154-024-09873-1] [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] [Accepted: 01/08/2024] [Indexed: 06/09/2024]
Abstract
Women with hypopituitarism have various degrees of androgen deficiency, which is marked among those with combined hypogonadotrophic hypogonadism and secondary adrenal insufficiency. The consequences of androgen deficiency and the effects of androgen replacement therapy have not been fully elucidated. While an impact of androgen deficiency on outcomes such as bone mineral density, quality of life, and sexual function is plausible, the available evidence is limited. There is currently no consensus on the definition of androgen deficiency in women and it is still controversial whether androgen substitution should be used in women with hypopituitarism and coexisting androgen deficiency. Some studies suggest beneficial clinical effects of androgen replacement but data on long-term benefits and risk are not available. Transdermal testosterone replacement therapy in hypopituitary women has shown some positive effects on bone metabolism and body composition. Studies of treatment with oral dehydroepiandrosterone have yielded mixed results, with some studies suggesting improvements in quality of life and sexual function. Further research is required to elucidate the impact of androgen deficiency and its replacement treatment on long-term outcomes in women with hypopituitarism. The lack of transdermal androgens for replacement in this patient population and limited outcome data limit its use. A cautious and personalized treatment approach in the clinical management of androgen deficiency in women with hypopituitarism is recommended while awaiting more efficacy and safety data.
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Affiliation(s)
- Daniela Esposito
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gröna Stråket 8, Gothenburg, 41345, Sweden.
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Åsa Tivesten
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Laboratory for Cardiovascular and Metabolic Research, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Catharina Olivius
- Wallenberg Laboratory for Cardiovascular and Metabolic Research, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Hospital of Halland, Kungsbacka, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gröna Stråket 8, Gothenburg, 41345, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy, Wallenberg Centre for Molecular and Translational Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gröna Stråket 8, Gothenburg, 41345, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Furman K, Gut P, Sowińska A, Ruchała M, Fichna M. Predictors of bone mineral density in patients receiving glucocorticoid replacement for Addison's disease. Endocrine 2024; 84:711-719. [PMID: 38334892 DOI: 10.1007/s12020-024-03709-3] [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: 11/01/2023] [Accepted: 01/18/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE Patients receiving long-term glucocorticoid (GC) treatment are at risk of osteoporosis, while bone effects of substitution doses in Addison's disease (AD) remain equivocal. The project was aimed to evaluate serum bone turnover markers (BTMs): osteocalcin, type I procollagen N-terminal propeptide (PINP), collagen C-terminal telopeptide (CTX), sclerostin, DKK-1 protein, and alkaline phosphatase (ALP) in relation to bone mineral density (BMD) during GC replacement. METHODS Serum BTMs and hormones were assessed in 80 patients with AD (22 males, 25 pre- and 33 postmenopausal females) on hydrocortisone (HC) substitution for ≥3 years. Densitometry with dual-energy X-ray absorptiometry covered the lumbar spine (LS) and femoral neck (FN). RESULTS Among BTMs, only PINP levels were altered in AD. BMD Z-scores remained negative except for FN in males. Considering T-scores, osteopenia was found in LS in 45.5% males, 24% young and 42.4% postmenopausal females, while osteoporosis in 9.0%, 4.0% and 21.1%, respectively. Lumbar BMD correlated positively with body mass (p = 0.0001) and serum DHEA-S (p = 9.899 × 10-6). Negative correlation was detected with HC dose/day/kg (p = 0.0320), cumulative HC dose (p = 0.0030), patient's age (p = 1.038 × 10-5), disease duration (p = 0.0004), ALP activity (p = 0.0041) and CTX level (p = 0.0105). However, only age, body mass, ALP, serum CTX, and sclerostin remained independent predictors of LS BMD. CONCLUSION Standard HC substitution does not considerably accelerate BMD loss in AD patients and their serum BTMs: CTX, osteocalcin, sclerostin, DKK-1, and ALP activity remain within the reference ranges. Independent predictors of low lumbar spine BMD, especially ALP activity, serum CTX and sclerostin, might be monitored during GC substitution.
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Affiliation(s)
- Katarzyna Furman
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
- Ludwik Perzyna Regional Hospital, Kalisz, Poland
| | - Paweł Gut
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Anna Sowińska
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznan, Poland
| | - Marek Ruchała
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland
| | - Marta Fichna
- Department of Endocrinology, Metabolism and Internal Medicine, Poznań University of Medical Sciences, Poznań, Poland.
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Chen S, Li S, Zhang X, Fan Y, Liu M. Low serum dehydroepiandrosterone is associated with diabetic dyslipidemia risk in males with type 2 diabetes. Front Endocrinol (Lausanne) 2023; 14:1272797. [PMID: 38075062 PMCID: PMC10704365 DOI: 10.3389/fendo.2023.1272797] [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: 08/04/2023] [Accepted: 11/07/2023] [Indexed: 12/18/2023] Open
Abstract
Objective Sex steroid hormones are associated with the advancement of metabolic diseases such as dyslipidemia. This cross-sectional study aimed to investigate the relationship between dehydroepiandrosterone, dehydroepiandrosterone sulfate, androstenedione, and testosterone levels and the risk of dyslipidemia in people with type 2 diabetes mellitus. Materials and Methods The analysis included 1,927 patients with type 2 diabetes mellitus. Serum dehydroepiandrosterone, dehydroepiandrosterone sulfate, androstenedione, and testosterone levels were determined using lipid chromatography-tandem mass spectrometry. Multivariable analyses were performed to investigate the association between the variables and dyslipidemia. Results The multivariable-adjusted odds ratio (OR) and 95% confidence interval (CI) of dyslipidemia across DHEA tertiles were 0.39 and 0.24-0.64, respectively (p trend = 0.001). This relationship was still maintained when analyzed as a continuous variable (odds ratio, 0.96; 95% confidence interval, 0.92-0.99; P < 0.01). However, in males with type 2 diabetes mellitus, no significant correlations were found between rising levels of dehydroepiandrosterone sulfate, androstenedione, and total testosterone and the risk of dyslipidemia (all P > 0.05). Furthermore, there was no significant association between androgen precursors and total testosterone with regard to the risk of developing dyslipidemia (all P > 0.05). Conclusions Serum dehydroepiandrosterone levels were substantially and adversely correlated with dyslipidemia in adult men with T2DM. These results indicated that dehydroepiandrosterone may have an essential role in the development of dyslipidemia. More prospective research is required to validate this link.
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Affiliation(s)
| | | | | | - Yuxin Fan
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Ming Liu
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
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4
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Ramos-Leví AM, Cañada E, Matias-Guiu JA. Cognitive dysfunction in patients with primary adrenal insufficiency: A systematic review. APPLIED NEUROPSYCHOLOGY. ADULT 2023; 30:802-813. [PMID: 35767730 DOI: 10.1080/23279095.2022.2090256] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Addison's disease (AD) entails a chronic insufficient production of gluco- and mineralocorticoids. Fatigue and decreased quality of life are frequently reported symptoms, but little is known about its effects on cognition. This study aims to explore the existence of cognitive impairment in patients with AD and the influence of treatment regimens. We conducted a systematic review. Inclusion criteria were met by 10 articles, most of them ranked as intermediate quality. Three studies analyzed the relationship between AD and cognitive impairment; one explored the effect of delaying treatment showing no effect on cognitive performance, and another one studied the effect of fludrocortisone treatment. Episodic memory was the most frequent cognitive domain impaired across studies, in comparison to healthy controls. Two papers investigated the relationship between impaired sleep quality and poor cognitive performance. Two studies related cognitive impairments with hypocortisolism-derived brain neuroglycopenia. Two studies investigated the effect of DHEA substitution. In conclusion, patients exhibit a moderately reduced performance in verbal learning. The pathophysiology of this impairment is likely multifactorial. Future studies should include larger sample sizes, the use of comprehensive and multi-domain neuropsychological and behavioral protocols, and neuroimaging.
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Affiliation(s)
- Ana M Ramos-Leví
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Universidad Autónoma, Madrid, Spain
| | - Emma Cañada
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Universidad Autónoma, Madrid, Spain
| | - Jordi A Matias-Guiu
- Department of Neurology, Hospital Clínico San Carlos, Instituto de Investigación San Carlos, IdISSC, Universidad Complutense, Madrid, Spain
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Laakso S, Xiaoyu T, Blouin S, Keplinger P, Välimäki VV, Kröger H, Mäkitie O, Hartmann MA. Bone Tissue Evaluation Indicates Abnormal Mineralization in Patients with Autoimmune Polyendocrine Syndrome Type I: Report on Three Cases. Calcif Tissue Int 2023; 112:675-682. [PMID: 36944707 DOI: 10.1007/s00223-023-01077-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/02/2023] [Indexed: 03/23/2023]
Abstract
Autoimmune polyendocrine syndrome type-1 (APS1) is characterized by autoimmune manifestations affecting different organs from early childhood on. Immunological abnormalities, the resulting endocrinopathies, and their treatments may compromise bone health. For the first time in APS1, we analyzed transiliac bone biopsy samples by bone histomorphometry and quantitative backscattered electron imaging in three adult patients (female P1, 38 years; male P2, 47 years; male P3, 25 years). All had biallelic mutations in the autoimmune regulator gene and in addition to endocrinopathies, also significant bone fragility. Histomorphometry showed bone volume in the lower normal range for P1 (BV/TV, - 0.98 SD) and P3 (- 1.34 SD), mainly due to reduced trabecular thickness (TbTh, - 3.63 and - 2.87 SD). In P1, osteoid surface was low (OS/BS, - 0.96 SD); active osteoblasts and double labeling were seen only on cortical bone. P3 showed a largely increased bone turnover rate (BFR/BV, + 4.53 SD) and increased mineralization lag time (Mlt, + 3.40 SD). Increased osteoid surface (OS/BS, + 2.03 and + 4.71 SD for P2 and P3) together with a large proportion of lowly mineralized bone area (Trab CaLow, + 2.22 and + 9.81 SD for P2 and P3) and focal mineralization defects were consistent with abnormal mineralization. In all patients, the density and area of osteocyte lacunae in cortical and trabecular bone were similar to healthy adults. The bone tissue characteristics were variable and included decreased trabecular thickness, increased amount of osteoid, and abnormal mineralization which are likely to contribute to bone fragility in patients with APS1.
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Affiliation(s)
- Saila Laakso
- Children's Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, Helsinki, Finland.
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
- Folkhälsan Research Center, Helsinki, Finland.
| | - Tong Xiaoyu
- Department of Orthopedics, Kuopio Musculoskeletal Research Unit, University of Eastern Finland, and, Kuopio University Hospital, Kuopio, Finland
| | - Stéphane Blouin
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department Hanusch Hospital, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Petra Keplinger
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department Hanusch Hospital, Vienna, Austria
| | - Ville-Valtteri Välimäki
- Department of Orthopedics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Heikki Kröger
- Department of Orthopedics, Kuopio Musculoskeletal Research Unit, University of Eastern Finland, and, Kuopio University Hospital, Kuopio, Finland
| | - Outi Mäkitie
- Children's Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Markus A Hartmann
- Ludwig Boltzmann Institute of Osteology at Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department Hanusch Hospital, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
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Li D. Quality of Life in Patients with Adrenal Insufficiency. Endocrinol Metab Clin North Am 2022; 51:741-753. [PMID: 36244690 DOI: 10.1016/j.ecl.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients with adrenal insufficiency, despite standard glucocorticoid replacement therapy, continue to experience and report impaired self-perceived health status and quality of life. In this review, we will describe quality of life in this patient population, and summarize the determinants of quality of life, based on previous survey-based studies and clinical trials. In addition, some new emerging data during the still ongoing coronavirus disease pandemic are also reviewed in the present article.
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Affiliation(s)
- Dingfeng Li
- Department of Endocrinology, Endocrine and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, F20, Cleveland, OH 44195, USA.
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7
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Mandal S, Mukhopadhyay P, Ghosh S. DHEA on Sexual Function in Sheehan Syndrome: A Randomized Double-Blind Placebo-Controlled Crossover Trial. J Clin Endocrinol Metab 2022; 107:e3395-e3402. [PMID: 35481572 DOI: 10.1210/clinem/dgac260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The majority of women with Sheehan syndrome (SS) suffer from sexual dysfunction. Severe androgen deficiency is a major contributory factor. Dehydroepiandrosterone (DHEA) supplementation has been reported to have variable efficacious in improving female sexual dysfunction (FSD) in several trials but studies using DHEA in SS are not available. OBJECTIVE We aimed to study the use of DHEA supplementation in patients with SS. METHODS In this crossover trial, 28 participants with SS (age 39.7 ± 8.6 years) were divided into 2 groups (using block randomization) who received DHEA supplements (25 mg twice daily) or matched placebo sequentially for 3 months each. Female Sexual Functioning Index (FSFI) score and serum DHEA sulfate (DHEAS) were measured at baseline and after completion of each phase. Glycemic parameters, lipid profile, and liver enzymes were also measured to assess metabolic side effects. RESULTS There was significant improvement in FSFI score from baseline to end of the study in the DHEA group compared with the placebo group (P = 0.006). Mean FSFI score and most of the individual domains of female sexual dysfunction (FSD) improved with DHEA significantly in both groups (P = 0.001 for each group with DHEA). In those who received DHEA first followed by placebo, FSFI declined significantly after placebo (P = 0.041) but remained at an acceptable level of sexual functioning. Serum DHEAS increased significantly with DHEA treatment. No significant changes in glycemic index, lipid profile, and liver enzymes were noted with DHEA treatment. CONCLUSION A short duration of DHEA supplementation in women with SS with FSD is efficacious and safe.
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Affiliation(s)
- Soumita Mandal
- Department of Endocrinology, R. G. Kar Medical College, Kolkata, India
| | - Pradip Mukhopadhyay
- Department of Endocrinology, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Sujoy Ghosh
- Department of Endocrinology, Institute of Post Graduate Medical Education & Research, Kolkata, India
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Impact of hydrocortisone replacement on bone mineral density and bone turnover markers in patients with primary adrenal insufficiency. Endocr Regul 2022; 56:209-215. [DOI: 10.2478/enr-2022-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objective. The study was aimed to assess the effect of hydrocortisone (HC) replacement therapy on bone mineral density (BMD) and bone turnover markers in patients with primary adrenal insufficiency (PAI).
Methods. A cross-sectional study was conducted in 37 PAI patients treated with HC. BMD and selected bone turnover markers (β-crosslaps and osteocalcin) were measured. A stepwise binary logistic regression model was applied to determine the independent variables associated with low BMD.
Results. Osteoporosis was noted in 14.3% and osteopenia in 34.3% of cases. These patients were older (p=0.01) and received higher daily HC dose compared to patients with normal BMD (p=0.01). BMD values in the lumbar spine and the femoral neck were negatively correlated with daily HC dose (r=–0.36, p=0.03 and r=–0.34, p=0.05, respectively). Plasma osteocalcin was negatively correlated with disease duration (r=–0.38, p=0.02) and cumulative HC dose (r=–0.43, p<0.01). In multivariate analysis, a daily HC dose ≥12 mg/m2/day was independently associated with a higher risk of osteopenia/osteoporosis [OR (95% CI), 9.0 (1.1–74.6); p=0.04].
Conclusions. Impaired bone mineralization in patients with PAI is correlated with HC dose. A daily HC dose ≥12 mg/m2/day was associated with an increased risk of osteopenia and osteoporosis in these patients.
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Van't Westeinde A, Ström S, Hirvikoski T, Dahlqvist P, Wahlberg J, Gezelius A, Kämpe O, Bensing S, Lajic S. Young adult Swedish patients with autoimmune Addison's disease report difficulties with executive functions in daily life despite overall good cognitive performance. Psychoneuroendocrinology 2022; 140:105714. [PMID: 35290880 DOI: 10.1016/j.psyneuen.2022.105714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Sub-optimal replacement of glucocorticoids (GC) in autoimmune Addison's disease (AAD) may affect cognitive functioning. The present study therefore sought to investigate cognitive performance and self-reported problems with executive functions in a cohort of young adult patients with AAD. DESIGN AND METHODS 67 patients with AAD (39 females), mean age 32 yrs. (range 19-41), and 80 control participants (43 females), mean age 29 yrs. (range 19-43), completed neuropsychological tests estimating verbal and non-verbal intellectual ability, learning, memory and executive functioning, in addition to self-report scales assessing problems with executive functions, fatigue and symptoms of anxiety and depression. RESULTS Patients performed within the average range on all cognitive tests compared to population norms. However, female AAD patients reported more problems than controls with both hot (emotion regulation) and cold (cognitive regulation) executive functions in daily life. Moreover, experienced problems with executive functions in both male and female patients were associated with increased mental fatigue and lower GC replacement doses. CONCLUSIONS Despite average performance in neuropsychological tests by both sexes, young adult female patients with AAD experience problems with executive functions in daily life. Coping with mental fatigue and optimization of pharmacotherapy may be important factors to be addressed in order to provide timely support for patients. Future research is needed to further determine other risk factors for experiencing executive function impairments in AAD.
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Affiliation(s)
- Annelies Van't Westeinde
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Sara Ström
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Tatja Hirvikoski
- Department of Women's and Children's Health, Pediatric Neuropsychiatry Unit, Center for Neurodevelopmental Disorders at Karolinska Institutet (KIND), Karolinska Institutet, SE-17177 Stockholm Sweden; Unit for Habilitation & Health, Stockholm County Council, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, SE-901 87 Umeå, Sweden
| | - Jeanette Wahlberg
- Department of Endocrinology and Department of Medical and Health Sciences, Linköpings University, SE-581 83 Linköping, Sweden; Department of Internal Medicine, School of Health and Medical Sciences, Örebro University, SE-702 81 Örebro, Sweden
| | - Anton Gezelius
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Olle Kämpe
- Department of Medicine (Solna), Center for Molecular Medicine, Karolinska Institutet, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
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Lin J, Kao TW, Cheng YC, Fan KC, Huang YC, Liu CW. Dehydroepiandrosterone status and efficacy of dehydroepiandrosterone supplementation for bone health in anorexia nervosa: A systematic review and meta-analysis. Int J Eat Disord 2022; 55:733-746. [PMID: 35460091 DOI: 10.1002/eat.23714] [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: 01/11/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study was designed to determine the status of dehydroepiandrosterone (DHEA) in women with anorexia nervosa (AN) and to assess the efficacy of DHEA supplementation as a treatment for bone health in women with AN. METHOD Studies were retrieved from the PubMed, Embase, Cochrane Library, MEDLINE, and Scopus databases from inception to February 14, 2022. Observational studies that compared serum DHEA levels between women with AN and healthy controls were included for meta-analysis, and randomized controlled trials (RCTs) that evaluated the effects of DHEA supplementation on bone mass were reviewed. RESULTS Meta-analysis of 15 cross-sectional studies revealed that patients with AN had significantly elevated serum DHEA levels (mean difference (MD) = 311.63 ng/dl; 95% confidence interval (CI), 78.01-545.25) and reduced DHEAS levels (MD = -24.90 μg/dl; 95% CI, -41.72 to -8.07) compared with healthy controls. A systematic review of seven RCTs found that DHEA monotherapy does not improve bone mineral density (BMD) compared with placebo after adjusting for weight gain. While the combination of DHEA and conjugated oral contraceptives has led to increased bone strength and decreased bone loss, the beneficial effect appears to be limited to older adolescents and adults with closed physes. Potential detrimental effects on BMD were identified in younger adolescents with open physes in one study. DISCUSSION Due to the lack of apparent benefit of DHEA in women with AN and its potential detrimental effect on BMD in young patients with AN, current evidence does not support the use of DHEA. PUBLIC SIGNIFICANCE This study demonstrates that women with anorexia nervosa have abnormal levels of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS), which have been suggested by previous studies to play a role in the development of low bone density in this condition. However, current evidence does not support the use of DHEA as a treatment to preserve bone health in patients with anorexia nervosa given the lack of clear benefit following its use and also because of a potential detrimental effect on bone mineral density in young patients with anorexia nervosa.
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Affiliation(s)
- James Lin
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ting-Wan Kao
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ying-Chih Cheng
- Research center of big data and meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Psychiatry, China Medical University Hsinchu Hospital, China Medical University, Hsinchu, Taiwan.,Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Kang-Chih Fan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Chen Huang
- Research center of big data and meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Dermatology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Che-Wei Liu
- Research center of big data and meta-analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Orthopedics, Cathay General Hospital, Taipei, Taiwan.,School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan.,School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
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11
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Bennett G, Cussen L, O'Reilly MW. The role for long-term use of dehydroepiandrosterone in adrenal insufficiency. Curr Opin Endocrinol Diabetes Obes 2022; 29:284-293. [PMID: 35621180 DOI: 10.1097/med.0000000000000728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Dehydroepiandrosterone (DHEA) is an androgen produced by the zona reticularis of the adrenal gland. Patients with adrenal insufficiency will have a deficiency of DHEA. Unlike glucocorticoid and mineralocorticoid replacement, DHEA supplementation is not considered essential for life and is therefore not routinely replaced in adrenal failure. DHEA deficiency is associated with morbidity, including adverse impacts on metabolic function, quality of life and sexuality in multiple studies. The role for replacement, however, remains unclear. RECENT FINDINGS The benefits of DHEA supplementation have been definitively demonstrated in a number of historical studies of patients with primary and secondary adrenal insufficiency. Beneficial impacts on quality of life, body composition, bone health and metabolic markers have been demonstrated. However, published data are inconsistent; controversies persist around the exact role of DHEA replacement and around which patient cohorts are most likely to benefit. There is also a paucity of recent randomized controlled trials in the medical literature to inform on optimal dose and duration of DHEA replacement in adrenal failure. SUMMARY Here, we review the evidence for DHEA supplementation in patients with adrenal insufficiency. We highlight knowledge gaps in the medical literature and areas that should be prioritized for future research endeavours.
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Affiliation(s)
| | - Leanne Cussen
- Department of Endocrinology, Beaumont Hospital
- Department of Medicine, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Republic of Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Beaumont Hospital
- Department of Medicine, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Republic of Ireland
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12
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Wierman ME, Kiseljak-Vassiliades K. Should Dehydroepiandrosterone Be Administered to Women? J Clin Endocrinol Metab 2022; 107:1679-1685. [PMID: 35254428 PMCID: PMC9113789 DOI: 10.1210/clinem/dgac130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Indexed: 01/11/2023]
Abstract
CONTEXT Androgen prohormones such as dehydroepiandrosterone (DHEA) increase in early puberty, peak in the second and third decade, and thereafter decline, independent of menopausal status. Investigators have examined their potential beneficial effects in normal women and those with DHEA-deficient states. EVIDENCE ACQUISITION A review of the literature from 1985 to 2021 on the potential benefits and risks of androgen prohormones in women. EVIDENCE SYNTHESIS Studies have examined the potential benefit of DHEA therapy for anti-aging, sexual dysfunction, infertility, metabolic bone health, cognition, and wellbeing in hormone-deficient states such as primary adrenal insufficiency, hypopituitarism, and anorexia as well as administration to normal women across the lifespan. CONCLUSIONS Data support small benefits in quality of life and mood but not for anxiety or sexual function in women with primary or secondary adrenal insufficiency or anorexia. No consistent beneficial effects of DHEA administration have been observed for menopausal symptoms, sexual function, cognition, or overall wellbeing in normal women. Local administration of DHEA shows benefit in vulvovaginal atrophy. Use of DHEA to improve induction of ovulation response in women with diminished ovarian reserve is not recommended. Risks of high physiologic or pharmacologic use of DHEA include androgenic and estrogenic side effects which are of concern for long-term administration. CLINICAL CASE A 49-year-old woman with Addison's disease who is on low dose estrogen with cyclic progesterone therapy for menopausal symptoms returns for follow-up. She is on a stable glucocorticoid replacement strategy of hydrocortisone 10 mg in the morning and 5 mg in the early afternoon and fludrocortisone 0.05 mg each morning. She has read on the internet that additional therapy with DHEA may help her overall quality of life and libido. She asks whether she should add this therapy to her regimen and at what dose.
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Affiliation(s)
- Margaret E Wierman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO 80045, USA
| | - Katja Kiseljak-Vassiliades
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO 80045, USA
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13
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Abstract
Adrenal insufficiency (AI), first described by Thomas Addison in 1855, is characterised by inadequate hormonal production by the adrenal gland, which could either be primary, due to destruction of the adrenal cortex, or secondary/tertiary, due to lack of adrenocorticotropic hormone or its stimulation by corticotropin-releasing hormone. This was an invariably fatal condition in Addison's days with most patients dying within a few years of diagnosis. However, discovery of cortisone in the 1940s not only improved the life expectancy of these patients but also had a dramatic effect on their overall quality of life. The diagnosis, easily confirmed by demonstrating inappropriately low cortisol secretion, is often delayed by months, and many patients present with acute adrenal crisis. Sudden withdrawal from chronic glucocorticoid therapy is the most common cause of AI. Currently, there remains a wide variation in the management of this condition across Europe. As primary AI is a relatively rare condition, most medical specialists will only manage a handful of these patients in their career. Despite many advances in recent years, there is currently no curative option, and modern cortisol replacement regimens fail to adequately mimic physiological cortisol rhythm. A number of new approaches including allograft of adrenocortical tissue and stem cell therapy are being tried but remain largely experimental.
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Affiliation(s)
- Rajeev Kumar
- Diabetes and Endocrinology, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - W S Wassif
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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14
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Abstract
Addison's disease typically results from the autoimmune destruction of the adrenal cortex and requires lifelong replacement with glucocorticoids and mineralocorticoids. Main symptoms are non-specific and, therefore, often overlooked or misleading. Patients are frequently not diagnosed until experiencing a life-threatening adrenal crisis. This article highlights the essential clinical characteristics, diagnostic aspects and principles of management of adrenal insufficiency.
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15
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Zdrojowy-Wełna A, Halupczok-Żyła J, Słoka N, Syrycka J, Gojny Ł, Bolanowski M. Trabecular bone score and sclerostin concentrations in patients with primary adrenal insufficiency. Front Endocrinol (Lausanne) 2022; 13:996157. [PMID: 36407318 PMCID: PMC9666397 DOI: 10.3389/fendo.2022.996157] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Patients with primary adrenal insufficiency need lifelong replacement therapy with glucocorticoids and mineralocorticoids, which may influence their bone quality. AIM The aim of the study was to evaluate densitometry parameters, trabecular bone score and sclerostin concentrations in patients with primary adrenal insufficiency in comparison to control group. MATERIALS AND METHODS We included 29 patients (62% females) with diagnose of autoimmune primary adrenal insufficiency (mean age 49.7 ± 11.7 years, mean duration of the disease 13.2± 13.6 years) and 33 healthy subjects (adjusted with age, sex and body mass index). Bone mineral density at the femoral neck, lumbar spine, total body and trabecular bone score were evaluated. Serum sclerostin concentrations were measured. RESULTS There were no significant differences in densitometry parameters (T-score, Z-score, bone mineral density in all locations) as well as in trabecular bone score in patients with adrenal insufficiency in comparison to control group. Mean serum sclerostin concentration was significantly higher in patients with adrenal insufficiency than in control group (44.7 ± 23.5 vs 30.7 ± 10.4 pmol/l, p=0.006). There was a negative correlation between trabecular bone score and the duration of adrenal insufficiency and age, also a negative correlation between femoral neck and total densitometry parameters and 24-hour urine cortisol as a marker of hydrocortisone daily dose in patients with adrenal insufficiency. CONCLUSIONS The bone status in patients with primary adrenal insufficiency was not impaired in comparison to control group, while sclerostin concentration was higher. The duration of the disease and higher hydrocortisone doses may affect negatively bone status.
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Affiliation(s)
- Aleksandra Zdrojowy-Wełna
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
- *Correspondence: Aleksandra Zdrojowy-Wełna,
| | - Jowita Halupczok-Żyła
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Natalia Słoka
- Laboratory of Molecular Endocrinology, Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Joanna Syrycka
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Łukasz Gojny
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
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16
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The Utilization of Dehydroepiandrosterone as a Sexual Hormone Precursor in Premenopausal and Postmenopausal Women: An Overview. Pharmaceuticals (Basel) 2021; 15:ph15010046. [PMID: 35056103 PMCID: PMC8781653 DOI: 10.3390/ph15010046] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/16/2021] [Accepted: 12/27/2021] [Indexed: 12/03/2022] Open
Abstract
Dehydroepiandrosterone (DHEA), and its metabolite, dehydroepiandrosterone sulfate ester (DHEAS), are the most abundant circulating steroid hormones, and are synthesized in the zona reticularis of the adrenal cortex, in the gonads, and in the brain. The precise physiological role of DHEA and DHEAS is not yet fully understood, but these steroid hormones can act as androgens, estrogens, and neurosteroids, and perform many roles in the human body. Since both levels decline with age, use of DHEA supplements have gained more attention due to being advertised as an antidote to aging in postmenopausal women, who may have concerns on age-related diseases and overall well-being. However, current research has not reached an overall consensus on the effects of DHEA on postmenopausal women. This overview is a summary of the current literature, addressing the metabolic pathway for DHEA synthesis and utilization, as well as the effects of DHEA on premenopausal and postmenopausal women with disease states and other factors. As for the therapeutic effects on menopausal syndrome and other age-related diseases, several studies have found that DHEA supplementations can alleviate vasomotor symptoms, preserve the integrity of the immune system, reduce bone loss, and increase muscle mass. Intravaginal DHEA has shown significant beneficial effects in menopausal women with severe vulvovaginal symptoms. On the other hand, DHEA supplements have not shown definitive effects in cardiovascular disease, adrenal insufficiency, insulin sensitivity, and cognition. Due to inadequate sample sizes and treatment durations of current studies, it is difficult to assess the safety and efficacy of DHEA and draw reliable conclusions for the physiological role, the optimal dosage, and the effects on premenopausal and postmenopausal women; therefore, the study of DHEA warrants future investigation. Further research into the roles of these steroid hormones may bring us closer to a therapeutic option in the future.
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17
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Saari V, Laakso S, Tiitinen A, Mäkitie O, Holopainen E. Endocrine Disorders and Genital Infections Impair Gynecological Health in APECED (APS-1). Front Endocrinol (Lausanne) 2021; 12:784195. [PMID: 34917035 PMCID: PMC8669951 DOI: 10.3389/fendo.2021.784195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/11/2021] [Indexed: 12/03/2022] Open
Abstract
Objective In autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) defects in the autoimmune regulator gene lead to impaired immunotolerance. We explored the effects of immunodeficiency and endocrinopathies on gynecologic health in patients with APECED. Design Cross-sectional cohort study combined with longitudinal follow-up data. Methods We carried out a gynecologic evaluation, pelvic ultrasound, and laboratory and microbiologic assessment in 19 women with APECED. Retrospective data were collected from previous study visits and hospital records. Results The study subjects' median age was 42.6 years (range, 16.7-65.5). Sixteen patients (84%) had premature ovarian insufficiency, diagnosed at the median age of 16.5 years; 75% of them used currently either combined contraception or hormonal replacement therapy. In 76% of women, the morphology and size of the uterus were determined normal for age, menopausal status, and current hormonal therapy. Fifteen patients (79%) had primary adrenal insufficiency; three of them used dehydroepiandrosterone substitution. All androgen concentrations were under the detection limit in 11 patients (58%). Genital infections were detected in nine patients (47%); most of them were asymptomatic. Gynecologic C. albicans infection was detected in four patients (21%); one of the strains was resistant to azoles. Five patients (26%) had human papillomavirus infection, three of which were high-risk subtypes. Cervical cell atypia was detected in one patient. No correlation between genital infections and anti-cytokine autoantibodies was found. Conclusions Ovarian and adrenal insufficiencies manifested with very low androgen levels in over half of the patients. Asymptomatic genital infections, but not cervical cell atypia, were common in female patients with APECED.
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Affiliation(s)
- Viivi Saari
- Children’s Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Saila Laakso
- Children’s Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Folkhälsan Institute of Genetics, Helsinki, Finland
| | - Aila Tiitinen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Outi Mäkitie
- Children’s Hospital and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Folkhälsan Institute of Genetics, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Elina Holopainen
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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18
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Dos Santos LR, Heilbrun EP, Félix CS, Duarte ML. Congenital Adrenal Hyperplasia Due to 17-α-hydroxylase Deficiency: A Case Report. TOUCHREVIEWS IN ENDOCRINOLOGY 2021; 17:138-140. [PMID: 35118460 DOI: 10.17925/ee.2021.17.2.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/24/2020] [Indexed: 11/24/2022]
Abstract
Congenital adrenal hyperplasia, an innate error in adrenal steroid biosynthesis, triggers a wide range of consequences based on the level of enzyme blockade. Due to the various forms of enzyme deficiency and degree of penetration, the clinical features are very variable. In this case report, we present a form of congenital adrenal hyperplasia due to an enzymatic defect of CYP17A1, with a late diagnosis. The recognition of this pathology should occur as early as possible to avoid sequelae, both metabolic and psychological.
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19
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Walsh TP, Baird GL, Atalay MK, Agarwal S, Arcuri D, Klinger JR, Mullin CJ, Morreo H, Normandin B, Shiva S, Whittenhall M, Ventetuolo CE. Experimental design of the Effects of Dehydroepiandrosterone in Pulmonary Hypertension (EDIPHY) trial. Pulm Circ 2021; 11:2045894021989554. [PMID: 34094503 PMCID: PMC8142004 DOI: 10.1177/2045894021989554] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/15/2020] [Indexed: 12/02/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) remains life-limiting despite numerous approved vasodilator therapies. Right ventricular (RV) function determines outcome in PAH but no treatments directly target RV adaptation. PAH is more common in women, yet women have better RV function and survival as compared to men with PAH. Lower levels of the adrenal steroid dehydroepiandrosterone (DHEA) and its sulfate ester are associated with more severe pulmonary vascular disease, worse RV function, and mortality independent of other sex hormones in men and women with PAH. DHEA has direct effects on nitric oxide (NO) and endothelin-1 (ET-1) synthesis and signaling, direct antihypertrophic effects on cardiomyocytes, and mitigates oxidative stress. Effects of Dehydroepiandrosterone in Pulmonary Hypertension (EDIPHY) is an on-going randomized double-blind placebo-controlled crossover trial of DHEA in men (n = 13) and pre- and post-menopausal women (n = 13) with Group 1 PAH funded by the National Heart, Lung and Blood Institute. We will determine whether orally administered DHEA 50 mg daily for 18 weeks affects RV longitudinal strain measured by cardiac magnetic resonance imaging, markers of RV remodeling and oxidative stress, NO and ET-1 signaling, sex hormone levels, other PAH intermediate end points, side effects, and safety. The crossover design will elucidate sex-based phenotypes in PAH and whether active treatment with DHEA impacts NO and ET-1 biosynthesis. EDIPHY is the first clinical trial of an endogenous sex hormone in PAH. Herein we present the study’s rationale and experimental design.
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Affiliation(s)
| | - Grayson L Baird
- Lifespan Health System, Providence, RI, USA.,Department of Diagnostic Imaging, Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael K Atalay
- Department of Diagnostic Imaging, Alpert Medical School of Brown University, Providence, RI, USA
| | - Saurabh Agarwal
- Department of Diagnostic Imaging, Alpert Medical School of Brown University, Providence, RI, USA
| | - Daniel Arcuri
- Department of Diagnostic Imaging, Alpert Medical School of Brown University, Providence, RI, USA
| | - James R Klinger
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Christopher J Mullin
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | - Sruti Shiva
- Department of Pharmacology and Chemical Biology, Vascular Medicine Institute, NO Metabolomics Core Facility, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mary Whittenhall
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Corey E Ventetuolo
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
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20
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Matulevicius V, Urbanavicius V, Lukosevicius S, Banisauskaite I, Donielaite G, Galkine A. Importance of Dehydroepiandrosterone Sulfate Assessment with Special Attention for Adrenal Tumours and Arterial Hypertension. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2021; 17:68-76. [PMID: 34539912 PMCID: PMC8417495 DOI: 10.4183/aeb.2021.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To investigate the significance of DHEAS assessment in males of different ages. METHODS Retrospective cohort study of patients investigated in two large academic centres. RESULTS The data of DHEAS assessment of 3533 patients (3013 females and 520 males) was analysed. DHEAS was 1.6 - 13.5 times more frequently investigated in women than in men. A peak of DHEAS evaluation test for women was at 25 years old and distribution was uniform in males over decades, excepting being lower in 0-9 and 75+ages. In the age group 10-24 years, DHEAS levels were higher in females. After 45 years, DHEAS was higher in men than in women. Analysis of 510 case records showed low DHEAS levels in boys (0-9 years) and in men aged 65 - 84+. Higher DHEAS levels were detected as a peak at 30 years old, but never after 55 years. In individuals with low DHEAS levels prevailed congenital adrenal hyperplasia (32%), adrenal tumours (30%) and primary or secondary adrenal insufficiency (19%). High DHEAS levels prevailed in patients with arterial hypertension (26%), overweight-obesity -(19%), non-toxic goiter (17%) and alopecia (9%). In the normal DHEAS miscellaneous diagnoses were met most frequently - 40%. Disorders exceeding 5% were non-toxic goiter (19%), adrenal tumours - 17%, overweight/obesity - 16% and arterial hypertension- 8%. In 71 women and 124 men adrenal neoplasms were detected. Higher frequency of these was observed in women in their 30s. A peak of adrenal neoplasms in men was at their 70s. This gender difference was not conditioned by earlier attempts to seek medical care by women. A significant correlation of DHEAS, weight, body mass index and systolic blood pressure with diastolic blood pressure was found. CONCLUSION Our study permits to determine which DHEAS secretion and clinical pattern might be associated in males of different ages.
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Affiliation(s)
- V. Matulevicius
- Lithuanian University of Health Sciences - Institute of Endocrinology, Department of Endocrinology
| | - V. Urbanavicius
- Lithuanian University of Health Sciences - Institute of Endocrinology, Vilnius University - Faculty of Medicine, Department of Endocrinology, Vilnius, Lithuania
| | - S. Lukosevicius
- Lithuanian University of Health Sciences - Institute of Endocrinology, Department of Radiology, Kaunas
| | - I. Banisauskaite
- Lithuanian University of Health Sciences - Institute of Endocrinology, Department of Endocrinology
| | - G. Donielaite
- Lithuanian University of Health Sciences - Institute of Endocrinology, Department of Endocrinology
| | - A. Galkine
- Lithuanian University of Health Sciences - Institute of Endocrinology, Vilnius University - Faculty of Medicine, Department of Endocrinology, Vilnius, Lithuania
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21
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Hahner S, Ross RJ, Arlt W, Bancos I, Burger-Stritt S, Torpy DJ, Husebye ES, Quinkler M. Adrenal insufficiency. Nat Rev Dis Primers 2021; 7:19. [PMID: 33707469 DOI: 10.1038/s41572-021-00252-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 12/25/2022]
Abstract
Adrenal insufficiency (AI) is a condition characterized by an absolute or relative deficiency of adrenal cortisol production. Primary AI (PAI) is rare and is caused by direct adrenal failure. Secondary AI (SAI) is more frequent and is caused by diseases affecting the pituitary, whereas in tertiary AI (TAI), the hypothalamus is affected. The most prevalent form is TAI owing to exogenous glucocorticoid use. Symptoms of AI are non-specific, often overlooked or misdiagnosed, and are related to the lack of cortisol, adrenal androgen precursors and aldosterone (especially in PAI). Diagnosis is based on measurement of the adrenal corticosteroid hormones, their regulatory peptide hormones and stimulation tests. The goal of therapy is to establish a hormone replacement regimen that closely mimics the physiological diurnal cortisol secretion pattern, tailored to the patient's daily needs. This Primer provides insights into the epidemiology, mechanisms and management of AI during pregnancy as well as challenges of long-term management. In addition, the importance of identifying life-threatening adrenal emergencies (acute AI and adrenal crisis) is highlighted and strategies for prevention, which include patient education, glucocorticoid emergency cards and injection kits, are described.
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Affiliation(s)
- Stefanie Hahner
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital Wuerzburg, Wuerzburg, Germany.
| | - Richard J Ross
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Wiebke Arlt
- Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Centre for Endocrinology, Diabetes, and Metabolism, Birmingham Health Partners, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephanie Burger-Stritt
- Department of Medicine I, Division of Endocrinology and Diabetology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway.,K.G. Jebsen Center for Autoimmune Diseases, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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22
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Husebye ES, Pearce SH, Krone NP, Kämpe O. Adrenal insufficiency. Lancet 2021; 397:613-629. [PMID: 33484633 DOI: 10.1016/s0140-6736(21)00136-7] [Citation(s) in RCA: 142] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/12/2020] [Accepted: 09/21/2020] [Indexed: 12/11/2022]
Abstract
Adrenal insufficiency can arise from a primary adrenal disorder, secondary to adrenocorticotropic hormone deficiency, or by suppression of adrenocorticotropic hormone by exogenous glucocorticoid or opioid medications. Hallmark clinical features are unintentional weight loss, anorexia, postural hypotension, profound fatigue, muscle and abdominal pain, and hyponatraemia. Additionally, patients with primary adrenal insufficiency usually develop skin hyperpigmentation and crave salt. Diagnosis of adrenal insufficiency is usually delayed because the initial presentation is often non-specific; physician awareness must be improved to avoid adrenal crisis. Despite state-of-the-art steroid replacement therapy, reduced quality of life and work capacity, and increased mortality is reported in patients with primary or secondary adrenal insufficiency. Active and repeated patient education on managing adrenal insufficiency, including advice on how to increase medication during intercurrent illness, medical or dental procedures, and profound stress, is required to prevent adrenal crisis, which occurs in about 50% of patients with adrenal insufficiency after diagnosis. It is good practice for physicians to provide patients with a steroid card, parenteral hydrocortisone, and training for parenteral hydrocortisone administration, in case of vomiting or severe illness. New modes of glucocorticoid delivery could improve the quality of life in some patients with adrenal insufficiency, and further advances in oral and parenteral therapy will probably emerge in the next few years.
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Affiliation(s)
- Eystein S Husebye
- Department of Clinical Science and KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Simon H Pearce
- Department of Endocrinology, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nils P Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK; Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Olle Kämpe
- Department of Clinical Science and KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway; Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Center of Molecular Medicine, and Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
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23
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Wang F, He Y, O Santos H, Sathian B, C Price J, Diao J. The effects of dehydroepiandrosterone (DHEA) supplementation on body composition and blood pressure: A meta-analysis of randomized clinical trials. Steroids 2020; 163:108710. [PMID: 32745490 DOI: 10.1016/j.steroids.2020.108710] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/13/2020] [Accepted: 07/27/2020] [Indexed: 12/14/2022]
Abstract
Dehydroepiandrosterone (DHEA) supplementation has been anecdotally considered as a tool to improve body composition and health status. We aimed to verify the impact of DHEA supplementation on traditional measurements of body composition and blood pressure (BP) due to their clinical applicability. A meta-analysis of randomized clinical trials was conducted based on the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Regarding anthropometric characteristics, DHEA supplementation did not change body weight (weighted mean difference (WMD): -0.16 kg, 95% CI: -1.02 to 0.70, p = 0.72) or body mass index (WMD: -0.18 kg/m2, 95% CI: -0.48 to 0.12, p = 0.24), but increased lean body mass (WMD: 0.45 kg, 95% CI: 0.15 to 0.75, p = 0.004) and decreased fat mass (WMD: -0.85%, 95% CI: -1.18 to -0.51, p = 0.000), when compared to control groups. Neither systolic (WMD: 0.98 mm Hg, 95% CI: -2.31 to 4.29, p = 0.56) nor diastolic BP were significantly changed (WMD: -1.62 mm Hg, 95% CI: -5.49 to 2.24, p = 0.49). Our findings demonstrate that DHEA supplementation increased lean body mass and decreased fat mass, but debate persists when translating the results into clinical benefit. Lastly, DHEA supplementation had a neutral effect on BP.
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Affiliation(s)
- Furong Wang
- College of Life Sciences, Northwest University, Xi'an 710069, China
| | - Yanfei He
- Department of Reproductive Health, Women and Children Health and Family Planning Service Center of Decheng District, Dezhou City, Shandong Province 253000, China
| | - Heitor O Santos
- School of Medicine, Federal University of Uberlandia (UFU), Uberlandia, Minas Gerais, Brazil
| | - Brijesh Sathian
- Deputy Chair for Research, Geriatrics and long term care department, Rumailah Hospital, Hamad Medical Corporation, P. O BOX 3050, Doha, Qatar
| | - James C Price
- Institute of Science and the Environment, University of Worcester, United Kingdom
| | - Jianjun Diao
- Department of Medical Records Management, Central Hospital Affiliated to Shandong First Medical University, Shandong University, No. 105 Jiefang Road, Jinan City, Shandong Province 250013, China.
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Li Y, Ren J, Li N, Liu J, Tan SC, Low TY, Ma Z. A dose-response and meta-analysis of dehydroepiandrosterone (DHEA) supplementation on testosterone levels: perinatal prediction of randomized clinical trials. Exp Gerontol 2020; 141:111110. [PMID: 33045358 DOI: 10.1016/j.exger.2020.111110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/01/2020] [Accepted: 10/02/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Dehydroepiandrosterone (DHEA) has been aggressively sold as a dietary supplement to boost testosterone levels although the impact of DHEA supplementation on testosterone levels has not been fully established. Therefore, we performed a systematic review and meta-analysis of RCTs to investigate the effect of oral DHEA supplementation on testosterone levels. METHODS A systematic literature search was performed in Scopus, Embase, Web of Science, and PubMed databases up to February 2020 for RCTs that investigated the effect of DHEA supplementation on testosterone levels. The estimated effect of the data was calculated using the weighted mean difference (WMD). Subgroup analysis was performed to identify the source of heterogeneity among studies. RESULTS Overall results from 42 publications (comprising 55 arms) demonstrated that testosterone level was significantly increased after DHEA administration (WMD: 28.02 ng/dl, 95% CI: 21.44-34.60, p = 0.00). Subgroup analyses revealed that DHEA increased testosterone level in all subgroups, but the magnitude of increment was higher in females compared to men (WMD: 30.98 ng/dl vs. 21.36 ng/dl); DHEA dosage of ˃50 mg/d compared to ≤50 mg/d (WMD: 57.96 ng/dl vs. 19.43 ng/dl); intervention duration of ≤12 weeks compared to ˃12 weeks (WMD: 44.64 ng/dl vs. 19 ng/dl); healthy participants compared to postmenopausal women, pregnant women, non-healthy participants and androgen-deficient patients (WMD: 52.17 ng/dl vs. 25.04 ng/dl, 16.44 ng/dl and 16.47 ng/dl); and participants below 60 years old compared to above 60 years old (WMD: 31.42 ng/dl vs. 23.93 ng/dl). CONCLUSION DHEA supplementation is effective for increasing testosterone levels, although the magnitude varies among different subgroups. More study needed on pregnant women and miscarriage.
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Affiliation(s)
- Yuanyuan Li
- Perinatal Center, Shijiazhuang Fourth Hospital, Shijiazhuang, Hebei 050000, China
| | - Jie Ren
- Obstetrics Department, Shijiazhuang Fourth Hospital, Shijiazhuang, Hebei 050000, China
| | - Na Li
- Obstetrics Department, Shijiazhuang Fourth Hospital, Shijiazhuang, Hebei 050000, China
| | - Jie Liu
- Obstetrics Department, Shijiazhuang Fourth Hospital, Shijiazhuang, Hebei 050000, China
| | - Shing Cheng Tan
- UKM Medical Molecular Biology Institute, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Teck Yew Low
- UKM Medical Molecular Biology Institute, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Zhimin Ma
- Perinatal Center, Shijiazhuang Fourth Hospital, Shijiazhuang, Hebei 050000, China.
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Kirby DJ, Buchalter DB, Anil U, Leucht P. DHEA in bone: the role in osteoporosis and fracture healing. Arch Osteoporos 2020; 15:84. [PMID: 32504237 DOI: 10.1007/s11657-020-00755-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/07/2020] [Indexed: 02/03/2023]
Abstract
Dehydroepiandrosterone (DHEA) is a metabolic intermediate in the biosynthesis of estrogens and androgens with a past clouded in controversy and bold claims. It was once touted as a wonder drug, a fountain of youth that could cure all ailments. However, in the 1980s DHEA was banned by the FDA given a lack of documented health benefits and long-term use data. DHEA had a revival in 1994 when it was released for open market sale as a nutritional supplement under the Dietary Supplement Health and Safety Act. Since that time, there has been encouraging research on the hormone, including randomized controlled trials and subsequent meta-analyses on various conditions that DHEA may benefit. Bone health has been of particular interest, as many of the metabolites of DHEA are known to be involved in bone homeostasis, specifically estrogen and testosterone. Studies demonstrate a significant association between DHEA and increased bone mineral density, likely due to DHEA's ability to increase osteoblast activity and insulin like growth factor 1 (IGF-1) expression. Interestingly, IGF-1 is also known to improve fracture healing, though DHEA, a potent stimulator of IGF-1, has never been tested in this scenario. The aim of this review is to discuss the history and mechanisms of DHEA as they relate to the skeletal system, and to evaluate if DHEA has any role in treating fractures.
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Affiliation(s)
- David J Kirby
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY, 10003, USA.
| | - Daniel B Buchalter
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY, 10003, USA
| | - Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY, 10003, USA
| | - Philipp Leucht
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY, 10003, USA
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Dineen R, Martin-Grace J, Thompson CJ, Sherlock M. The management of glucocorticoid deficiency: Current and future perspectives. Clin Chim Acta 2020; 505:148-159. [DOI: 10.1016/j.cca.2020.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 01/10/2023]
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Xie M, Zhong Y, Xue Q, Wu M, Deng X, O Santos H, Tan SC, Kord-Varkaneh H, Jiao P. Impact of dehydroepianrosterone (DHEA) supplementation on serum levels of insulin-like growth factor 1 (IGF-1): A dose-response meta-analysis of randomized controlled trials. Exp Gerontol 2020; 136:110949. [PMID: 32304719 DOI: 10.1016/j.exger.2020.110949] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/11/2020] [Accepted: 04/12/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM Inconsistencies exist with regard to the influence of dehydroepiandrosterone (DHEA) supplementation on insulin-like growth factor 1 (IGF-1) levels. The inconsistencies could be attributed to several factors, such as dosage, gender, and duration of intervention, among others. To address these inconsistencies, we conducted a systematic review and meta-analysis to combine findings from randomized controlled trials (RCTs) on this topic. METHODS Electronic databases (Scopus, PubMed/Medline, Web of Science, Embase and Google Scholar) were searched for relevant literature published up to February 2020. RESULTS Twenty-four qualified trials were included in this meta-analysis. It was found that serum IGF-1 levels were significantly increased in the DHEA group compared to the control (weighted mean differences (WMD): 16.36 ng/ml, 95% CI: 8.99, 23.74; p = .000). Subgroup analysis revealed that a statistically significant increase in serum IGF-1 levels was found only in women (WMD: 23.30 ng/ml, 95% CI: 13.75, 32.87); in participants who supplemented 50 mg/d DHEA (WMD: 15.75 ng/ml, 95% CI: 7.61, 23.89); in participants undergoing DHEA intervention for >12 weeks (WMD: 17.2 ng/ml, 95% CI: 8.02, 26.22); in participants without an underlying comorbidity (WMD: 19.11 ng/ml, 95% CI: 10.69, 27.53); and in participants over the age of 60 years (WMD: 19.79 ng/ml, 95% CI: 9.86, 29.72). CONCLUSION DHEA supplementation may increase serum IGF-I levels especially in women and older subjects. However, further studies are warranted before DHEA can be recommended for clinical use.
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Affiliation(s)
- Min Xie
- Operating Room Nursing Department, Xiangya Third Hospital of Central South University, Changsha, Hunan 400013, China
| | - Yanfa Zhong
- Department of Laboratory Medicine, Dezhou Hospital of Traditional Chinese Medicine, Dezhou, Shandong 253000, China
| | - Qing Xue
- Department of Laboratory Medicine, Dezhou Hospital of Traditional Chinese Medicine, Dezhou, Shandong 253000, China
| | - Meirong Wu
- Operating Room Nursing Department, Xiangya Third Hospital of Central South University, Changsha, Hunan 400013, China
| | - Xiaoxian Deng
- Operating Room Nursing Department, Xiangya Third Hospital of Central South University, Changsha, Hunan 400013, China
| | - Heitor O Santos
- School of Medicine, Federal University of Uberlandia (UFU), Uberlandia, Minas Gerais, Brazil
| | - Shing Cheng Tan
- UKM Medical Molecular Biology Institute, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Hamed Kord-Varkaneh
- Student Research Committee, Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Peng Jiao
- Department of Endocrinology, Dezhou Hospital of Traditional Chinese Medicine, Dezhou, Shandong 253000, China.
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Mäntyselkä A, Haapala EA, Lindi V, Häkkinen MR, Auriola S, Jääskeläinen J, Lakka TA. Associations of IGF-1 and Adrenal Androgens with Cognition in Childhood. Horm Res Paediatr 2020; 91:329-335. [PMID: 31401625 DOI: 10.1159/000501719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 06/24/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Little is known about the association between adrenarche and cognition in general populations of children. We therefore studied the associations of dehydroepiandrosterone sulfate (DHEAS), androstenedione (A4), testosterone, insulin-like growth factor-1 (IGF-1), and adrenarche with cognition among prepubertal children. METHODS These cross-sectional analyses are based on baseline data of the Physical Activity and Nutrition in Children Study. A total of 387 children (183 girls, 204 boys) were included in the analyses. Raven's Coloured Progressive Matrices (CPM) score was used to assess nonverbal reasoning. Serum adrenal androgens and IGF-1 concentrations were measured and clinical signs of androgen action were evaluated. RESULTS Higher IGF-1 among boys (β = 0.149, p =0.033) was related to a better Raven's CPM score after adjustment for age and parental education. Adrenal androgens in girls or boys or IGF-1 in girls were not associated with the score. There were no differences in Raven's CPM score between children with biochemical adrenarche (DHEAS ≥1.08 µmol/L; ≥40 µg/dL) or with clinical signs of androgen action and children without them. CONCLUSION The results suggest that higher serum IGF-1 among boys is related to better cognition in prepubertal children. We could not provide evidence for the associations of adrenal maturation with cognition in prepubertal children.
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Affiliation(s)
- Aino Mäntyselkä
- Department of Pediatrics, School of Medicine, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland,
| | - Eero A Haapala
- Institute of Biomedicine, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Virpi Lindi
- Institute of Biomedicine, School of Medicine, University of Eastern Finland, Kuopio, Finland.,University of Eastern Finland Library, Kuopio, Finland
| | - Merja R Häkkinen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Seppo Auriola
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Jarmo Jääskeläinen
- Department of Pediatrics, School of Medicine, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland
| | - Timo A Lakka
- Institute of Biomedicine, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Clinical Physiology and Nuclear Medicine, School of Medicine, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Institute of Exercise Medicine, Kuopio, Finland
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29
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Laakso S, Borchers J, Toiviainen-Salo S, Pekkinen M, Mäkitie O. Severe Phenotype of APECED (APS1) Increases Risk for Structural Bone Alterations. Front Endocrinol (Lausanne) 2020; 11:109. [PMID: 32210917 PMCID: PMC7067693 DOI: 10.3389/fendo.2020.00109] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 02/19/2020] [Indexed: 12/31/2022] Open
Abstract
Objective: Immunological abnormalities, the resulting endocrinopathies and their treatments may impact bone health in patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED, APS1). The aim of the present study was to describe skeletal characteristics in patients with APECED and the prevalence and risk factors of compromised bone health. Patients and methods: We performed a cross-sectional study on 44 patients (27 females) with APECED and 82 age-, gender- and ethnicity-matched control subjects (54 females). We determined the prevalence of osteoporosis by dual-energy X-ray absorptiometry and skeletal characteristics by peripheral quantitative computed tomography at radius and tibia. Results: Patients were examined at the median age of 37.8 years (range, 7.0-70.1). Dual-energy X-ray absorptiometry indicated osteoporosis in four adult patients (9%); radiographs showed vertebral fractures in three patients. The prevalence of multiple non-spinal fractures was higher in patients than in controls. On peripheral quantitative computed tomography, bone characteristics at distal and proximal radius did not differ between the groups. At distal tibia, patients had lower total (p = 0.009) and trabecular (p = 0.033) volumetric bone mineral density. At the proximal tibia, patients had lower cortical thickness (p < 0.001) than controls. Severity of APECED phenotype influenced both radial and tibial characteristics: cortical thickness and total and trabecular volumetric bone mineral density were lower in patients with ≥7 disease manifestations as compared with more mildly affected patients, whose values were similar to controls. Conclusions: APECED associated with bone structural alterations, especially in patients with a high number of disease manifestations. This may increase the risk of fractures with aging, but symptomatic osteoporosis was rare.
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MESH Headings
- Absorptiometry, Photon
- Adolescent
- Adult
- Aged
- Bone Density
- Bone Diseases, Metabolic/diagnosis
- Bone Diseases, Metabolic/epidemiology
- Bone Diseases, Metabolic/etiology
- Child
- Cross-Sectional Studies
- Female
- Fractures, Bone/diagnosis
- Fractures, Bone/epidemiology
- Fractures, Bone/etiology
- Humans
- Male
- Middle Aged
- Osteoporosis/diagnosis
- Osteoporosis/epidemiology
- Osteoporosis/etiology
- Phenotype
- Polyendocrinopathies, Autoimmune/complications
- Polyendocrinopathies, Autoimmune/epidemiology
- Polyendocrinopathies, Autoimmune/pathology
- Prevalence
- Risk Factors
- Severity of Illness Index
- Young Adult
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Affiliation(s)
- Saila Laakso
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- *Correspondence: Saila Laakso
| | - Joonatan Borchers
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Sanna Toiviainen-Salo
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Pediatric Radiology, Medical Imaging Center, Helsinki University Hospital, Helsinki, Finland
| | - Minna Pekkinen
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Outi Mäkitie
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
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Abstract
Primary adrenal insufficiency (PAI) occurs in 1/5000-1/7000 individuals in the general population. Autoimmune Addison's disease (AAD) is the major cause of PAI and is a major component of autoimmune polyendocrine syndrome type 1 (APS1) and type 2 (APS2). Presence of 21-hydroxylase autoantibodies (21OHAb) identifies subjects with ongoing clinical or pre-clinical adrenal autoimmunity. AAD requires life-long substitutive therapy with two-three daily doses of hydrocortisone (HC) (15-25 mg/day) or one daily dose of dual-release HC and with fludrocortisone (0.5-2.0 mg/day). The lowest possible HC dose must be identified according to clinical and biochemical parameters to minimize long-term complications that include osteoporosis and cardiovascular and metabolic alterations. Women with AAD have lower fertility and parity as compared to age-matched healthy controls. Patients must be educated to double-triple HC dose in the case of fever or infections and to switch to parenteral HC in the case of vomiting, diarrhoea or acute hypotension.
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Affiliation(s)
- Serena Saverino
- Section of Internal Medicine and Endocrine and Metabolic Sciences, Department of Medicine, University of Perugia, Perugia, Italy
| | - Alberto Falorni
- Section of Internal Medicine and Endocrine and Metabolic Sciences, Department of Medicine, University of Perugia, Perugia, Italy.
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Bentley C, Hazeldine J, Greig C, Lord J, Foster M. Dehydroepiandrosterone: a potential therapeutic agent in the treatment and rehabilitation of the traumatically injured patient. BURNS & TRAUMA 2019; 7:26. [PMID: 31388512 PMCID: PMC6676517 DOI: 10.1186/s41038-019-0158-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
Severe injuries are the major cause of death in those aged under 40, mainly due to road traffic collisions. Endocrine, metabolic and immune pathways respond to limit the tissue damage sustained and initiate wound healing, repair and regeneration mechanisms. However, depending on age and sex, the response to injury and patient prognosis differ significantly. Glucocorticoids are catabolic and immunosuppressive and are produced as part of the stress response to injury leading to an intra-adrenal shift in steroid biosynthesis at the expense of the anabolic and immune enhancing steroid hormone dehydroepiandrosterone (DHEA) and its sulphated metabolite dehydroepiandrosterone sulphate (DHEAS). The balance of these steroids after injury appears to influence outcomes in injured humans, with high cortisol: DHEAS ratio associated with increased morbidity and mortality. Animal models of trauma, sepsis, wound healing, neuroprotection and burns have all shown a reduction in pro-inflammatory cytokines, improved survival and increased resistance to pathological challenges with DHEA supplementation. Human supplementation studies, which have focused on post-menopausal females, older adults, or adrenal insufficiency have shown that restoring the cortisol: DHEAS ratio improves wound healing, mood, bone remodelling and psychological well-being. Currently, there are no DHEA or DHEAS supplementation studies in trauma patients, but we review here the evidence for this potential therapeutic agent in the treatment and rehabilitation of the severely injured patient.
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Affiliation(s)
- Conor Bentley
- 1NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospital Birmingham, Birmingham, B15 2WB UK.,2School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK.,3MRC-Arthritis Research UK Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, Birmingham University Medical School, Birmingham, B15 2TT UK
| | - Jon Hazeldine
- 1NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospital Birmingham, Birmingham, B15 2WB UK.,3MRC-Arthritis Research UK Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, Birmingham University Medical School, Birmingham, B15 2TT UK
| | - Carolyn Greig
- 2School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK.,4NIHR Biomedical Research Centre, University Hospital Birmingham, Birmingham, UK
| | - Janet Lord
- 1NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospital Birmingham, Birmingham, B15 2WB UK.,3MRC-Arthritis Research UK Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, Birmingham University Medical School, Birmingham, B15 2TT UK.,4NIHR Biomedical Research Centre, University Hospital Birmingham, Birmingham, UK
| | - Mark Foster
- 1NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospital Birmingham, Birmingham, B15 2WB UK.,5Royal Centre for Defence Medicine, Birmingham Research Park, Birmingham, B15 2SQ UK
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Skov J, Sundström A, Ludvigsson JF, Kämpe O, Bensing S. Sex-Specific Risk of Cardiovascular Disease in Autoimmune Addison Disease-A Population-Based Cohort Study. J Clin Endocrinol Metab 2019; 104:2031-2040. [PMID: 30608542 PMCID: PMC6469226 DOI: 10.1210/jc.2018-02298] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 12/28/2018] [Indexed: 12/03/2022]
Abstract
CONTEXT Little is known of cardiovascular disease (CVD) in autoimmune Addison disease (AAD). Inadequate glucocorticoid replacement might potentially increase CVD risk. OBJECTIVE To examine CVD in AAD in subgroups of ischemic heart disease (IHD) and cerebrovascular disease (CeVD) and investigate the effects of glucocorticoid and mineralocorticoid dosing. DESIGN, SETTING, AND PATIENTS In this cohort-control study, we used Swedish health registries from 1964 to 2013 to identify 1500 subjects with AAD and 13,758 matched controls. Incident CVD was analyzed from 2006 to 2013. Adjusted hazard ratios (aHRs) were calculated using Cox proportional hazard models. Glucocorticoid and mineralocorticoid doses were stratified to examine dose-related risks. RESULTS During 8807 person-years (PY), 94 events of first CVD (10.7/1000 PY) in patients with AAD occurred compared with 563 events during 80,163 PY (7.0/1000 PY) in controls. IHD was significantly more common in women (aHR, 2.15; 95% CI, 1.49 to 3.10) but not men (aHR, 1.16; 95% CI, 0.75 to 1.78) with AAD compared with controls. No increase in CeVD risk was detected (aHR, 0.88; 95% CI, 0.56 to 1.37, women; aHR, 0.88; 95% CI 0.53 to 1.50, men). CVD was associated with greater glucocorticoid and mineralocorticoid replacement doses in women but not men. CONCLUSION The risk of IHD but not CeVD is increased in AAD, especially in women. The risk of CVD independently correlated with greater glucocorticoid and mineralocorticoid replacement doses in women. Our data suggest that close monitoring and early treatment of risk factors for CVD, among women in particular, might be warranted.
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Affiliation(s)
- Jakob Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anders Sundström
- Centre for Pharmacoepidemiology, Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Olle Kämpe
- Center for Molecular Medicine, Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- K.G. Jebsen Center for Autoimmune Diseases, University of Bergen, Bergen, Norway
| | - Sophie Bensing
- 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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Salah DB, Charfi N, Elleuch M, Kacem FH, Rekik N, Mnif M, Mnif F, Abid M. [Cardiovascular and metabolic impact of glucocorticoid substitution therapy in patients with Addison's disease]. Pan Afr Med J 2019; 30:251. [PMID: 30627312 PMCID: PMC6307925 DOI: 10.11604/pamj.2018.30.251.12546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/11/2018] [Indexed: 12/01/2022] Open
Abstract
Les études récentes menées chez des patients atteints de maladie d'Addison (MA) ont permis de révéler que cette pathologie, même traitée, reste grevée d'une morbi-mortalité non négligeable. L'objectif de notre étude était de déterminer les effets délétères de la substitution glucocorticoïde au long cours principalement sur le plan métabolique et cardiovasculaire. Il s'agit d'une étude rétrospective qui a inclu 28 patients ayant une MA traitée, évoluant depuis plus que 15 ans. L'âge moyen était de 58,53 ans avec une prédominance féminine à 65%. La durée moyenne de suivi était de 17,87 ans. La dose d'hydrocortisone était initialement à 32,5mg/j (20,52 mg/m2) et à 27,9mg/j (16,41mg/m2) au moment de l'étude. La prévalence du syndrome métabolique (SM) au cours de la MA était de 35,71% après une durée de traitement supérieur à 15 ans. On note au terme du suivi que 28,57% des patients étaient obèses. Vingt-cinq (25)% des patients avaient développé une HTA et un diabète de type 2. La prévalence de la dyslipidémie était passé de 3,57% à 42,85%. Un seul patient avait présenté un infarctus de myocarde à 25 ans de suivi. Les facteurs favorisant la survenue du SM dans notre étude étaient l'ancienneté de la maladie et la perte du poids à la découverte de la maladie. L'ajustement du traitement substitutif au cours de la maladie d'Addison reste un enjeu au vu de la morbi-mortalité liée au surdosage. Un suivi régulier, et une approche thérapeutique personnalisée sont nécessaires pour améliorer le pronostic de ses patients.
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Affiliation(s)
- Dhoha Ben Salah
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Nadia Charfi
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Mouna Elleuch
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Faten Hadj Kacem
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Nabila Rekik
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Mouna Mnif
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Fatma Mnif
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
| | - Mohamed Abid
- Service d'Endocrinologie et Diabétologie du CHU Hédi Chaker Sfax, Tunisie
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Vera FM, Manzaneque JM, Rodríguez FM, Vadillo M, Navajas F, Heiniger AI, Pérez V, Blanca MJ. Assessment of hormonal parameters and psychological well-being in healthy subjects after a Taoist qigong program: An exploratory study. Scand J Psychol 2018; 60:43-49. [PMID: 30428134 DOI: 10.1111/sjop.12501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 09/27/2018] [Indexed: 02/02/2023]
Abstract
Qigong is an ancient form of health maintenance, which is part of Traditional China Medicine. Numerous beneficial mental and physical effects have been classically ascribed to this traditional psychosomatic method. The purpose of this work has been to assess the effects of Taoist qigong practice on several hormonal parameters of the Hipotalamic-Pituitary-Adrenal axis and specific measures of psychological well-being in healthy subjects. Forty-three healthy volunteers participated in the study, of whom 22 were randomly allocated to the experimental group, and 21 were assigned to the control group. Experimental participants underwent a qigong training program for one month. Blood samples for the quantification of hormonal parameters, and several instruments to assess anxiety and depression symptoms as well as subjective sleep quality, were obtained before and after the program. Statistically significant differences were found between the experimental and control groups, with the experimental group showing lower blood levels of adrenocorticotropic hormone (ACTH). This study shows that Taoist qigong is a psychosomatic method able to exert a modulatory action on ACTH levels in healthy subjects. We consider the need to continue exploring the psychobiological modulation of this qigong method and its possible repercussion for human health care.
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Affiliation(s)
| | | | | | | | | | - Ana I Heiniger
- Servicio de Hematología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Vidal Pérez
- Servicio de Análisis Clínicos, Hospital Regional Universitario de Málaga, Málaga, Spain
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Powrie YSL, Smith C. Central intracrine DHEA synthesis in ageing-related neuroinflammation and neurodegeneration: therapeutic potential? J Neuroinflammation 2018; 15:289. [PMID: 30326923 PMCID: PMC6192186 DOI: 10.1186/s12974-018-1324-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 09/24/2018] [Indexed: 02/06/2023] Open
Abstract
It is a well-known fact that DHEA declines on ageing and that it is linked to ageing-related neurodegeneration, which is characterised by gradual cognitive decline. Although DHEA is also associated with inflammation in the periphery, the link between DHEA and neuroinflammation in this context is less clear. This review drew from different bodies of literature to provide a more comprehensive picture of peripheral vs central endocrine shifts with advanced age—specifically in terms of DHEA. From this, we have formulated the hypothesis that DHEA decline is also linked to neuroinflammation and that increased localised availability of DHEA may have both therapeutic and preventative benefit to limit neurodegeneration. We provide a comprehensive discussion of literature on the potential for extragonadal DHEA synthesis by neuroglial cells and reflect on the feasibility of therapeutic manipulation of localised, central DHEA synthesis.
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Affiliation(s)
- Y S L Powrie
- Department of Physiological Sciences, Stellenbosch University, Private Bag X1, Matieland, Stellenbosch, 7602, South Africa
| | - C Smith
- Department of Physiological Sciences, Stellenbosch University, Private Bag X1, Matieland, Stellenbosch, 7602, South Africa.
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Ho W, Druce M. Quality of life in patients with adrenal disease: A systematic review. Clin Endocrinol (Oxf) 2018; 89:119-128. [PMID: 29672878 DOI: 10.1111/cen.13719] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/12/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evaluating the patient with adrenal disease is challenging due to the lack of precise clinical and biochemical parameters for disease control. Quality of life (QOL) evaluation aims to measure the patient's subjective experience. OBJECTIVE To describe how QOL is defined and measured in adrenal disease, critically appraise the use of QOL tools in published literature, discuss the implications of these findings and provide direction for further research in this field. MATERIALS AND METHODS We searched the Cochrane library, EMBASE, Google Scholar, PsycINFO, PubMed, Web of Science databases to identify only primary studies where self-reported QOL was measured as a parameter in adults with confirmed adrenal disease, and results presented in English. Key data were independently extracted from each study and adherence to reporting guidelines evaluated. RESULTS A total of 117 studies involving 13 717 subjects were included. The vast majority of studies did not define QOL. The most common approach was to combine generic and domain-specific tools, although disease-specific tools are increasingly being used. Adherence to reporting guidelines was variable. A narrative synthesis of the findings was performed. CONCLUSION We present the first systematic review of QOL in adrenal disease. Quality of life is reduced in patients with adrenal disease, irrespective of adrenal hyperfunction or hypofunction. Quality of life improved with therapy but was not completely reversed despite biochemical remission. Authors should adhere to consistent reporting practices which are interpretable by clinicians. Further research is required to explain the mechanisms driving impaired QOL and value of QOL evaluations in the clinical context.
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Affiliation(s)
- Winnie Ho
- Centre for Endocrinology, Barts and the London School of Medicine & Dentistry, William Harvey Research Institute, Queen Mary University of London, London, UK
- Department of Endocrinology, Western Health, Melbourne, Vic., Australia
| | - Maralyn Druce
- Centre for Endocrinology, Barts and the London School of Medicine & Dentistry, William Harvey Research Institute, Queen Mary University of London, London, UK
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Elhassan YS, Idkowiak J, Smith K, Asia M, Gleeson H, Webster R, Arlt W, O’Reilly MW. Causes, Patterns, and Severity of Androgen Excess in 1205 Consecutively Recruited Women. J Clin Endocrinol Metab 2018; 103:1214-1223. [PMID: 29342266 PMCID: PMC5868408 DOI: 10.1210/jc.2017-02426] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/09/2018] [Indexed: 12/21/2022]
Abstract
Context Androgen excess in women is predominantly due to underlying polycystic ovary syndrome (PCOS). However, there is a lack of clarity regarding patterns and severity of androgen excess that should be considered predictive of non-PCOS pathology. Objective We examined the diagnostic utility of simultaneous measurement of serum dehydroepiandrosterone sulfate (DHEAS), androstenedione (A4), and testosterone (T) to delineate biochemical signatures and cutoffs predictive of non-PCOS disorders in women with androgen excess. Design Retrospective review of all women undergoing serum androgen measurement at a large tertiary referral center between 2012 and 2016. Serum A4 and T were measured by tandem mass spectrometry and DHEAS by immunoassay. Patients with at least one increased serum androgen underwent phenotyping by clinical notes review. Results In 1205 women, DHEAS, A4, and T were measured simultaneously. PCOS was the most common diagnosis in premenopausal (89%) and postmenopausal women (29%). A4 was increased in all adrenocortical carcinoma (ACC) cases (n = 15) and T in all ovarian hyperthecosis (OHT) cases (n = 7); all but one case of congenital adrenal hyperplasia (CAH; n = 18) were identified by increased levels of A4 and/or T. In premenopausal women, CAH was a prevalent cause of severe A4 (59%) and T (43%) excess; severe DHEAS excess was predominantly due to PCOS (80%). In postmenopausal women, all cases of severe DHEAS and A4 excess were caused by ACC and severe T excess equally by ACC and OHT. Conclusions Pattern and severity of androgen excess are important predictors of non-PCOS pathology and may be used to guide further investigations as appropriate.
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Affiliation(s)
- Yasir S Elhassan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Jan Idkowiak
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Karen Smith
- Department of Clinical Biochemistry, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Miriam Asia
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Helena Gleeson
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Rachel Webster
- Department of Clinical Biochemistry, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Michael W O’Reilly
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
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Group 4: Replacement therapy for adrenal insufficiency. ANNALES D'ENDOCRINOLOGIE 2017; 78:525-534. [DOI: 10.1016/j.ando.2017.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Hong AR, Ryu OH, Kim SY, Kim SW. Characteristics of Korean Patients with Primary Adrenal Insufficiency: A Registry-Based Nationwide Survey in Korea. Endocrinol Metab (Seoul) 2017; 32:466-474. [PMID: 29271619 PMCID: PMC5744733 DOI: 10.3803/enm.2017.32.4.466] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/27/2017] [Accepted: 10/23/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Primary adrenal insufficiency (PAI) is a rare, potentially life-threatening condition. There are few Korean studies on PAI, and most have had small sample sizes. We aimed to examine the etiology, clinical characteristics, treatment, and mortality of PAI in Korean patients. METHODS A nationwide, multicenter, registry-based survey was conducted to identify adults diagnosed with or treated for PAI at 30 secondary or tertiary care institutions in Korea between 2000 and 2014. RESULTS A total of 269 patients with PAI were identified. The prevalence of PAI was 4.17 per million. The estimated incidence was 0.45 per million per year. The mean age at diagnosis was 49.0 years, and PAI was more prevalent in men. Adrenal tuberculosis was the most common cause of PAI in patients diagnosed before 2000; for those diagnosed thereafter, adrenal metastasis and tuberculosis were comparable leading causes. The etiology of PAI was not identified in 34.9% of cases. Of the patients receiving glucocorticoid replacement therapy, prednisolone was more frequently administered than hydrocortisone (69.4% vs. 26.5%, respectively), and only 27.1% of all patients received fludrocortisone. We observed an increased prevalence of metabolic disease and osteoporosis during the follow-up period (median, 60.2 months). The observed overall mortality and disease-specific mortality rates were 11.9% and 3.1%, respectively. CONCLUSION The prevalence of PAI is significantly lower in Koreans than in reports from Western countries. The high frequency undetermined etiology in patients with PAI suggests the need to reveal accurate etiology of PAI in Korea.
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Affiliation(s)
- A Ram Hong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ohk Hyun Ryu
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Seong Yeon Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea.
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Lebbe M, Taylor AE, Visser JA, Kirkman-Brown JC, Woodruff TK, Arlt W. The Steroid Metabolome in the Isolated Ovarian Follicle and Its Response to Androgen Exposure and Antagonism. Endocrinology 2017; 158:1474-1485. [PMID: 28323936 PMCID: PMC5460835 DOI: 10.1210/en.2016-1851] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 02/17/2017] [Indexed: 11/29/2022]
Abstract
The ovarian follicle is a major site of steroidogenesis, crucially required for normal ovarian function and female reproduction. Our understanding of androgen synthesis and metabolism in the developing follicle has been limited by the sensitivity and specificity issues of previously used assays. Here we used liquid chromatography-tandem mass spectrometry to map the stage-dependent endogenous steroid metabolome in an encapsulated in vitro follicle growth system, from murine secondary through antral follicles. Furthermore, follicles were cultured in the presence of androgen precursors, nonaromatizable active androgen, and androgen receptor (AR) antagonists to assess effects on steroidogenesis and follicle development. Cultured follicles showed a stage-dependent increase in endogenous androgen, estrogen, and progesterone production, and incubations with the sex steroid precursor dehydroepiandrosterone revealed the follicle as capable of active androgen synthesis at early developmental stages. Androgen exposure and antagonism demonstrated AR-mediated effects on follicle growth and antrum formation that followed a biphasic pattern, with low levels of androgens inducing more rapid follicle maturation and high doses inhibiting oocyte maturation and follicle growth. Crucially, our study provides evidence for an intrafollicular feedback circuit regulating steroidogenesis, with decreased follicle androgen synthesis after exogenous androgen exposure and increased androgen output after additional AR antagonist treatment. We propose that this feedback circuit helps maintain an equilibrium of androgen exposure in the developing follicle. The observed biphasic response of follicle growth and function in increasing androgen supplementations has implications for our understanding of polycystic ovary syndrome pathophysiology and the dose-dependent utility of androgens in in vitro fertilization settings.
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Affiliation(s)
- Marie Lebbe
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
- Division of Reproductive Science in Medicine, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611
| | - Angela E. Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Jenny A. Visser
- Department of Internal Medicine, Erasmus MC, 3015 CN Rotterdam, The Netherlands
| | - Jackson C. Kirkman-Brown
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
- Tommy’s National Centre for Miscarriage Research, Birmingham Women’s Hospital NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - Teresa K. Woodruff
- Division of Reproductive Science in Medicine, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, United Kingdom
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Handelsman DJ, Matsumoto AM, Gerrard DF. Doping Status of DHEA Treatment for Female Athletes with Adrenal Insufficiency. Clin J Sport Med 2017; 27:78-85. [PMID: 26844622 DOI: 10.1097/jsm.0000000000000300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To review the doping status of dehydroepiandrosterone (DHEA) for female athletes with adrenal insufficiency within the framework of Therapeutic Use Exemption (TUE) applications for this proandrogen, which is included on the World Anti-Doping Agency (WADA)'s Prohibited List. DATA SOURCES AND MAIN RESULTS Current knowledge of adrenal pathophysiology with a focus on the physiological role and pharmacological effects of DHEA in female athletes including placebo-controlled clinical trials of DHEA and consensus clinical practice and prescribing guidelines. CONCLUSIONS Because there is no convincing clinical evidence to support the use of DHEA replacement therapy in women with adrenal failure, a TUE for DHEA is not justified by definite health benefit for either secondary or primary adrenal failure. This is consistent with the 2014 update of the US Endocrine Society guidelines, meta-analyses of DHEA treatment in women with or without adrenal failure, current WADA TUE guidance document for adrenal insufficiency and recent case law of WADA's Court of Arbitration for Sport.
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Affiliation(s)
- David J Handelsman
- *ANZAC Research Institute, University of Sydney, Concord Hospital, New South Wales, Australia; †Geriatric Research, Education and Clinical Center, VA Puget Sound Health Care System, and Department of Medicine, University of Washington School of Medicine, Seattle, Washington; and ‡Dunedin School of Medicine, University of Otago, New Zealand Chair, WADA TUE Expert Group, Dunedin, New Zealand
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van der Valk ES, Smans LCCJ, Hofstetter H, Stubbe JH, de Vries M, Backx FJG, Hermus ARMM, Zelissen PMJ. Decreased physical activity, reduced QoL and presence of debilitating fatigue in patients with Addison's disease. Clin Endocrinol (Oxf) 2016; 85:354-60. [PMID: 26953557 DOI: 10.1111/cen.13059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/27/2016] [Accepted: 03/04/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Health-related quality of life in patients with Addison's disease has been assessed in various European countries, indicating a reduced quality of life. However, no studies have addressed the impact of Addison's disease on physical activity. OBJECTIVE The aim of this study was to investigate the quality of life in Dutch patients with Addison's disease particularly regarding the presence of fatigue and the ability to be physically active. METHODS In this cross-sectional study, a postal survey was performed among Dutch patients with Addison's disease on stable glucocorticoid replacement therapy with hydrocortisone or cortisone acetate. For quality of life and physical activity assessment, patients completed general and health-related quality of life and physical activity questionnaires, and scores were compared to Dutch controls. RESULTS A total of 328 patients with Addison's disease were studied. In patients with Addison's disease, only 45·7% met the standard of physical activity (Combinorm) compared to 67·8% of Dutch controls (P < 0·01). Forty-eight per cent of patients showed abnormal fatigue, while 61% had severe fatigue. The CIS fatigue scores were significantly higher compared to controls (P < 0·01). We found reduced general subjective health-related QoL scores in both male and female patients, especially in younger patients <65 years of age. CONCLUSION Physical activity is decreased in patients with Addison's disease, combined with a reduced subjective health-related QoL and increased fatigue.
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Affiliation(s)
| | - Lisanne C C J Smans
- Department of Internal Medicine and Endocrinology, University Medical Center, Utrecht, the Netherlands
| | | | - Janine H Stubbe
- Amsterdam university of applied sciences and University of the arts, Codarts Rotterdam, Rotterdam, the Netherlands
| | - Marieke de Vries
- Department of Internal Medicine and Endocrinology, University Medical Center, Utrecht, the Netherlands
| | - Frank J G Backx
- Clinical Sports Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ad R M M Hermus
- Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Pierre M J Zelissen
- Department of Internal Medicine and Endocrinology, University Medical Center, Utrecht, the Netherlands
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Bensing S, Hulting AL, Husebye ES, Kämpe O, Løvås K. MANAGEMENT OF ENDOCRINE DISEASE: Epidemiology, quality of life and complications of primary adrenal insufficiency: a review. Eur J Endocrinol 2016; 175:R107-16. [PMID: 27068688 DOI: 10.1530/eje-15-1242] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/06/2016] [Indexed: 12/13/2022]
Abstract
In this article, we review published studies covering epidemiology, natural course and mortality in primary adrenal insufficiency (PAI) or Addison's disease. Autoimmune PAI is a rare disease with a prevalence of 100-220 per million inhabitants. It occurs as part of an autoimmune polyendocrine syndrome in more than half of the cases. The patients experience impaired quality of life, reduced parity and increased risk of preterm delivery. Following a conventional glucocorticoid replacement regimen leads to a reduction in bone mineral density and an increase in the prevalence of fractures. Registry studies indicate increased mortality, especially evident in patients diagnosed with PAI at a young age and in patients with the rare disease autoimmune polyendocrine syndrome type-1. Most notably, unnecessary deaths still occur because of adrenal crises. All these data imply the need to improve the therapy and care of patients with PAI.
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Affiliation(s)
- Sophie Bensing
- Department of Molecular Medicine and SurgeryKarolinska Institutet, and Department of Endocrinology, Diabetes and Metabolism, Karolinska University Hospital, Stockholm, Sweden
| | - Anna-Lena Hulting
- Department of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - Eystein S Husebye
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway Department of MedicineHaukeland University Hospital, Bergen, Norway
| | - Olle Kämpe
- Department of Medicine (Solna)Centre for Molecular Medicine, Karolinska Institutet, and Department of Endocrinology, Diabetes and Metabolism, Karolinska University Hospital, Stockholm, Sweden
| | - Kristian Løvås
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway Department of MedicineHaukeland University Hospital, Bergen, Norway
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Uçar A, Öner N, Özek G, Çetinçakmak MG, Abuhandan M, Yıldırım A, Kaya C, Ünverdi S, Emeksiz HC, Yılmaz Y, Yetim A. Evaluation of the glucocorticoid, mineralocorticoid, and adrenal androgen secretion dynamics in a large cohort of patients aged 6-18 years with transfusion-dependent β-thalassemia major, with an emphasis on the impact of cardiac iron load. Endocrine 2016; 53:240-8. [PMID: 26839091 DOI: 10.1007/s12020-016-0872-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 01/16/2016] [Indexed: 11/29/2022]
Abstract
The variable presence of adrenal insufficiency (AI) due to hypocortisolemia (HC) in patients with thalassemia is well established; however, the prevalence of adrenocortical hypofunction (ACH) in the zona glomerulosa and zona reticularis of the adrenal cortex is unknown. To establish the prevalence of ACH, we examined the cortisol response to 1-µg and 250-µg ACTH tests, plasma aldosterone (A)/plasma renin activity (PRA) ratio, and serum dehydroepiandrosterone sulfate (DHEAS) levels in a large cohort of patients with thalassemia, and to investigate the impact of total body iron load (TBIL) on adrenocortical function. The setting used was University hospital and government-based tertiary care center. One hundred twenty-one (52 females) patients with β-thalassemia major (β-TM) and 72 healthy peers (38 females) were enrolled. The patients underwent a 250-µg cosyntropin test if their peak cortisol was <500 nmol/L in a 1-µg cosyntropin test. Magnetic resonance imaging (MRI) was performed to assess the MRI-based liver iron content and cardiac MRI T2* iron. The associations between ACH and TBIL were investigated. The patients with thalassemia had lower ACTH, cortisol, DHEAS, and A/PRA values compared with the controls (p < 0.001). Thirty-nine patients (32.2 %) had HC [primary (n = 1), central (n = 36), combined (n = 2)], and 47 (38.8 %) patients had reduced DHEAS levels; 29 (24.0 %) patients had reduced A/PRA ratios. Forty-six (38.0 %) patients had hypofunction in one of the adrenal zones, 26 (21.5 %) had hypofunction in two adrenal zones, and 9 (7.4 %) had hypofunction in all three zones. Patient age and TBIL surrogates were significant independent parameters associated with ACH. Cardiac MRI T2* iron was the only significant parameter that predicted the severity of ACH at a cut-off of 20.6 ms, with 81 % sensitivity and 78 % specificity. Patients with thalassemia have a high prevalence of AI due to HC and zona glomerulosa and zona reticularis hypofunction. TBIL surrogates can predict ACH, but cardiac iron was the only surrogate that was adequately sensitive to predict the severity of ACH.
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Affiliation(s)
- Ahmet Uçar
- Department of Paediatric Endocrinology & Diabetes, Şişli Hamidiye Etfal Education & Research Hospital, Istanbul, Turkey.
| | - Nergiz Öner
- Department of Paediatric Hematology & Oncology, Children's State Hospital of Sanliurfa, Sanliurfa, Turkey
| | - Gülcihan Özek
- Department of Paediatric Hematology & Oncology, Children's State Hospital of Sanliurfa, Sanliurfa, Turkey
| | | | - Mahmut Abuhandan
- Department of Paediatrics, Harran School of Medicine, Harran University, Sanliurfa, Turkey
| | - Ali Yıldırım
- Department of Paediatric Cardiology, Children's State Hospital of Sanliurfa, Sanliurfa, Turkey
| | - Cemil Kaya
- Department of Paediatrics, Children's State Hospital of Sanliurfa, Sanliurfa, Turkey
| | - Sena Ünverdi
- Department of Paediatric Radiology, Children's State Hospital of Sanliurfa, Sanliurfa, Turkey
| | - Hamdi Cihan Emeksiz
- Department of Paediatric Endocrinology & Diabetes, Trabzon Kanuni Education & Research Hospital, Trabzon, Turkey
| | - Yasin Yılmaz
- Department of Paediatrics, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Aylin Yetim
- Department of Adolescent Medicine, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
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Dumic M, Putarek NR, Kusec V, Barisic N, Koehler K, Huebner A. Low bone mineral density for age/osteoporosis in triple A syndrome-an overlooked symptom of unexplained etiology. Osteoporos Int 2016; 27:521-6. [PMID: 26243364 DOI: 10.1007/s00198-015-3265-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 07/24/2015] [Indexed: 01/11/2023]
Abstract
UNLABELLED Triple A syndrome (alacrima, achalasia, adrenal failure, progressive neurodegenerative disease) is caused by mutations in the AAAS gene which encodes the protein alacrima achalasia adrenal insufficiency neurologic disorder (ALADIN). Our investigation suggests that low bone mineral density (BMD) for age/osteoporosis could be a common but overlooked symptom of unexplained etiology in this rare multisystemic disease. INTRODUCTION The purpose of this study is to evaluate incidence and etiology of BMD for age/osteoporosis, a possibly overlooked symptom in triple A syndrome. METHODS Dual-energy X-ray absorptiometry (DXA) of the femoral neck, total hip, lumbar spine, and radius, bone turnover markers, minerals, total alkaline phosphatase (ALP), 25-hydroxy vitamin D (25-OHD), 1,25-dihydroxy vitamin D (1,25-OH2D), intact parathyroid hormone (PTH), and adrenal androgens (dehydroepiandrosterone sulfate (DHEAS) and androstenedione) were measured in five male and four female patients. RESULTS At time of diagnosis, low BMD for age was suspected on X-ray in seven of nine patients aged 2-11 years (not performed in two patients); normal levels of minerals and ALP were found in nine patients and low levels of adrenal androgens in eight patients (not measured in one patient). Reevaluation 5-35 years after introduction of 12 mg/m(2)/day hydrocortisone showed low BMD for age in two children, osteopenia in one, and osteoporosis in six adults. Normal levels of minerals, ALP, PTH, 1,25-OH2D, procollagen type 1, crosslaps, and osteocalcin were found in all patients. Low levels of adrenal androgens were found in all and 25OHD deficiency in six patients. Body mass index was <25 % for age and sex in eight of nine patients. CONCLUSION Low BMD for age/osteoporosis in our patients probably is not a result of glucocorticoid therapy but could be the consequence of low level of adrenal androgens, neurological impairment causing physical inactivity, inadequate sun exposure, and protein malnutrition secondary to achalasia. Considering ubiquitous ALADIN expression, low BMD/osteoporosis may be a primary phenotypic feature of the disease. Besides optimizing glucocorticoid dose, physical activity, adequate sun exposure, appropriate nutrition, and vitamin D supplementation, therapy with DHEA should be considered.
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Affiliation(s)
- M Dumic
- Department of Pediatrics, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Kispaticeva 12, 10000, Zagreb, Croatia.
| | - N R Putarek
- Department of Pediatrics, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Kispaticeva 12, 10000, Zagreb, Croatia
| | - V Kusec
- Klinik für Kinder-und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - N Barisic
- Department of Pediatrics, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Kispaticeva 12, 10000, Zagreb, Croatia
| | - K Koehler
- Klinik für Kinder-und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - A Huebner
- Klinik für Kinder-und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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Chandy DD, Bhatia E. BONE MINERAL DENSITY IN PATIENTS WITH ADDISON DISEASE ON REPLACEMENT THERAPY WITH PREDNISOLONE. Endocr Pract 2015; 22:434-9. [PMID: 26684152 DOI: 10.4158/ep151014.or] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In primary adrenal insufficiency (PAI), replacement with prednisolone may result in lower bone mineral density (BMD) compared with hydrocortisone therapy. However, the number of patients studied on prednisolone is small and the results are conflicting. We conducted a cross-sectional study to determine BMD and its relation with therapy in patients on physiologic doses of prednisolone replacement. METHODS Forty-one consecutive patients (31 males, age [mean ± SD] 50.9 ± 13.0 years), receiving prednisolone (hydrocortisone equivalent [HCE] 13.0 ± 3.0 mg/m(2)) for 104 ± 95 months were studied. BMD was evaluated by dual-energy X-ray absorptiometry and compared with an age- and sex-matched reference group of healthy Indian subjects (n = 677). RESULTS Among males, BMD Z-scores (mean [95% confidence interval {CI}]) at lumbar spine (-0.42 [-0.80, -0.04]), femoral neck (-0.50 [-0.95, -0.06]) and total hip (-0.58 [-0.90, -0.26]) were significantly lower than the reference population. Z-scores in female patients did not differ from controls. Among postmenopausal females and males >50 years, 43% had osteoporosis (T-score ≤-2.5), as compared with 25% in the reference group (P = .04). There was no correlation between BMD Z-scores and HCE dose or duration of therapy. On multivariate regression analysis, body mass index was the only significant predictor of BMD. A high proportion of males (45%) had low serum testosterone (<300 ng/dL), but there was no correlation between testosterone and BMD. CONCLUSIONS Male patients with PAI receiving physiologic prednisolone replacement had a small but significant diminution in BMD at all sites.
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Lee P, Greenfield JR. What is the optimal bone-preserving strategy for patients with Addison's disease? Clin Endocrinol (Oxf) 2015; 83:157-61. [PMID: 25640730 DOI: 10.1111/cen.12730] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 01/14/2015] [Accepted: 01/26/2015] [Indexed: 11/30/2022]
Abstract
Addison's disease is associated with low bone mineral density and increased risk of hip fractures. Causes are multifactorial, contributed by underlying adrenocortical hormonal deficiency, associated autoimmune endocrinopathies, electrolyte disturbances and, in some patients, supraphysiologic glucocorticoid replacement. Recent realization of physiologic cortisol production rate has revised downwards glucocorticoid replacement dosages. Meanwhile, new research has emerged suggesting complex interplay between sodium and calcium homoeostasis under the influence of mineralocorticoid and parathyroid hormone that may impact bone health. As the prevalence of Addison's disease is rising, and osteoporosis and fractures are associated with significant morbidity and increased mortality, attention to bone preservation in Addison's disease is of clinical relevance and importance. We suggest an approach to bone health in Addison's disease integrating physiologic adrenocortical hormonal replacement with electrolyte and mineral homoeostasis optimization.
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Affiliation(s)
- Paul Lee
- Department of Endocrinology, St Vincent's Hospital and Diabetes and Metabolism Branch, Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Jerry R Greenfield
- Department of Endocrinology, St Vincent's Hospital and Diabetes and Metabolism Branch, Garvan Institute of Medical Research, Sydney, NSW, Australia
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Shohat-Tal A, Sen A, Barad DH, Kushnir V, Gleicher N. Genetics of androgen metabolism in women with infertility and hypoandrogenism. Nat Rev Endocrinol 2015; 11:429-41. [PMID: 25942654 DOI: 10.1038/nrendo.2015.64] [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] [Indexed: 12/11/2022]
Abstract
Hypoandrogenism in women with low functional ovarian reserve (LFOR, defined as an abnormally low number of small growing follicles) adversely affects fertility. The androgen precursor dehydroepiandrosterone (DHEA) is increasingly used to supplement treatment protocols in women with LFOR undergoing in vitro fertilization. Due to differences in androgen metabolism, however, responses to DHEA supplementation vary between patients. In addition to overall declines in steroidogenic capacity with advancing age, genetic factors, which result in altered expression or enzymatic function of key steroidogenic proteins or their upstream regulators, might further exacerbate variations in the conversion of DHEA to testosterone. In this Review, we discuss in vitro studies and animal models of polymorphisms and gene mutations that affect the conversion of DHEA to testosterone and attempt to elucidate how these variations affect female hormone profiles. We also discuss treatment options that modulate levels of testosterone by targeting the expression of steroidogenic genes. Common variants in genes encoding DHEA sulphotransferase, aromatase, steroid 5α-reductase, androgen receptor, sex-hormone binding globulin, fragile X mental retardation protein and breast cancer type 1 susceptibility protein have been implicated in androgen metabolism and, therefore, can affect levels of androgens in women. Short of screening for all potential genetic variants, hormonal assessments of patients with low testosterone levels after DHEA supplementation facilitate identification of underlying genetic defects. The genetic predisposition of patients can then be used to design individualized fertility treatments.
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Affiliation(s)
- Aya Shohat-Tal
- Center for Human Reproduction, 21 E. 69th Street, New York, NY 10021, USA
| | - Aritro Sen
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - David H Barad
- Center for Human Reproduction, 21 E. 69th Street, New York, NY 10021, USA
| | - Vitaly Kushnir
- Center for Human Reproduction, 21 E. 69th Street, New York, NY 10021, USA
| | - Norbert Gleicher
- Center for Human Reproduction, 21 E. 69th Street, New York, NY 10021, USA
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Abstract
Dehydroepiandrosterone (DHEA) and its sulfated form dehydroepiandrosterone sulfate (DHEAS) are the most abundant circulating steroid hormones in humans. In animal studies, their low levels have been associated with age-related involuntary changes, including reduced lifespan. Extrapolation of animal data to humans turned DHEA into a 'superhormone' and an 'anti-aging' panacea. It has been aggressively marketed and sold in large quantities as a dietary supplement. Recent double-blind, placebo-controlled human studies provided evidence to support some of these claims. In the elderly, DHEA exerts an immunomodulatory action, increasing the number of monocytes, T cells expressing T-cell receptor gamma/delta (TCRγδ) and natural killer (NK) cells. It improves physical and psychological well-being, muscle strength and bone density, and reduces body fat and age-related skin atrophy stimulating procollagen/sebum production. In adrenal insufficiency, DHEA restores DHEA/DHEAS and androstenedione levels, reduces total cholesterol, improves well-being, sexual satisfaction and insulin sensitivity, and prevents loss of bone mineral density. Normal levels of CD4+CD25(hi) and FoxP3 (forkhead box P3) are restored. In systemic lupus erythematosus, DHEA is steroid-sparing. In an unblinded study, it induced remission in the majority of patients with inflammatory bowel disease. DHEA modulates cardiovascular signalling pathways and exerts an anti-inflammatory, vasorelaxant and anti-remodelling effect. Its low levels correlate with increased cardiovascular disease and all-cause mortality. DHEA/DHEAS appear protective in asthma and allergy. It attenuates T helper 2 allergic inflammation, and reduces eosinophilia and airway hyperreactivity. Low levels of DHEAS accompany adrenal suppression. It could be used to screen for the side effects of steroids. In women, DHEA improves sexual satisfaction, fertility and age-related vaginal atrophy. Many factors are responsible for the inconsistent/negative results of some studies. Overreliance on animal models (DHEA is essentially a human molecule), different dosing protocols with non-pharmacological doses often unachievable in humans, rapid metabolism of DHEA, co-morbidities and organ-specific differences render data interpretation difficult. Nevertheless, a growing body of evidence supports the notion that DHEA is not just an overrated dietary supplement but a useful drug for some, but not all, human diseases. Large-scale randomised controlled trials are needed to fine-tune the indications and optimal dosing protocols before DHEA enters routine clinical practice.
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Khanna A, Khurana R, Kyriacou A, Davies R, Ray DW. Management of adrenocortical insufficiency with continuous subcutaneous hydrocortisone infusion: long-term experience in three patients. Endocrinol Diabetes Metab Case Rep 2015; 2015:150005. [PMID: 26124953 PMCID: PMC4482159 DOI: 10.1530/edm-15-0005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 04/27/2015] [Indexed: 11/12/2022] Open
Abstract
To assess continuous subcutaneous hydrocortisone infusion (CSHI) in patients with adrenocortical insufficiency (AI) and difficulties with oral replacement. Three patients with AI and frequent hospital admissions attributed to adrenal crises were treated with CSHI, which was delivered via a continuous subcutaneous infusion. All three patients preferred CSHI and remained on it long term, which permitted prolonged follow-up analysis. All three patients reported symptomatic improvement, and in two cases, reduced hospital admission rates and inpatient stay lengths were observed. The cost of hospital admissions and overall treatment was reduced in all cases. CSHI offers a practical and acceptable alternative to oral replacement in a subset of patients with AI. The cost of initiating and maintaining the pump is offset in the long term by reduced frequency and duration of emergency admissions. CSHI can therefore be considered in a select group of patients who are resistant to treatment with conventional oral glucocorticoids.
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Affiliation(s)
- A Khanna
- Faculty of Medical and Health Sciences , University of Manchester , Manchester, M13 9PT , UK
| | - R Khurana
- Central Manchester University Hospitals NHS Foundation Trust , Manchester, M13 9WL , UK
| | - A Kyriacou
- University Hospital of South Manchester , Manchester, M23 9LT , UK
| | - R Davies
- Central Manchester University Hospitals NHS Foundation Trust , Manchester, M13 9WL , UK
| | - D W Ray
- Faculty of Medical and Health Sciences , University of Manchester , Manchester, M13 9PT , UK ; Central Manchester University Hospitals NHS Foundation Trust , Manchester, M13 9WL , UK
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