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Mazzeo P, Tizianel I, Galuppini F, Sbaraglia M, Barbot M. Uncommon adrenal rest tumors and massive adrenal enlargement in adult with congenital adrenal hyperplasia mimicking metastasis from pleomorphic sarcoma. BMC Endocr Disord 2024; 24:103. [PMID: 38977992 PMCID: PMC11229217 DOI: 10.1186/s12902-024-01635-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/26/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH) encompassed a bunch of autosomal recessive disorders characterized by impaired cortisol levels due to an enzymatic deficiency in steroid synthesis. In adult male patients with CAH, a frequent complication related to poor disease control is the development of ectopic adrenocortical tissue in the testes, named testicular adrenal rest tumors (TART). Conversely, ovarian adrenal rest tumors (OART) in females are extremely rare and adrenal rests in sites other than gonads are so uncommon to have been described only few times in literature. CASE PRESENTATION We report a case of a male patient with untreated CAH and oncologic history of pleomorphic sarcoma who presented with massive bilateral adrenal enlargement and adrenal rest tumors in peri-lumbar and peri-cecal sites, which mimicked metastasis from sarcoma. CONCLUSIONS The development of massive adrenal enlargement and ectopic adrenal rest tumors in sites other than gonads, even if very uncommon, should be suspected in patients with CAH and prolonged periods of undertreatment.
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Affiliation(s)
- Pierluigi Mazzeo
- Department of Medicine DIMED, University of Padua, Padua, Italy
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Via Ospedale Civile, Padua, 105 - 35128, Italy
| | - Irene Tizianel
- Department of Medicine DIMED, University of Padua, Padua, Italy
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Via Ospedale Civile, Padua, 105 - 35128, Italy
| | - Francesca Galuppini
- Department of Medicine DIMED, University of Padua, Padua, Italy
- Pathology Unit, University-Hospital of Padua, Padua, Italy
| | - Marta Sbaraglia
- Department of Medicine DIMED, University of Padua, Padua, Italy
- Pathology Unit, University-Hospital of Padua, Padua, Italy
| | - Mattia Barbot
- Department of Medicine DIMED, University of Padua, Padua, Italy.
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Via Ospedale Civile, Padua, 105 - 35128, Italy.
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Ridder LO, Balle CM, Skakkebæk A, Lind-Holst M, Nielsen MM, Hermann P, Hansen S, Nielsen DG, Knorr S, Andersen NH, Viuff MH, Berglund A, Gravholt CH. Endocrine, cardiac and neuropsychological aspects of adult congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2024; 100:515-526. [PMID: 38572909 DOI: 10.1111/cen.15055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE To investigate the metabolic, cardiovascular, and neuropsychological phenotype, quality of life (QoL), and hormonal regulation in individuals with congenital adrenal hyperplasia (CAH), a group of autosomal recessive disorders characterized by impaired synthesis of cortisol in the adrenal cortex and, if untreated compensatory hyperandrogenism. CAH is associated with an increased cardiovascular and metabolic morbidity, possibly due to overtreatment with glucocorticoids, leading to weight gain, insulin resistance, and metabolic syndrome. DESIGN, PARTICIPANTS, MEASUREMENTS Thirty-seven individuals with CAH and 33 age- and sex-matched controls were evaluated at a single centre at Aarhus University Hospital with echocardiography, electrocardiogram, 24-h blood pressure, biochemistry, anthropometrics, and autism spectrum, anxiety, depression, personality, cognitive failures, and QoL were assessed using questionnaires. RESULTS CAH individuals had lower height than controls (170.5 vs. 182.9 cm in males and 160.2 vs. 170.1 cm in females, p < 0.01). Compared with female controls, females with CAH had higher haemoglobin (8.8 vs. 8.2 mmol/L, p = 0.003) and BMI (29.7 vs. 25.5 kg/m2, p = 0.006), reduced insulin sensitivity (HOMA-IR): 2.7 vs. 1.9, p = 0.018), prolonged E-wave deceleration time (193 vs. 174 cm, p = 0.015), and E/é ratios (5.4 vs. 4.5, p = 0.017), and lower self-reported QoL. Males with CAH had more cognitive complaints (p = 0.034) and higher autistic scores (19.9 vs. 14.9; p = 0.068) compared with male controls. More individuals with CAH than controls reported writing problems. CONCLUSION A sex-specific comorbidity profile is evident in CAH, with females presenting with decreased metabolic and overall self-reported health, whereas males with CAH presented with increased cognitive complaints and autistic traits.
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Affiliation(s)
- Lukas Ochsner Ridder
- Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Anne Skakkebæk
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Marie Lind-Holst
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Mølby Nielsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Pernille Hermann
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Stinus Hansen
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | | | - Sine Knorr
- Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Steno Diabetes Center, Aarhus University Hospital, Aarhus, Denmark
| | | | - Mette Hansen Viuff
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Agnethe Berglund
- Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
| | - Claus Højbjerg Gravholt
- Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Tschaidse L, Wimmer S, Nowotny HF, Auer MK, Lottspeich C, Dubinski I, Schiergens KA, Schmidt H, Quinkler M, Reisch N. Frequency of stress dosing and adrenal crisis in paediatric and adult patients with congenital adrenal hyperplasia: a prospective study. Eur J Endocrinol 2024; 190:275-283. [PMID: 38584334 DOI: 10.1093/ejendo/lvae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/03/2024] [Accepted: 02/06/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE Patients with congenital adrenal hyperplasia (CAH) require life-long glucocorticoid replacement, including stress dosing (SD). This study prospectively assessed adrenal crisis (AC) incidence, frequency, and details of SD and disease knowledge in adult and paediatric patients and their parents. DESIGN Prospective, observational study. METHODS Data on AC and SD were collected via a patient diary. In case of AC, medical records were reviewed and patient interviews conducted. Adherence to sick day rules of the German Society of Endocrinology (DGE) and disease knowledge using the German version of the CAH knowledge assessment questionnaire (CAHKAQ) were assessed. RESULTS In 187 adult patients, the AC incidence was 8.4 per 100 patient years (py) and 5.1 in 100 py in 38 children. In adults, 195.4 SD episodes per 100 py were recorded, in children 169.7 per 100 py. In children 72.3% and in adults 34.8%, SD was performed according to the recommendations. Children scored higher on the CAHKAQ than adults (18.0 [1.0] vs 16.0 [4.0]; P = .001). In adults, there was a positive correlation of the frequency of SD and the incidence of AC (r = .235, P = .011) and CAHKAQ score (r = .233, P = .014), and between the incidence of AC and CAHKAQ (r = .193, P = .026). CONCLUSION The AC incidence and frequency of SD in children and adults with CAH are high. In contrast to the paediatric cohort, the majority of SD in adults was not in accordance with the DGE recommendations, underlining the need for structured and repeated education of patients with particular focus on transition.
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Affiliation(s)
- Lea Tschaidse
- Department of Medicine IV, LMU University Hospital, LMU Munich, 80336 Munich, Germany
| | - Sophie Wimmer
- Department of Medicine IV, LMU University Hospital, LMU Munich, 80336 Munich, Germany
| | - Hanna F Nowotny
- Department of Medicine IV, LMU University Hospital, LMU Munich, 80336 Munich, Germany
| | - Matthias K Auer
- Department of Medicine IV, LMU University Hospital, LMU Munich, 80336 Munich, Germany
| | - Christian Lottspeich
- Department of Medicine IV, LMU University Hospital, LMU Munich, 80336 Munich, Germany
| | - Ilja Dubinski
- Department of Paediatrics, Division of Paediatric Endocrinology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Katharina A Schiergens
- Department of Paediatrics, Division of Paediatric Endocrinology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Heinrich Schmidt
- Department of Paediatrics, Division of Paediatric Endocrinology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, 80336 Munich, Germany
| | | | - Nicole Reisch
- Department of Medicine IV, LMU University Hospital, LMU Munich, 80336 Munich, Germany
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Kiewert C, Jedanowski J, Hauffa BP, Petersenn S, Mann K, Führer D, Unger N. Transition from Paediatric to Adult Care in CAH: 20 Years of Experience at a Tertiary Referral Center. Horm Metab Res 2024; 56:45-50. [PMID: 38171370 DOI: 10.1055/a-2201-6548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Transition medicine aims at the coordinated transfer of young patients with a chronic disease from paediatric to adult care. The present study reflects 20 years of experience in transitioning patients with congenital adrenal hyperplasia (CAH) in a single center setting. Our endocrine transition-clinic was established in 2002 and offers joint paediatric and adult consultations. Data were evaluated retrospectively from 2002 to 2005 and 2008 to present. Fifty-nine patients (29 males) were transferred. Median age was 18.4 years (17.6-23.6). Ninety percent of the patients presented with 21-hydroxlase-deficiency (21-OHD), 38 patients (23 m) with salt-wasting (sw), 7 (1 m) with simple-virilising (sv) and 8 (3 m) with the non-classic (nc) form. Rarer enzyme deficiencies were found in 6 cases: 17α-OHD (2 sisters), P450-oxidoreductase-deficiency (2 siblings), 3β-hydroxysteroid-dehydrogenase-deficiency (1 m) and 11β-OHD (1 female). Thirty-four patients (57.6%, 20 m) are presently still attending the adult clinic, 1 patient (1.7%, m) moved away and 24 (40.7%, 8 m) were lost to follow-up (13 sw-21-OHD, 6 sv-21-OHD, 5 nc-21-OHD). Thirty-seven patients (62.7%) attended the adult clinic for >2 years after transfer, 17 (28.8%) for >10 years. In the lost to follow-up group, median time of attendance was 16.3 months (0-195.2). Defining a successful transfer as two or more visits in the adult department after initial consultation in the transition clinic, transfer was efficient in 84.7% of the cases. A seamless transfer to adult care is essential for adolescents with CAH. It requires a continuous joint support during the transition period, remains challenging, and necessitates adequate funding.
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Affiliation(s)
- Cordula Kiewert
- Division of Paediatric Endocrinology and Diabetes, Member of ENDO-ERN, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Julia Jedanowski
- Department of Endocrinology, Diabetes and Metabolism, Member of ENDO-ERN, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Berthold P Hauffa
- Division of Paediatric Endocrinology and Diabetes, Member of ENDO-ERN, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany, and University of Duisburg-Essen, Germany
| | - Klaus Mann
- Department of Endocrinology, Diabetes and Metabolism, Member of ENDO-ERN, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Dagmar Führer
- Department of Endocrinology, Diabetes and Metabolism, Member of ENDO-ERN, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Nicole Unger
- Department of Endocrinology, Diabetes and Metabolism, Member of ENDO-ERN, University Hospital Essen, University of Duisburg-Essen, Germany
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Lee SC, Baranowski ES, Sakremath R, Saraff V, Mohamed Z. Hypoglycaemia in adrenal insufficiency. Front Endocrinol (Lausanne) 2023; 14:1198519. [PMID: 38053731 PMCID: PMC10694272 DOI: 10.3389/fendo.2023.1198519] [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: 04/01/2023] [Accepted: 07/26/2023] [Indexed: 12/07/2023] Open
Abstract
Adrenal insufficiency encompasses a group of congenital and acquired disorders that lead to inadequate steroid production by the adrenal glands, mainly glucocorticoids, mineralocorticoids and androgens. These may be associated with other hormone deficiencies. Adrenal insufficiency may be primary, affecting the adrenal gland's ability to produce cortisol directly; secondary, affecting the pituitary gland's ability to produce adrenocorticotrophic hormone (ACTH); or tertiary, affecting corticotrophin-releasing hormone (CRH) production at the level of the hypothalamus. Congenital causes of adrenal insufficiency include the subtypes of Congenital Adrenal Hyperplasia, Adrenal Hypoplasia, genetic causes of Isolated ACTH deficiency or Combined Pituitary Hormone Deficiencies, usually caused by mutations in essential transcription factors. The most commonly inherited primary cause of adrenal insufficiency is Congenital Adrenal Hyperplasia due to 21-hydroxylase deficiency; with the classical form affecting 1 in 10,000 to 15,000 cases per year. Acquired causes of adrenal insufficiency can be subtyped into autoimmune (Addison's Disease), traumatic (including haemorrhage or infarction), infective (e.g. Tuberculosis), infiltrative (e.g. neuroblastoma) and iatrogenic. Iatrogenic acquired causes include the use of prolonged exogenous steroids and post-surgical causes, such as the excision of a hypothalamic-pituitary tumour or adrenalectomy. Clinical features of adrenal insufficiency vary with age and with aetiology. They are often non-specific and may sometimes become apparent only in times of illness. Features range from those related to hypoglycaemia such as drowsiness, collapse, jitteriness, hypothermia and seizures. Features may also include signs of hypotension such as significant electrolyte imbalances and shock. Recognition of hypoglycaemia as a symptom of adrenal insufficiency is important to prevent treatable causes of sudden deaths. Cortisol has a key role in glucose homeostasis, particularly in the counter-regulatory mechanisms to prevent hypoglycaemia in times of biological stress. Affected neonates particularly appear susceptible to the compromise of these counter-regulatory mechanisms but it is recognised that affected older children and adults remain at risk of hypoglycaemia. In this review, we summarise the pathogenesis of hypoglycaemia in the context of adrenal insufficiency. We further explore the clinical features of hypoglycaemia based on different age groups and the burden of the disease, focusing on hypoglycaemic-related events in the various aetiologies of adrenal insufficiency. Finally, we sum up strategies from published literature for improved recognition and early prevention of hypoglycaemia in adrenal insufficiency, such as the use of continuous glucose monitoring or modifying glucocorticoid replacement.
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Affiliation(s)
- Shien Chen Lee
- Department of Paediatrics, Princess Royal Hospital, Telford, United Kingdom
| | - Elizabeth S. Baranowski
- Department of Paediatric Endocrinology, Birmingham Women’s and Children’s Hospital, Birmingham, United Kingdom
| | - Rajesh Sakremath
- Department of Paediatrics, Princess Royal Hospital, Telford, United Kingdom
| | - Vrinda Saraff
- Department of Paediatric Endocrinology, Birmingham Women’s and Children’s Hospital, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, United Kingdom
| | - Zainaba Mohamed
- Department of Paediatric Endocrinology, Birmingham Women’s and Children’s Hospital, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, United Kingdom
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Nowotny HF, Marchant Seiter T, Ju J, Gottschlich A, Schneider H, Zopp S, Vogel F, Tschaidse L, Auer MK, Lottspeich C, Kobold S, Rothenfusser S, Beuschlein F, Reincke M, Braun L, Reisch N. Major immunophenotypic abnormalities in patients with primary adrenal insufficiency of different etiology. Front Immunol 2023; 14:1275828. [PMID: 38045693 PMCID: PMC10690587 DOI: 10.3389/fimmu.2023.1275828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/27/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction Patients with primary adrenal insufficiency (PAI) suffer from increased risk of infection, adrenal crises and have a higher mortality rate. Such dismal outcomes have been inferred to immune cell dysregulation because of unphysiological cortisol replacement. As the immune landscape of patients with different types of PAI has not been systematically explored, we set out to immunophenotype PAI patients with different causes of glucocorticoid (GC) deficiency. Methods This cross-sectional single center study includes 28 patients with congenital adrenal hyperplasia (CAH), 27 after bilateral adrenalectomy due to Cushing's syndrome (BADx), 21 with Addison's disease (AD) and 52 healthy controls. All patients with PAI were on a stable GC replacement regimen with a median dose of 25 mg hydrocortisone per day. Peripheral blood mononuclear cells were isolated from heparinized blood samples. Immune cell subsets were analyzed using multicolor flow cytometry after four-hour stimulation with phorbol myristate acetate and ionomycin. Natural killer (NK-) cell cytotoxicity and clock gene expression were investigated. Results The percentage of T helper cell subsets was downregulated in AD patients (Th1 p = 0.0024, Th2 p = 0.0157, Th17 p < 0.0001) compared to controls. Cytotoxic T cell subsets were reduced in AD (Tc1 p = 0.0075, Tc2 p = 0.0154) and CAH patients (Tc1 p = 0.0055, Tc2 p = 0.0012) compared to controls. NKCC was reduced in all subsets of PAI patients, with smallest changes in CAH. Degranulation marker CD107a expression was upregulated in BADx and AD, not in CAH patients compared to controls (BADx p < 0.0001; AD p = 0.0002). In contrast to NK cell activating receptors, NK cell inhibiting receptor CD94 was upregulated in BADx and AD, but not in CAH patients (p < 0.0001). Although modulation in clock gene expression could be confirmed in our patient subgroups, major interindividual-intergroup dissimilarities were not detected. Discussion In patients with different etiologies of PAI, distinct differences in T and NK cell-phenotypes became apparent despite the use of same GC preparation and dose. Our results highlight unsuspected differences in immune cell composition and function in PAI patients of different causes and suggest disease-specific alterations that might necessitate disease-specific treatment.
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Affiliation(s)
- Hanna F. Nowotny
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Jing Ju
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Adrian Gottschlich
- Division of Clinical Pharmacology, University Hospital, LMU Munich, Munich, Germany
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
| | - Holger Schneider
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Stephanie Zopp
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Frederick Vogel
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lea Tschaidse
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Matthias K. Auer
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Sebastian Kobold
- Division of Clinical Pharmacology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- Einheit für Klinische Pharmakologie (EKLiP), Helmholtz Munich, Research Center for Environmental Health (HMGU), Neuherberg, Germany
| | - Simon Rothenfusser
- Division of Clinical Pharmacology, University Hospital, LMU Munich, Munich, Germany
- Einheit für Klinische Pharmakologie (EKLiP), Helmholtz Munich, Research Center for Environmental Health (HMGU), Neuherberg, Germany
| | - Felix Beuschlein
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich (USZ) und Universität Zürich (UZH), Zurich, Switzerland
| | - Martin Reincke
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Leah Braun
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Nicole Reisch
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
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Rushworth RL, Falhammar H, Torpy DJ. Factors underlying a disproportionate increase in hospital admissions for adrenal insufficiency in women aged 20-29 years. Front Endocrinol (Lausanne) 2023; 14:1252577. [PMID: 38027206 PMCID: PMC10656680 DOI: 10.3389/fendo.2023.1252577] [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: 07/04/2023] [Accepted: 08/17/2023] [Indexed: 12/01/2023] Open
Abstract
Since the year 2000, admissions for adrenal insufficiency (AI) and adrenal crises (AC) have shown a particular increase in young adult females. We examined data on acute non-surgical hospitalisations for AI/AC from New South Wales, Australia, to determine relevant factors that may have contributed to this increase. Data were analysed to ascertain associations between various comorbid psychosocial issues, identified by relevant ICD-10-AM codes in each record, and ACs. From 2005 to 2021. There were 877 admissions for an acute non-surgical illness in this age group. The average admission rate for females [63.5/million/year] was almost twice that for males [34.0/million/year] (p<0.01), as was the average female AC admission rate [14.7/million/year] relative to that in males [6.75/million/year] (p=NS). Infection was present in 41.6% (n=365) of the admissions and Type 1 diabetes mellitus was present in 12.2% (n=107). Overall, psychosocial factors were considered by the senior clinician to have contributed to the illness episode in 22.1% of all admissions and 29.0% of AC admissions. Having one or more psychosocial problems was associated with an AC in females (37.4%, n=49, in those having an AC, p<0.001) but not males. Females with an AC also had a higher mean composite psychosocial, psychiatric and drug/alcohol score [0.47 (0.67)] than females without an AC [0.32 (0.62) p<0.05]. No comparable associations were found in male patients. An increase in the rates of hospitalisations that included a code for at least one psychosocial problem was highly correlated with increases in admission rates for both ACs (r=0.82, p<0.001) and all AI (r=0.98, p<0.001) in females but there was no such relationship in males. This new evidence suggests that psychosocial factors may play an important role in ongoing rates of ACs in treated AI (incidence approximately 6-8 ACs/100PY) particularly in young adult females. In order to minimize AC episodes, all barriers to self-management need exploration on an individual patient basis and with regard to the patient population as a whole.
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Affiliation(s)
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - David J. Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Medicine, The University of Adelaide, Adelaide, SA, Australia
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8
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Sarafoglou K, Merke DP, Reisch N, Claahsen-van der Grinten H, Falhammar H, Auchus RJ. Interpretation of Steroid Biomarkers in 21-Hydroxylase Deficiency and Their Use in Disease Management. J Clin Endocrinol Metab 2023; 108:2154-2175. [PMID: 36950738 PMCID: PMC10438890 DOI: 10.1210/clinem/dgad134] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/07/2023] [Indexed: 03/24/2023]
Abstract
The most common form of congenital adrenal hyperplasia is 21-hydroxylase deficiency (21OHD), which in the classic (severe) form occurs in roughly 1:16 000 newborns worldwide. Lifelong treatment consists of replacing cortisol and aldosterone deficiencies, and supraphysiological dosing schedules are typically employed to simultaneously attenuate production of adrenal-derived androgens. Glucocorticoid titration in 21OHD is challenging as it must balance the consequences of androgen excess vs those from chronic high glucocorticoid exposure, which are further complicated by interindividual variability in cortisol kinetics and glucocorticoid sensitivity. Clinical assessment and biochemical parameters are both used to guide therapy, but the specific purpose and goals of each biomarker vary with age and clinical context. Here we review the approach to medication titration for children and adults with classic 21OHD, with an emphasis on how to interpret adrenal biomarker values in guiding this process. In parallel, we illustrate how an understanding of the pathophysiologic and pharmacologic principles can be used to avoid and to correct complications of this disease and consequences of its management using existing treatment options.
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Affiliation(s)
- Kyriakie Sarafoglou
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN 55454, USA
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, USA
| | - Deborah P Merke
- Department of Pediatrics, National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, 80336 Munich, Germany
| | - Hedi Claahsen-van der Grinten
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, SE-17176, Stockholm, Sweden
| | - Richard J Auchus
- Departments of Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Auer MK, Nordenström A, Lajic S, Reisch N. Congenital adrenal hyperplasia. Lancet 2023; 401:227-244. [PMID: 36502822 DOI: 10.1016/s0140-6736(22)01330-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 05/17/2022] [Accepted: 06/13/2022] [Indexed: 12/13/2022]
Abstract
Congenital adrenal hyperplasia is a group of autosomal recessive disorders leading to multiple complex hormonal imbalances caused by various enzyme deficiencies in the adrenal steroidogenic pathway. The most common type of congenital adrenal hyperplasia is due to steroid 21-hydroxylase (21-OHase, henceforth 21OH) deficiency. The rare, classic (severe) form caused by 21OH deficiency is characterised by life-threatening adrenal crises and is the most common cause of atypical genitalia in neonates with 46,XX karyotype. After the introduction of life-saving hormone replacement therapy in the 1950s and neonatal screening programmes in many countries, nowadays neonatal survival rates in patients with congenital adrenal hyperplasia are high. However, disease-related mortality is increased and therapeutic management remains challenging, with multiple long-term complications related to treatment and disease affecting growth and development, metabolic and cardiovascular health, and fertility. Non-classic (mild) forms of congenital adrenal hyperplasia caused by 21OH deficiency are more common than the classic ones; they are detected clinically and primarily identified in female patients with hirsutism or impaired fertility. Novel treatment approaches are emerging with the aim of mimicking physiological circadian cortisol rhythm or to reduce adrenal hyperandrogenism independent of the suppressive effect of glucocorticoids.
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Affiliation(s)
- Matthias K Auer
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany.
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10
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Tschaidse L, Reisch N, Arlt W, Brac de la Perriere A, Linden Hirschberg A, Juul A, Mallappa A, Merke DP, Newell-Price JDC, Perry CG, Prete A, Rees DA, Stikkelbroeck NMML, Touraine PA, Coope H, Porter J, Ross RJM, Quinkler M. Modified-release hydrocortisone is associated with lower plasma renin activity in patients with salt-wasting congenital adrenal hyperplasia. Eur J Endocrinol 2023; 188:6991929. [PMID: 36654495 DOI: 10.1093/ejendo/lvac006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/06/2022] [Accepted: 11/30/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Poorly controlled salt-wasting (SW) congenital adrenal hyperplasia (CAH) patients often require high 9α-fluorocortisol doses as they show high levels of 17-hydroxyprogesterone (17OHP), which is a mineralocorticoid (MC)-receptor antagonist. DESIGN We investigated the renin-angiotensin-aldosterone system in patients with SW-CAH receiving twice daily modified-release hydrocortisone (MR-HC, Efmody) compared with standard glucocorticoid (GC) therapy. METHODS Data were analyzed from the 6-month, phase 3 study of MR-HC (n = 42) versus standard GC therapy (n = 41). MC replacement therapy remained unchanged throughout the study. Blood pressure, serum potassium, serum sodium, plasma renin activity (PRA), and serum 17OHP and androstenedione concentrations were analyzed at baseline, 4, 12, and 24 weeks. RESULTS The median serum 17OHP in the morning was significantly lower on MR-HC compared with standard GC at 24 weeks (2.5 nmol L-1 (IQR 8.3) versus 10.5 nmol L-1 (IQR 55.2), P = .001). PRA decreased significantly from baseline to 24 weeks in patients on MR-HC (0.83 ng L-1 s-1 (IQR 1.0) to 0.48 ng L-1 s-1 (IQR 0.61), P = .012) but not in patients on standard GC (0.53 ng L-1 s-1 (IQR 0.66) to 0.52 ng L-1 s-1 (IQR 0.78), P = .613). Serum sodium concentrations increased from baseline to 24 weeks in patients on MR-HC (138.8 ± 1.9 mmol L-1 to 139.3 ± 1.8 mmol L-1, P = .047), but remained unchanged on standard GC (139.8 ± 1.6 mmol L-1 to 139.3 ± 1.9 mmol L-1, P = .135). No significant changes were seen in systolic and diastolic blood pressure and serum potassium levels. CONCLUSION 6 months of MR-HC therapy decreased PRA and increased sodium levels indicating a greater agonist action of the 9α-fluorocortisol dose, which may be due to the decreased levels of the MC-receptor antagonist 17OHP.
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Affiliation(s)
- Lea Tschaidse
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Nicole Reisch
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, United Kingdom
| | - Aude Brac de la Perriere
- Hospices Civils de Lyon, Fédération d'Endocrinologie, Groupement hospitalier Est, Bron Cedex, France
| | - Angelica Linden Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet and Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Juul
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ashwini Mallappa
- AstraZeneca, Gaithersburg, Maryland, United States
- National Institutes of Health Clinical Center, Bethesda, Maryland, United States
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland, United States
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, United States
| | | | - Colin G Perry
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Alessandro Prete
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, United Kingdom
| | - D Aled Rees
- Neuroscience and Mental Health Research Institute, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | | | - Philippe A Touraine
- University Hospitals Pitié Salpêtrière - Charles Foix, Center for Rare Endocrine and Gynecological Disorders, Paris, France
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11
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Abstract
Treatment for congenital adrenal hyperplasia (CAH) was introduced in the 1950s following the discovery of the structure and function of adrenocortical hormones. Although major advances in molecular biology have delineated steroidogenic mechanisms and the genetics of CAH, management and treatment of this condition continue to present challenges. Management is complicated by a combination of comorbidities that arise from disease-related hormonal derangements and treatment-related adverse effects. The clinical outcomes of CAH can include life-threatening adrenal crises, altered growth and early puberty, and adverse effects on metabolic, cardiovascular, bone and reproductive health. Standard-of-care glucocorticoid formulations fall short of replicating the circadian rhythm of cortisol and controlling efficient adrenocorticotrophic hormone-driven adrenal androgen production. Adrenal-derived 11-oxygenated androgens have emerged as potential new biomarkers for CAH, as traditional biomarkers are subject to variability and are not adrenal-specific, contributing to management challenges. Multiple alternative treatment approaches are being developed with the aim of tailoring therapy for improved patient outcomes. This Review focuses on challenges and advances in the management and treatment of CAH due to 21-hydroxylase deficiency, the most common type of CAH. Furthermore, we examine new therapeutic developments, including treatments designed to replace cortisol in a physiological manner and adjunct agents intended to control excess androgens and thereby enable reductions in glucocorticoid doses.
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Affiliation(s)
- Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, MD, USA.
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
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12
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Rushworth RL, Chrisp GL, Bownes S, Torpy DJ, Falhammar H. Adrenal crises in adolescents and young adults. Endocrine 2022; 77:1-10. [PMID: 35583847 PMCID: PMC9242908 DOI: 10.1007/s12020-022-03070-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/03/2022] [Indexed: 12/19/2022]
Abstract
PURPOSE Review the literature concerning adrenal insufficiency (AI) and adrenal crisis (AC) in adolescents and young adults. METHODS Searches of PubMed identifying relevant reports up to March 2022. RESULTS AI is rare disorder that requires lifelong glucocorticoid replacement therapy and is associated with substantial morbidity and occasional mortality among adolescents and young adults. Aetiologies in this age group are more commonly congenital, with acquired causes, resulting from tumours in the hypothalamic-pituitary area and autoimmune adrenalitis among others, increasing with age. All patients with AI are at risk of AC, which have an estimated incidence of 6 to 8 ACs/100 patient years. Prevention of ACs includes use of educational interventions to achieve competency in dose escalation and parenteral glucocorticoid administration during times of physiological stress, such as an intercurrent infection. While the incidence of AI/AC in young children and adults has been documented, there are few studies focussed on the AC occurrence in adolescents and young adults with AI. This is despite the range of developmental, psychosocial, and structural changes that can interfere with chronic disease management during this important period of growth and development. CONCLUSION In this review, we examine the current state of knowledge of AC epidemiology in emerging adults; examine the causes of ACs in this age group; and suggest areas for further investigation that are aimed at reducing the incidence and health impact of ACs in these patients.
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Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, 160 Oxford St, Darlinghurst, NSW, 2010, Australia
| | - Georgina L Chrisp
- School of Medicine, Sydney, The University of Notre Dame, 160 Oxford St, Darlinghurst, NSW, 2010, Australia
| | - Suzannah Bownes
- School of Medicine, Sydney, The University of Notre Dame, 160 Oxford St, Darlinghurst, NSW, 2010, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, SE-17176, Stockholm, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden.
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13
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Nowotny H, Neumann U, Tardy-Guidollet V, Ahmed SF, Baronio F, Battelino T, Bertherat J, Blankenstein O, Bonomi M, Bouvattier C, Brac de la Perrière A, Brucker S, Cappa M, Chanson P, Claahsen-van der Grinten HL, Colao A, Cools M, Davies JH, Dörr HG, Fenske WK, Ghigo E, Giordano R, Gravholt CH, Huebner A, Husebye ES, Igbokwe R, Juul A, Kiefer FW, Léger J, Menassa R, Meyer G, Neocleous V, Phylactou LA, Rohayem J, Russo G, Scaroni C, Touraine P, Unger N, Vojtková J, Yeste D, Lajic S, Reisch N. Prenatal dexamethasone treatment for classic 21-hydroxylase deficiency in Europe. Eur J Endocrinol 2022; 186:K17-K24. [PMID: 35235536 PMCID: PMC9010809 DOI: 10.1530/eje-21-0554] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the current medical practice in Europe regarding prenatal dexamethasone (Pdex) treatment of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. DESIGN AND METHODS A questionnaire was designed and distributed, including 17 questions collecting quantitative and qualitative data. Thirty-six medical centres from 14 European countries responded and 30 out of 36 centres were reference centres of the European Reference Network on Rare Endocrine Conditions, EndoERN. RESULTS Pdex treatment is currently provided by 36% of the surveyed centres. The treatment is initiated by different specialties, that is paediatricians, endocrinologists, gynaecologists or geneticists. Regarding the starting point of Pdex, 23% stated to initiate therapy at 4-5 weeks postconception (wpc), 31% at 6 wpc and 46 % as early as pregnancy is confirmed and before 7 wpc at the latest. A dose of 20 µg/kg/day is used. Dose distribution among the centres varies from once to thrice daily. Prenatal diagnostics for treated cases are conducted in 72% of the responding centres. Cases treated per country and year vary between 0.5 and 8.25. Registries for long-term follow-up are only available at 46% of the centres that are using Pdex treatment. National registries are only available in Sweden and France. CONCLUSIONS This study reveals a high international variability and discrepancy in the use of Pdex treatment across Europe. It highlights the importance of a European cooperation initiative for a joint international prospective trial to establish evidence-based guidelines on prenatal diagnostics, treatment and follow-up of pregnancies at risk for CAH.
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Affiliation(s)
- Hanna Nowotny
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Uta Neumann
- Centre for Chronic Sick Children, Department of Paediatric Endocrinology and Diabetology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Véronique Tardy-Guidollet
- Laboratoire de Biochimie et Biologie Moléculaire, Hospices Civils de Lyon, Centre National de Référence ‘Développement Génital: du fœtus à l’adulte DEV-GEN’ Université Lyon I, Lyon, France
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Federico Baronio
- Paediatric Endocrinology Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, University Children’s Hospital, Ljubljana, Slovenia
| | - Jérôme Bertherat
- Service d’Endocinologie et Maladies Métaboliques, Hôpitaux Universitaires Paris-Centre, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Oliver Blankenstein
- Centre for Chronic Sick Children, Department of Paediatric Endocrinology and Diabetology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marco Bonomi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Department of Endocrine and Metabolic Diseases and Lab of Endocrine and Metabolic Research, IRCSS Istituto Auxologico Italiano, Milan, Italy
| | - Claire Bouvattier
- Service d’Endocrinologie de l’Enfant, GHU Paris-Sud, Hôpital de Bicêtre, Paris, France
- Centre National de Référence ‘Développement Génital: du fœtus à l’adulte DEV-GEN’, Paris, France
| | - Aude Brac de la Perrière
- Fédération d’Endocrinologie, de Diabétologie et des Maladies Métaboliques, Hospices Civils des Lyon, Centre National de Référence ‘Développement Génital: du fœtus à l’adulte DEV-GEN’, Lyon, France
| | - Sara Brucker
- Department of Women’s Health, University Women’s Hospital, University of Tübingen, Tübingen, Germany
| | - Marco Cappa
- Endocrinology Unit, Paediatric University Department, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Université Paris-Saclay, Service d’Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de Hypophyse, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Hedi L Claahsen-van der Grinten
- Department of Paediatric Endocrinology, Amalia Children’s Hospital, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita’ Federico II di Napoli, Naples, Italy
| | - Martine Cools
- Department of Paediatric Endocrinology, Ghent University Hospital, University of Ghent, Ghent, Belgium
| | - Justin H Davies
- Paediatric Endocrinology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Helmut-Günther Dörr
- Paediatric Endocrinology, Department of Paediatrics, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Wiebke K Fenske
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Ezio Ghigo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Turin, Turin, Italy
| | - Roberta Giordano
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Turin, Turin, Italy
| | - Claus H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Angela Huebner
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Eystein Sverre Husebye
- Department of Clinical Science and KG Jebsen Centre for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Rebecca Igbokwe
- West Midlands Regional Genetics Laboratory, Birmingham Women’s Hospital NHS Foundation Trust, Birmingham, UK
| | - Anders Juul
- Department of Growth and Reproduction, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Florian W Kiefer
- Clinical Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Juliane Léger
- Department of Paediatric Endocrinology and Diabetology and Reference Centre for Rare Diseases of Growth and Development, AP-HP Paris Nord Université de Paris, CHU Robert-Debre, Paris, France
| | - Rita Menassa
- Laboratoire de Biochimie et Biologie Moléculaire, Hospices Civils de Lyon, Centre National de Référence ‘Développement Génital: du fœtus à l’adulte DEV-GEN’ Université Lyon I, Lyon, France
| | - Gesine Meyer
- Division of Endocrinology, Department of Internal Medicine 1, Goethe University Frankfurt Faculty 16 Medicine, Frankfurt am Main, Germany
| | - Vassos Neocleous
- Department of Molecular Genetics, Function and Therapy, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
- Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Leonidas A Phylactou
- Department of Molecular Genetics, Function and Therapy, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
- Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Julia Rohayem
- Centre of Reproductive Medicine and Andrology, Clinical and Operative Andrology, University of Münster, Münster, Germany
| | - Gianni Russo
- Department of Paediatrics, Endocrine Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Carla Scaroni
- Dipartimento di Medicina, U.O.C. Endocrinologia, Università di Padova, Padova, Italy
| | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Centre for Rare Endocrine and Gynaecological Disorders, Sorbonne Université, Assistance Publique Hopitaux de Paris, Paris, France
| | - Nicole Unger
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, Essen, Germany
| | - Jarmila Vojtková
- Department of Paediatrics, Jessenius Faculty of Medicine, Comenius University in Bratislava, University Hospital in Martin, Martin, Slovakia
| | - Diego Yeste
- Paediatric Endocrinology Service, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
- CIBERER, ISCIII, Madrid, Spain
| | - Svetlana Lajic
- Department of Women’s and Children’s Health, Karolinska Institutet/Karolinska University Hospital, Paediatric Endocrinology Unit (QB83), Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
- Correspondence should be addressed to N Reisch;
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14
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Quinkler M, Kienitz T. The ISAQ Score Does Not Predict Adrenal Crisis in Patients with Primary Adrenal Insufficiency. Exp Clin Endocrinol Diabetes 2022; 130:554-560. [PMID: 35240692 DOI: 10.1055/a-1734-2466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aimed to investigate the ability of the immune system assessment questionnaire (ISAQ) to predict adrenal crisis (AC) and infectious events in patients with primary adrenal insufficiency (PAI). DESIGN This was a prospective single-centre study over three years. METHODS Patients answered the ISAQ at baseline and were seen every 4-6 months in the endocrine outpatient clinic. At each visit previous infectious periods which required an increase in daily glucocorticoid dosage and AC were reported and documented. Seventy-five patients with PAI (53 women; 43 patients with autoimmune PAI, 20 patients with salt-wasting congenital adrenal hyperplasia and 12 patients who underwent bilateral adrenalectomy) were analysed. Due to the COVID-19 pandemic and consecutive lockdown measures, the data were analysed separately for March 2018 to March 2020 (period 1), and March 2020 to March 2021 (period 2). RESULTS During period 1 the ISAQ score significantly correlated with the number of reported infectious events (r=0.351; p<0.01), but not during period 2 (r=0.059, p=0.613), in which the number of infectious events per patient-year significantly decreased (1.1±0.1 vs 0.4±0.1; p<0.001). The frequency of AC decreased from 8.8 to 2.4 per 100 patient-years between the two study periods. The ISAQ score was not different between patients with or without AC. CONCLUSIONS The ISAQ score does not identify patients prone to ACs. The COVID-19 pandemic and consecutive lockdown measures significantly diminished the frequency of infectious events and ACs.
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Affiliation(s)
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
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15
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[Hypoxic and hypoglycemic brain damage as a result of an adrenal cortex crisis-An important differential diagnosis in cases of unspecific symptoms]. Anaesthesist 2022; 71:462-466. [PMID: 35226122 DOI: 10.1007/s00101-022-01088-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 12/16/2021] [Accepted: 12/30/2021] [Indexed: 11/26/2022]
Abstract
Acute adrenal cortex insufficiency is a rare disease, which is hard to diagnose because of its diffuse symptoms. Symptoms, such as general weakness, nausea or vomiting, fatigue, hyponatremia, hyperkalemia, hypoglycemia and pronounced hypotension up to shock can be crucial in the diagnosis of an adrenal cortex crisis. The underlying disease of adrenal cortex insufficiency is also characterized by not always obvious symptoms, which are differently expressed depending on whether it is the primary or secondary type.After the diagnosis is made it is important to educate the patients, determine the optimal dosage of the substitution and ensure the compliance of the patients to optimize the further process and avoid an adrenal crisis. An adrenal crisis is one of the reasons for a higher mortality of these patients, which is well-described in the current literature. Descriptions of fatal courses and their reasons are rare; however, knowledge of the disease and the importance of rapid intervention is very important, especially for physicians who work in the emergency room or intensive care unit (ICU).This article reports about a female patient with a known secondary adrenal cortex insufficiency who developed the complete picture of an adrenal crisis. Despite rapid diagnosis and initiation of treatment massive brain damage could not be averted due to hypoxia and hypoglycemia. This case report demonstrates the potential symptoms, in particular a massive hypoglycemia and an initial shock refractory to catecholamine. It also shows the severity of that disease and the importance of rapid treatment even though it is difficult to make the diagnosis.
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16
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 176] [Impact Index Per Article: 88.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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17
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Abstract
Congenital adrenal hyperplasia (CAH) is one of the most common autosomal recessive disorders and is characterized by cortisol deficiency. The most common cause of CAH is a mutation in the CYP21A2 gene, resulting in 21-hydroxylase deficiency in the adrenal cortex. The lack of cortisol causes an increase in adrenocorticotropic hormone (ACTH), which in turn results in an excess of adrenal androgens. Aldosterone synthesis may also be impaired. The clinical manifestation of CAH depends on the residual activity of 21-hydroxylase and the subsequent lack of cortisol and adrenal androgen excess. While classic CAH is a potentially life-threatening condition, non-classic CAH is mild to asymptomatic. Therapy of classic CAH consists of glucocorticoid and mineralocorticoid substitution. Despite optimization of therapy, CAH still leads to increased morbidity and mortality in patients. The clinical consequences of androgen excess in affected women range from intrauterine virilisation of external genitalia in classic CAH patients to mild symptoms of hyperandrogenism in non-classic forms. Increased demand for cortisol during illness or physical and psychological stress situations can trigger life-threatening adrenal crises. As current glucocorticoid therapy cannot mimic the physiological circadian rhythm and is usually supraphysiological in dose to control androgen excess, therapy-associated long-term consequences such as decreased bone health and an increased cardiometabolic risk profile are common. The burden of the disease may also lead to impaired quality of life and mental health. For this reason, regular screening and follow-up of patients with CAH should be performed in specialized centers to detect and treat possible comorbidities at an early stage.
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18
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Chrisp GL, Quartararo M, Torpy DJ, Falhammar H, Rushworth RL. Trends in hospital admissions for adrenal insufficiency in adolescents and young adults in the 21 st century. Front Endocrinol (Lausanne) 2022; 13:986342. [PMID: 36204108 PMCID: PMC9530131 DOI: 10.3389/fendo.2022.986342] [Citation(s) in RCA: 4] [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: 07/05/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Very little is known about the epidemiology of adrenal crises (AC) and adrenal insufficiency (AI) in adolescents and young adults. METHODS Data on all admissions to Australian hospitals between 2000/1 to 2019/20 for a principal diagnosis of AI (including AC) in 10-24 year olds were extracted from a national repository. Age and sex-specific rates and age-adjusted rates were compared. FINDINGS Over the study, there were 3386 admissions for a principal diagnosis of AI; 24.0% (n=812) were for an AC and 50·7% (n=1718) were for secondary AI. Age-adjusted AI admissions increased from 31·70/million in 2000/1 to 54·68/million in 2019/20 (p<0·0001). Age-adjusted AC admissions also increased, most notably in the second decade (from 5·80/million in 2010/11 to 15·75/million in 2019/20) (p<0·00001). Average AI and AC admission rates were comparable between the sexes, but rates increased significantly in females, especially in those aged 20 to 24 years, whose AC rate in 2019/20 (39·65/million) was significantly higher than the corresponding rate in 2000/1 (3·15/million) (p<0·00001). Average age-adjusted SAI admission rates were higher in males (23·92/million) than females (15·47/million) (p<0·00001). However, SAI admission rates increased only among females (from 11·81/million to 22·12/million in 2019/20), with an increase in 20-24 year old females in the second decade from 5·07/million in 2010 to 20·42/million (p<0·00001). Age adjusted admissions for congenital adrenal hyperplasia, primary AI (PAI) and drug-induced AI did not change significantly over the study. INTERPRETATION AC/AI admissions increased over the first two decades of this century in the emerging adult population, particularly among females who also experienced a marked increase in AC admission rates, most evident in the second decade. Although uncertain, possible explanations include: dose of glucocorticoid replacement; non-adherence to therapy; psychosocial factors; and difficulty in transition to adult services. Admissions for SAI also increased, while rates of PAI and CAH remained constant.
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Affiliation(s)
| | - Maria Quartararo
- The University of Notre Dame, Australia, Darlinghurst, NSW, Australia
| | - David J. Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - R. Louise Rushworth
- The University of Notre Dame, Australia, Darlinghurst, NSW, Australia
- *Correspondence: R. Louise Rushworth,
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19
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Ishii T, Kashimada K, Amano N, Takasawa K, Nakamura-Utsunomiya A, Yatsuga S, Mukai T, Ida S, Isobe M, Fukushi M, Satoh H, Yoshino K, Otsuki M, Katabami T, Tajima T. Clinical guidelines for the diagnosis and treatment of 21-hydroxylase deficiency (2021 revision). Clin Pediatr Endocrinol 2022; 31:116-143. [PMID: 35928387 PMCID: PMC9297175 DOI: 10.1297/cpe.2022-0009] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
Congenital adrenal hyperplasia is a category of disorders characterized by impaired
adrenocortical steroidogenesis. The most frequent disorder of congenital adrenal
hyperplasia is 21-hydroxylase deficiency, which is caused by pathogenic variants of
CAY21A2 and is prevalent between 1 in 18,000 and 20,000 in Japan. The
clinical guidelines for 21-hydroxylase deficiency in Japan have been revised twice since a
diagnostic handbook in Japan was published in 1989. On behalf of the Japanese Society for
Pediatric Endocrinology, the Japanese Society for Mass Screening, the Japanese Society for
Urology, and the Japan Endocrine Society, the working committee updated the guidelines for
the diagnosis and treatment of 21-hydroxylase deficiency published in 2014, based on
recent evidence and knowledge related to this disorder. The recommendations in the updated
guidelines can be applied in clinical practice considering the risks and benefits to each
patient.
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Affiliation(s)
- Tomohiro Ishii
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Kenichi Kashimada
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Naoko Amano
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | | | - Shuichi Yatsuga
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
| | - Tokuo Mukai
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Shinobu Ida
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | | | | | | | | | | | | | - Toshihiro Tajima
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
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20
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Weber J, Tanawattanacharoen VK, Seagroves A, Liang MC, Koppin CM, Ross HM, Bachega TASS, Geffner ME, Serrano-Gonzalez M, Bhullar G, Kim MS. Low Adrenomedullary Function Predicts Acute Illness in Infants With Classical Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2022; 107:e264-e271. [PMID: 34397083 PMCID: PMC8826013 DOI: 10.1210/clinem/dgab600] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Indexed: 01/28/2023]
Abstract
CONTEXT Youth with classical congenital adrenal hyperplasia (CAH) exhibit abnormal adrenomedullary function with decreased epinephrine levels noted in newborns and young infants. Little is known about how this relates to morbidity during the first year of life. OBJECTIVE This work aimed to study plasma epinephrine levels in infants with classical CAH and examine the clinical significance of epinephrine deficiency in the first year of life. METHODS This prospective cohort study comprised participants recruited from a pediatric tertiary care center: 36 infants with classical CAH due to 21-hydroxylase deficiency and 27 age-matched unaffected controls with congenital hypothyroidism. Main outcome measures included plasma epinephrine levels (N = 27), CYP21A2 genotype (N = 15), and incidence of acute illnesses from birth to age 1 year (N = 28). RESULTS Epinephrine levels in CAH infants independently predicted illness incidence in the first year of life (β = -0.018, R = -0.45, P = .02) and were negatively correlated with 17-hydroxyprogesterone at diagnosis (R = -0.51, P = .007). Infants with salt-wasting CAH exhibited lower epinephrine levels as newborns than simple-virilizing infants (P = .02). CAH patients had lower epinephrine as newborns than did controls (P = .007) and showed decreases in epinephrine from birth to age 1 year (P = .04). Null genotype was associated with lower newborn epinephrine and more illness in the first year of life, compared to less severe mutation categories. CONCLUSION Lower epinephrine levels are associated with increased risk of illness among CAH infants. While not currently part of clinical standard of care, measuring epinephrine levels and assessing genotype may help predict acute illness in the first year of life.
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Affiliation(s)
- Jonathan Weber
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Veeraya K Tanawattanacharoen
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Amy Seagroves
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Mark C Liang
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Christina M Koppin
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Heather M Ross
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Tania A S S Bachega
- Laboratory of Hormones and Molecular Genetics-LIM 42, Division of Endocrinology, Clinics Hospital, School of Medicine, São Paulo University, São Paulo 05508-220, Brazil
| | - Mitchell E Geffner
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
- Keck School of Medicine of University of Southern California, Los Angeles, California 90033, USA
- The Saban Research Institute at Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Monica Serrano-Gonzalez
- Keck School of Medicine of University of Southern California, Los Angeles, California 90033, USA
- Division of Pediatric Endocrinology, Hasbro Children’s Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island 02903, USA
| | - Gagandeep Bhullar
- Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California 90027, USA
| | - Mimi S Kim
- Correspondence: Mimi S. Kim, MD, Center for Endocrinology, Diabetes and Metabolism, Children’s Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 61, Los Angeles, CA 90027, USA.
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21
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Prete A, Auchus RJ, Ross RJ. Clinical advances in the pharmacotherapy of congenital adrenal hyperplasia. Eur J Endocrinol 2021; 186:R1-R14. [PMID: 34735372 PMCID: PMC8679847 DOI: 10.1530/eje-21-0794] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 11/04/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patients with 21-hydroxylase deficiency congenital adrenal hyperplasia (21OHD-CAH) have poor health outcomes with increased mortality, short stature, impaired fertility, and increased cardiovascular risk factors such as obesity. To address this, there are therapies in development that target the clinical goal of treatment, which is to control excess androgens with an adrenal replacement dose of glucocorticoid. METHODS Narrative review of publications on recent clinical developments in the pharmacotherapy of congenital adrenal hyperplasia. SUMMARY Therapies in clinical development target different levels of the hypothalamo-pituitary-adrenal axis. Two corticotrophin-releasing factor type 1 (CRF1) receptor antagonists, Crinecerfont and Tildacerfont, have been trialled in poorly controlled 21OHD-CAH patients, and both reduced ACTH and androgen biomarkers while patients were on stable glucocorticoid replacement. Improvements in glucocorticoid replacement include replacing the circadian rhythm of cortisol that has been trialled with continuous s.c. infusion of hydrocortisone and Chronocort, a delayed-release hydrocortisone formulation. Chronocort optimally controlled 21OHD-CAH in 80% of patients on an adrenal replacement dose of hydrocortisone, which was associated with patient-reported benefits including restoration of menses and pregnancies. Adrenal-targeted therapies include the steroidogenesis-blocking drug Abiraterone acetate, which reduced adrenal androgen biomarkers in poorly controlled patients. CONCLUSIONS CRF1 receptor antagonists hold promise to avoid excess glucocorticoid replacement in patients not controlled on standard or circadian glucocorticoid replacement such as Chronocort. Gene and cell therapies are the only therapeutic approaches that could potentially correct both cortisol deficiency and androgen excess.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, Departments of Pharmacology and Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Richard J Ross
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Correspondence should be addressed to R J Ross;
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22
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Lousada LM, Mendonca BB, Bachega TASS. Adrenal crisis and mortality rate in adrenal insufficiency and congenital adrenal hyperplasia. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:488-494. [PMID: 34283908 PMCID: PMC10522175 DOI: 10.20945/2359-3997000000392] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 05/18/2021] [Indexed: 11/23/2022]
Abstract
Primary adrenal insufficiency (PAI) is characterized by the inability of the adrenal cortex to produce sufficient amounts of glucocorticoids and/or mineralocorticoids. Addison's disease (AD) and congenital adrenal hyperplasia (CAH) are the most frequent disorders in adults and children, respectively. Despite the diagnostic advances and the availability of glucocorticoid and mineralocorticoid replacements, adrenal crisis (AC) is still a potentially lethal condition contributing to the increased mortality, not only during the first year of life, but also throughout life. Failure in increasing glucocorticoid doses during acute stress, when greater amounts of glucocorticoids are required, can lead to AC and an increase morbimortality rate of PAI. Considering a mortality rate of 0.5 per 100 patient years, up to 1,500 deaths from AC are expected in Brazil in the coming decade, which represents an alarming situation. The major clinical features are hypotension and volume depletion. Nonspecific symptoms such as fatigue, lack of energy, anorexia, nausea, vomiting, and abdominal pain are common. The main precipitating factors are gastrointestinal diseases, other infectious disease, stressful events (e.g., major pain, surgery, strenuous physical activity, heat, and pregnancy), and withdrawal of glucocorticoid therapy. Suspected AC requires immediate therapeutic action with intravenous (iv) hydrocortisone, fluid infusion, monitoring support, and antibiotics if necessary. AC is best prevented through patient education, precocious identification and by adjusting the glucocorticoid dosage in stressor situations. The emergency card, warning about acute glucocorticoid replacement, has high value in reducing the morbidity and mortality of AC.
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Affiliation(s)
- Lia Mesquita Lousada
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular (LIM42), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Berenice B Mendonca
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular (LIM42), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Tania A S S Bachega
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular (LIM42), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
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23
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Heath C, Siafarikas A, Sommerfield A, Ungern‐Sternberg BS. Peri-operative steroid management in the paediatric population. Acta Anaesthesiol Scand 2021; 65:1187-1194. [PMID: 34263943 DOI: 10.1111/aas.13952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/14/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with adrenal insufficiency are at risk of adrenal crisis, a potentially life-threatening emergency in the peri-operative period due to their attenuated ability to mount a cortisol response. There is a lack of standardization regarding peri-operative stress-dose glucocorticoids in paediatric clinical practice with the absence of agreed protocols. For the individual patient, the risk of adrenal crisis must be weighed against the potential adverse clinical outcomes associated with unnecessary or supra-physiologic glucocorticoid dosing in susceptible patients. Specific clinical concerns in the paediatric population include osteopenia, growth restriction and increased risk of cardiovascular disease in adulthood. This review aimed to identify and evaluate available literature in the field of peri-operative stress-dose glucocorticoids. METHODS A comprehensive literature search was conducted to construct a narrative review. RESULTS The outcome of this review identified that paediatric patients, unlike adults, do not show a graded response to surgical stress with implications for glucocorticoid stress dose regimens for general anaesthesia and less invasive surgical procedures. The studies highlight a lack of information on physiological steroid responses to stress situations and differences in the approach to glucocorticoid replacement strategies in the paediatric population. CONCLUSION The review identified there is a lack of high-quality paediatric-specific studies evaluating appropriate stress-dose glucocorticoid regimens in paediatric patients with or at risk of adrenal insufficiency. Further research is needed to establish clear evidence-based clinical guidelines for paediatric peri-operative practice regarding steroid stress dosing in adrenal insufficiency. Current knowledge would suggest that a balanced view of risks and benefits should be taken appropriate to the clinical context, to dictate peri-operative stress-dose glucocorticoids use that permits safe perioperative management.
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Affiliation(s)
- Chloe Heath
- Department of Anaesthesia and Pain Management Perth Children’s Hospital Perth Western Australia Australia
| | - Aris Siafarikas
- Department of Paediatric Endocrinology Perth Children’s Hospital Perth Western Australia Australia
- Faculty of Medicine, Paediatrics The University of Western Australia Nedlands Western Australia Australia
- Institute for Health ResearchUniversity of Notre Dame Fremantle Western Australia Australia
- Telethon Kids Institute Perth Western Australia Australia
| | - Aine Sommerfield
- Department of Anaesthesia and Pain Management Perth Children’s Hospital Perth Western Australia Australia
- Perioperative Medicine Team Telethon Kids Institute Perth Western Australia Australia
| | - Britta S. Ungern‐Sternberg
- Department of Anaesthesia and Pain Management Perth Children’s Hospital Perth Western Australia Australia
- Perioperative Medicine Team Telethon Kids Institute Perth Western Australia Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine Medical School The University of Western Australia Perth Western Australia Australia
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24
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Younes N, Bourdeau I, Lacroix A. Latent Adrenal Insufficiency: From Concept to Diagnosis. Front Endocrinol (Lausanne) 2021; 12:720769. [PMID: 34512551 PMCID: PMC8429826 DOI: 10.3389/fendo.2021.720769] [Citation(s) in RCA: 6] [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: 06/04/2021] [Accepted: 08/09/2021] [Indexed: 11/22/2022] Open
Abstract
Primary adrenal insufficiency (PAI) is a rare disease and potentially fatal if unrecognized. It is characterized by destruction of the adrenal cortex, most frequently of autoimmune origin, resulting in glucocorticoid, mineralocorticoid, and adrenal androgen deficiencies. Initial signs and symptoms can be nonspecific, contributing to late diagnosis. Loss of zona glomerulosa function may precede zona fasciculata and reticularis deficiencies. Patients present with hallmark manifestations including fatigue, weight loss, abdominal pain, melanoderma, hypotension, salt craving, hyponatremia, hyperkalemia, or acute adrenal crisis. Diagnosis is established by unequivocally low morning serum cortisol/aldosterone and elevated ACTH and renin concentrations. A standard dose (250 µg) Cosyntropin stimulation test may be needed to confirm adrenal insufficiency (AI) in partial deficiencies. Glucocorticoid and mineralocorticoid substitution is the hallmark of treatment, alongside patient education regarding dose adjustments in periods of stress and prevention of acute adrenal crisis. Recent studies identified partial residual adrenocortical function in patients with AI and rare cases have recuperated normal hormonal function. Modulating therapies using rituximab or ACTH injections are in early stages of investigation hoping it could maintain glucocorticoid residual function and delay complete destruction of adrenal cortex.
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Affiliation(s)
| | | | - Andre Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
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25
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Rushworth RL, Gouvoussis N, Goubar T, Maguire A, Munns CF, Neville KA, Torpy DJ. Acute illness in children with secondary adrenal insufficiency. Clin Endocrinol (Oxf) 2021; 94:913-919. [PMID: 33544418 DOI: 10.1111/cen.14427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/22/2020] [Accepted: 01/14/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE AND BACKGROUND Secondary adrenal insufficiency (SAI) is a rare condition in childhood which can be associated with high levels of morbidity in some patients. The causes of increased levels of illness are not well defined and warrant further investigation. METHODS A retrospective cohort of patients with SAI was constructed by examining records of all attendances for acute illness by SAI patients at the emergency department of the two specialist paediatric hospitals in Sydney, Australia between 2004 and 2016. Demographic, clinical, and physiological characteristics together with pre-hospital illness management strategies were assessed. RESULTS There were 168 presentations for an acute illness by 47 children with SAI. Comorbid diabetes insipidus (DI) was present in 46.8% (n = 22), 77.3% (n = 17) of whom were male (P < .05). Patients with comorbid DI were more likely to be admitted (86.7%, n = 65 vs 60.2%, n = 56 for non-DI, P < .01); had a longer hospital stay (6.5 (8.7) vs 2.5 (2.6) days, P < .001); and higher rates of IV HC administration (56.0%, n = 42 vs 35.5%, n = 33), P < .01). The medically-diagnosed adrenal crisis (AC) rate was 3.68 ACs/100PY. Stress dose use was reported by fewer DI patients (58.7%, n = 44) than non-DI patients (78.5%, n = 73, P < .01). Previous attendance at hospital was positively associated with stress dose use (OR = 1.08, 95% CI 1.00, 1.16). CONCLUSION Secondary adrenal insufficiency can cause significant morbidity in children. Comorbid DI is associated with higher levels of hospitalisation, longer hospital stays and lower levels of pre-emergent stress dose use. Educational interventions in this subgroup of SAI patients may reduce the burden of morbidity.
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Affiliation(s)
| | - Nikki Gouvoussis
- School of Medicine, Sydney, The University of Notre Dame, Sydney, Australia
| | - Thomas Goubar
- School of Medicine, Sydney, The University of Notre Dame, Sydney, Australia
| | - Ann Maguire
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Westmead, Australia
- Faculty of Medicine and Health, Children's Hospital Westmead Clinical School, University of Sydney, Sydney, Australia
| | - Craig F Munns
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Westmead, Australia
- Faculty of Medicine and Health, Children's Hospital Westmead Clinical School, University of Sydney, Sydney, Australia
| | - Kristen A Neville
- Department of Endocrinology, Sydney Children's Hospital, Randwick, NSW, Australia
- School of Women and Children's Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, SA, Australia
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26
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Merke DP, Mallappa A, Arlt W, Brac de la Perriere A, Lindén Hirschberg A, Juul A, Newell-Price J, Perry CG, Prete A, Rees DA, Reisch N, Stikkelbroeck N, Touraine P, Maltby K, Treasure FP, Porter J, Ross RJ. Modified-Release Hydrocortisone in Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2021; 106:e2063-e2077. [PMID: 33527139 PMCID: PMC8063257 DOI: 10.1210/clinem/dgab051] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Indexed: 12/11/2022]
Abstract
CONTEXT Standard glucocorticoid therapy in congenital adrenal hyperplasia (CAH) regularly fails to control androgen excess, causing glucocorticoid overexposure and poor health outcomes. OBJECTIVE We investigated whether modified-release hydrocortisone (MR-HC), which mimics physiologic cortisol secretion, could improve disease control. METHODS A 6-month, randomized, phase 3 study was conducted of MR-HC vs standard glucocorticoid, followed by a single-arm MR-HC extension study. Primary outcomes were change in 24-hour SD score (SDS) of androgen precursor 17-hydroxyprogesterone (17OHP) for phase 3, and efficacy, safety and tolerability of MR-HC for the extension study. RESULTS The phase 3 study recruited 122 adult CAH patients. Although the study failed its primary outcome at 6 months, there was evidence of better biochemical control on MR-HC, with lower 17OHP SDS at 4 (P = .007) and 12 (P = .019) weeks, and between 07:00h to 15:00h (P = .044) at 6 months. The percentage of patients with controlled 09:00h serum 17OHP (< 1200 ng/dL) was 52% at baseline, at 6 months 91% for MR-HC and 71% for standard therapy (P = .002), and 80% for MR-HC at 18 months' extension. The median daily hydrocortisone dose was 25 mg at baseline, at 6 months 31 mg for standard therapy, and 30 mg for MR-HC, and after 18 months 20 mg MR-HC. Three adrenal crises occurred in phase 3, none on MR-HC and 4 in the extension study. MR-HC resulted in patient-reported benefit including menses restoration in 8 patients (1 on standard therapy), and 3 patient and 4 partner pregnancies (none on standard therapy). CONCLUSION MR-HC improved biochemical disease control in adults with reduction in steroid dose over time and patient-reported benefit.
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Affiliation(s)
- Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Aude Brac de la Perriere
- Hospices Civils de Lyon, Fédération d’Endocrinologie, Groupement hospitalier Est, Bron Cedex, France
| | - Angelica Lindén Hirschberg
- Department of Women’s and Children’s Health, Karolinska Institutet and Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Juul
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D Aled Rees
- Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Pitie Salpêtriere Hospital, France
- Sorbonne University, Center for Rare Endocrine and Gynecological Disorders, Paris, France
| | | | | | | | - Richard J Ross
- University of Sheffield, Sheffield, UK
- Diurnal Ltd, Cardiff, UK
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27
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Molecular Analysis of 21-Hydroxylase Deficiency Reveals Two Novel Severe Genotypes in Affected Newborns. Mol Diagn Ther 2021; 25:327-337. [PMID: 33710594 DOI: 10.1007/s40291-021-00520-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVE Congenital adrenal hyperplasia involves a series of autosomal recessive disorders where adrenal steroidogenesis is affected. We present a detailed molecular investigation of 13 newborns affected from the severe form of congenital adrenal hyperplasia related to 21-hydroxylase deficiency. METHODS All patients were diagnosed with classical congenital adrenal hyperplasia in the neonatal period due to adrenal crisis and/or ambiguous genitalia presentation. None of the infants was identified through a congenital adrenal hyperplasia newborn screening program. A molecular analysis of the CYP21A2 gene and a familiar segregation analysis were performed. RESULTS Adrenal crisis was the most severe manifestation in the male salt-wasting newborns while all female patients presented with atypical genitalia. Newborns were correctly genotyped and no genotype-phenotype divergences were found. Two novel severe genotypes, not previously reported, were identified. The novel CYP21A2 frameshift mutations (c.793delG and c.297dupG) were added to the other 45 variants recently reported in the literature, leading to a total count of 279 pathogenic variants affecting the gene. CONCLUSIONS We have successfully genotyped 13 infants diagnosed with classical congenital adrenal hyperplasia after birth. Our molecular approach led to the identification of two novel frameshift CYP21A2 pathogenic variants related to the salt-wasting form of congenital adrenal hyperplasia.
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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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Nowotny H, Ahmed SF, Bensing S, Beun JG, Brösamle M, Chifu I, Claahsen van der Grinten H, Clemente M, Falhammar H, Hahner S, Husebye E, Kristensen J, Loli P, Lajic S, Reisch N. Therapy options for adrenal insufficiency and recommendations for the management of adrenal crisis. Endocrine 2021; 71:586-594. [PMID: 33661460 PMCID: PMC7929907 DOI: 10.1007/s12020-021-02649-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/22/2021] [Indexed: 12/16/2022]
Abstract
Adrenal insufficiency (AI) is a life-threatening condition requiring life-long glucocorticoid (GC) substitution therapy, as well as stress adaptation to prevent adrenal crises. The number of individuals with primary and secondary adrenal insufficiency in Europe is estimated to be 20-50/100.000. A growing number of AI cases are due to side effects of GC treatment used in different treatment strategies for cancer and to immunotherapy in cancer treatment. The benefit of hormone replacement therapy is evident but long-term adverse effects may arise due to the non-physiological GC doses and treatment regimens used. Given multiple GC replacement formulations available comprising short-acting, intermediate, long-acting and novel modified-release hydrocortisone as well as subcutaneous formulations, this review offers a concise summary on the latest therapeutic improvements for treatment of AI and prevention of adrenal crises. As availability of various glucocorticoid formulations and access to expert centers across Europe varies widely, European Reference Networks on rare endocrine conditions aim at harmonizing treatment and ensure access to specialized patient care for individual case-by-case treatment decisions. To improve the availability across Europe to cost effective oral and parenteral formulations of hydrocortisone will save lives.
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Affiliation(s)
- Hanna Nowotny
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, Scotland, UK
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Johan G Beun
- European Patient Advocacy Group for Adrenal Diseases, European Reference Network on Rare Endocrine Conditions (Endo ERN), Endo ERN Coordinating Centre, Leiden, The Netherlands
- AdrenalNET, Soest, The Netherlands
| | - Manuela Brösamle
- European Patient Advocacy Group for Adrenal Diseases, European Reference Network on Rare Endocrine Conditions (Endo ERN), Endo ERN Coordinating Centre, Leiden, The Netherlands
| | - Irina Chifu
- Division of Endocrinology and Diabetology, Department of Internal Medicine I, University Hospital of Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Hedi Claahsen van der Grinten
- Amalia Children's Hospital, Department of Pediatric Endocrinology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Maria Clemente
- Pediatric Endocrinology Unit, Hospital Vall d´Hebron, Autonomous University of Barcelona, CIBERER, Barcelona, Spain
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Stefanie Hahner
- Division of Endocrinology and Diabetology, Department of Internal Medicine I, University Hospital of Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Eystein Husebye
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, and Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Jette Kristensen
- European Patient Advocacy Group for Adrenal Diseases, European Reference Network on Rare Endocrine Conditions (Endo ERN), Endo ERN Coordinating Centre, Leiden, The Netherlands
| | - Paola Loli
- Division of Endocrinology, San Raffaele Vita-Salute University, IRCCS San Raffaele Hospital, Milan, Italy
| | - Svetlana Lajic
- Department of Women´s and Children´s Health, Division of Pediatrics, Unit for Pediatric Endocrinology and Metabolic Disorders, Karolinska Institutet/Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany.
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30
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Ali SR, Bryce J, Haghpanahan H, Lewsey JD, Tan LE, Atapattu N, Birkebaek NH, Blankenstein O, Neumann U, Balsamo A, Ortolano R, Bonfig W, Claahsen-van der Grinten HL, Cools M, Costa EC, Darendeliler F, Poyrazoglu S, Elsedfy H, Finken MJJ, Fluck CE, Gevers E, Korbonits M, Guaragna-Filho G, Guran T, Guven A, Hannema SE, Higham C, Hughes IA, Tadokoro-Cuccaro R, Thankamony A, Iotova V, Krone NP, Krone R, Lichiardopol C, Luczay A, Mendonca BB, Bachega TASS, Miranda MC, Milenkovic T, Mohnike K, Nordenstrom A, Einaudi S, van der Kamp H, Vieites A, de Vries L, Ross RJM, Ahmed SF. Real-World Estimates of Adrenal Insufficiency-Related Adverse Events in Children With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2021; 106:e192-e203. [PMID: 32995889 PMCID: PMC7990061 DOI: 10.1210/clinem/dgaa694] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/24/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Although congenital adrenal hyperplasia (CAH) is known to be associated with adrenal crises (AC), its association with patient- or clinician-reported sick day episodes (SDE) is less clear. METHODS Data on children with classic 21-hydroxylase deficiency CAH from 34 centers in 18 countries, of which 7 were Low or Middle Income Countries (LMIC) and 11 were High Income (HIC), were collected from the International CAH Registry and analyzed to examine the clinical factors associated with SDE and AC. RESULTS A total of 518 children-with a median of 11 children (range 1, 53) per center-had 5388 visits evaluated over a total of 2300 patient-years. The median number of AC and SDE per patient-year per center was 0 (0, 3) and 0.4 (0.0, 13.3), respectively. Of the 1544 SDE, an AC was reported in 62 (4%), with no fatalities. Infectious illness was the most frequent precipitating event, reported in 1105 (72%) and 29 (47%) of SDE and AC, respectively. On comparing cases from LMIC and HIC, the median SDE per patient-year was 0.75 (0, 13.3) vs 0.11 (0, 12.0) (P < 0.001), respectively, and the median AC per patient-year was 0 (0, 2.2) vs 0 (0, 3.0) (P = 0.43), respectively. CONCLUSIONS The real-world data that are collected within the I-CAH Registry show wide variability in the reported occurrence of adrenal insufficiency-related adverse events. As these data become increasingly used as a clinical benchmark in CAH care, there is a need for further research to improve and standardize the definition of SDE.
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Affiliation(s)
- Salma R Ali
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
| | - Jillian Bryce
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
| | - Houra Haghpanahan
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - James D Lewsey
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Li En Tan
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | | | - Niels H Birkebaek
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Oliver Blankenstein
- Centre for Chronic Sick Children, Institute for Experimental Paediatric Endocrinology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Uta Neumann
- Centre for Chronic Sick Children, Institute for Experimental Paediatric Endocrinology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Pediatric Unit, Center for Rare Endocrine Conditions (Endo-ERN), S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Rita Ortolano
- Department of Medical and Surgical Sciences, Pediatric Unit, Center for Rare Endocrine Conditions (Endo-ERN), S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Walter Bonfig
- Department of Paediatrics, Technical University München, Munich, Germany
- Department of Paediatrics, Klinikum Wels-Grieskirchen, Wels, Austria
| | | | - Martine Cools
- University Hospital Ghent, Ghent University, Ghent, Belgium
| | - Eduardo Correa Costa
- Pediatric Surgery Service, Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil
| | - Feyza Darendeliler
- Istanbul Faculty of Medicine, Department of Paediatrics, Paediatric Endocrinology Unit, Istanbul University, Istanbul, Turkey
| | - Sukran Poyrazoglu
- Istanbul Faculty of Medicine, Department of Paediatrics, Paediatric Endocrinology Unit, Istanbul University, Istanbul, Turkey
| | - Heba Elsedfy
- Department of Pediatrics, Ain Shams University, Cairo, Egypt
| | - Martijn J J Finken
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Endocrinology, Amsterdam, The Netherlands
| | - Christa E Fluck
- Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics and Department of BioMedical Research, Bern University Hospital Inselspital, University of Bern, Bern, Switzerland
| | - Evelien Gevers
- Department of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Márta Korbonits
- Department of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Guilherme Guaragna-Filho
- Department of Pediatrics, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Tulay Guran
- Marmara University, Department of Pediatric Endocrinology and Diabetes, Pendik, Istanbul, Turkey
| | - Ayla Guven
- Health Science University, Medical Faculty, Zeynep Kamil Women and Children Hospital, Pediatric Endocrinology Clinic, Istanbul, Turkey
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Claire Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, University Of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | | | - Ajay Thankamony
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Violeta Iotova
- Department of Paediatrics, Medical University-Varna, UMHAT “Sv. Marina,” Varna, Bulgaria
| | - Nils P Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Ruth Krone
- Birmingham Women’s & Children’s Hospital, Department for Endocrinology & Diabetes, Birmingham, UK
| | - Corina Lichiardopol
- Department of Endocrinology, University of Medicine and Pharmacy Craiova, University Emergency Hospital, Craiova, Romania
| | - Andrea Luczay
- Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Berenice B Mendonca
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital Das Clinicas, Faculdade De Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Tania A S S Bachega
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital Das Clinicas, Faculdade De Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Mirela C Miranda
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital Das Clinicas, Faculdade De Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Tatjana Milenkovic
- Department of Endocrinology, Mother and Child Health Care Institute of Serbia “Dr Vukan Čupić,” Belgrade, Serbia
| | | | | | - Silvia Einaudi
- Pediatric Endocrinology Regina Margherita Children’s Hospital, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Hetty van der Kamp
- Wilhelmina Kinderziekenhuis, Division of Pediatric Endocrinology, Utrecht, Netherlands
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas, División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Liat de Vries
- The Jesse and Sara Lea Shafer Institute of Endocrinology and Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikvah, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Richard J M Ross
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
- Office for Rare Conditions, Royal Hospital for Children & Queen Elizabeth University Hospital, Glasgow, UK
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Worth C, Vyas A, Banerjee I, Lin W, Jones J, Stokes H, Komlosy N, Ball S, Clayton P. Acute Illness and Death in Children With Adrenal Insufficiency. Front Endocrinol (Lausanne) 2021; 12:757566. [PMID: 34721304 PMCID: PMC8548653 DOI: 10.3389/fendo.2021.757566] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/15/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Adrenal Insufficiency (AI) can lead to life-threatening Adrenal Crisis (AC) and Adrenal Death (AD). Parents are trained to prevent, recognise and react to AC but there is little available information on what parents are actually doing at home to manage symptomatic AI. METHODS Three approaches were taken: (A) A retrospective analysis of patient characteristics in children and young people with AD over a 13-year period, (B) An interview-aided questionnaire to assess the circumstances around AC in children currently in our adrenal clinic, and (C) a separate study of parent perceptions of the administration of parenteral hydrocortisone. RESULTS Thirteen patients died (median age 10 years) over a thirteen-year period resulting in an estimated incidence of one AD per 300 patient years. Those with unspecified adrenal insufficiency were overrepresented (P = 0.004). Of the 127 patients contacted, thirty-eight (30%) were identified with hospital attendance with AC. Responses from twenty patients (median age 7.5 years) with AC reported nausea/vomiting (75%) and drowsiness (70%) as common symptoms preceding AC. All patients received an increase in oral hydrocortisone prior to admission but only two received intramuscular hydrocortisone. Questionnaires revealed that 79% of parents reported confidence in the administration of intramuscular hydrocortisone and only 20% identified a missed opportunity for injection. CONCLUSIONS In children experiencing AC, parents followed 'sick day' guidance for oral hydrocortisone, but rarely administered intramuscular hydrocortisone. This finding is discrepant from the 79% of parents who reported confidence in this task. Local training programmes for management of AC are comprehensive, but insufficient to prevent the most serious crises. New strategies to encourage use of parenteral hydrocortisone need to be devised.
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Affiliation(s)
- Chris Worth
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
- *Correspondence: Chris Worth,
| | - Avni Vyas
- School of Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
- School of Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Wei Lin
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Julie Jones
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Helen Stokes
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Nicci Komlosy
- Department of Endocrinology, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Steven Ball
- School of Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Department of Endocrinology, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Peter Clayton
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
- School of Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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Affiliation(s)
- Deborah P Merke
- From the National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (D.P.M.); and the Division of Metabolism, Endocrinology, and Diabetes and the Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor (R.J.A.)
| | - Richard J Auchus
- From the National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (D.P.M.); and the Division of Metabolism, Endocrinology, and Diabetes and the Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor (R.J.A.)
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Kienitz T, Hahner S, Burger-Stritt S, Quinkler M. Therapeutic Patient Education for Adrenal Insufficiency under COVID-19 Pandemic Conditions. Exp Clin Endocrinol Diabetes 2020; 129:241-249. [PMID: 32767286 PMCID: PMC8043669 DOI: 10.1055/a-1217-7208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Adrenal insufficiency (AI) requires life-long treatment with glucocorticoid
replacement therapy. Over- or under-substitution carries the risk of
increased morbidity in the form of side effects or adrenal crises.
Glucocorticoid replacement therapy needs to be flexible with dose adaptation
in special situations. This could not be managed by medical personnel on a
daily basis, but requires an educated patient who has a good knowledge of
the disease, understands his medical therapy and is able to perform
situational dose adaptation. The rarity of the disease in combination with
the need to respond to stressful situations with rapid glucocorticoid dose
adjustment underlines that a well-trained patient is crucial for optimal
management of the disease. In this literature review we provide background information further
clarifying the need of education in patients with AI including the current
shortcomings of medical therapy and of the treatment of patients with AI. We
outline the aims of therapeutic patient education, present the concept of
structured patient education in Germany, and discuss available results of
patient group education programs. Furthermore, we propose strategies how
therapeutic patient education for adrenal insufficiency can be organized
under COVID-19 pandemic conditions.
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Affiliation(s)
- Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| | - Stefanie Hahner
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Stephanie Burger-Stritt
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
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Chrisp GL, Torpy DJ, Maguire AM, Quartararo M, Falhammar H, King BR, Munns CF, Hameed S, Rushworth RL. The effect of patient-managed stress dosing on electrolytes and blood pressure in acute illness in children with adrenal insufficiency. Clin Endocrinol (Oxf) 2020; 93:97-103. [PMID: 32301148 DOI: 10.1111/cen.14196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 03/19/2020] [Accepted: 04/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adrenal crises (AC) are acute episodes of adrenal insufficiency (AI). Manifestations include hypotension and electrolyte disturbances. Glucocorticoid stress dosing (SD) can prevent AC progression, but its effect on physiological parameters has not been assessed in a 'real world setting'. AIMS To assess the effect of prior self-managed glucocorticoid dose escalation on physiological markers in children with congenital adrenal hyperplasia (CAH) presenting to hospital for an acute illness. METHODS An audit of records of all children with CAH presenting to paediatric referral hospital between 2000 and 2015. Potassium, sodium and glucose levels, and hypotension were compared between children who had and had not used SD. RESULTS There were 321 attendances by patients with CAH and an acute illness during the study period. Any form of SD was used by 64.2% (n = 206); intramuscular (IM) hydrocortisone was used by 22.1% (n = 71) and oral only by 41.7% (n = 134). Use of SD (oral and/or IM) was associated with a significantly lower mean potassium level (4.02 ± 0.71 vs. 4.27 ± 0.79 mmol/l, P < .05). Linear regression analysis showed that age (beta: -0.04 years (95% CI -0.06, -0.02)), diarrhoea (beta: -0.41 (95% CI -0.06, -0.02)) and any form of stress dosing (oral, IM or both) (beta: -0.29 (95% CI -0.55, -0.04)) were each independently and significantly associated with potassium levels. SD was not significantly associated with sodium or glucose concentrations or with estimates of hypotension. CONCLUSION Patient-initiated SD resulted in a significant reduction in hyperkalaemia and lowered mean potassium levels in paediatric patients with CAH but did not alter significantly sodium and glucose concentrations or incidences of hypotension.
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Affiliation(s)
- Georgina L Chrisp
- School of Medicine Sydney, The University of Notre Dame, Darlinghurst, NSW, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, SA, Australia
| | - Ann M Maguire
- The Children's Hospital, Westmead, NSW, Australia
- Medical School, The University of Sydney, NSW, Australia
| | - Maria Quartararo
- School of Medicine Sydney, The University of Notre Dame, Darlinghurst, NSW, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research and Royal Darwin Hospital, Tiwi, NT, Australia
| | - Bruce R King
- John Hunter Children's Hospital Newcastle, NSW, Australia
- University of Newcastle, Newcastle, NSW, Australia
| | - Craig F Munns
- The Children's Hospital, Westmead, NSW, Australia
- Medical School, The University of Sydney, NSW, Australia
| | - Shihab Hameed
- The Children's Hospital, Westmead, NSW, Australia
- Sydney Children's Hospital, Randwick, NSW, Australia
- School of Women's and Children's Health, University of New South Wales, Kensington, NSW, Australia
| | - R Louise Rushworth
- School of Medicine Sydney, The University of Notre Dame, Darlinghurst, NSW, Australia
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Bothou C, Anand G, Li D, Kienitz T, Seejore K, Simeoli C, Ebbehoj A, Ward EG, Paragliola RM, Ferrigno R, Badenhoop K, Bensing S, Oksnes M, Esposito D, Bergthorsdottir R, Drake W, Wahlberg J, Reisch N, Hahner S, Pearce S, Trainer P, Etzrodt-Walter G, Thalmann SP, Sævik ÅB, Husebye E, Isidori AM, Falhammar H, Meyer G, Corsello SM, Pivonello R, Murray R, Bancos I, Quinkler M, Beuschlein F. Current Management and Outcome of Pregnancies in Women With Adrenal Insufficiency: Experience from a Multicenter Survey. J Clin Endocrinol Metab 2020; 105:5840404. [PMID: 32424397 PMCID: PMC7320831 DOI: 10.1210/clinem/dgaa266] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/15/2020] [Indexed: 12/31/2022]
Abstract
CONTEXT Appropriate management of adrenal insufficiency (AI) in pregnancy can be challenging due to the rarity of the disease and lack of evidence-based recommendations to guide glucocorticoid and mineralocorticoid dosage adjustment. OBJECTIVE Multicenter survey on current clinical approaches in managing AI during pregnancy. DESIGN Retrospective anonymized data collection from 19 international centers from 2013 to 2019. SETTING AND PATIENTS 128 pregnancies in 113 women with different causes of AI: Addison disease (44%), secondary AI (25%), congenital adrenal hyperplasia (25%), and acquired AI due to bilateral adrenalectomy (6%). RESULTS Hydrocortisone (HC) was the most commonly used glucocorticoid in 83% (97/117) of pregnancies. Glucocorticoid dosage was increased at any time during pregnancy in 73/128 (57%) of cases. In these cases, the difference in the daily dose of HC equivalent between baseline and the third trimester was 8.6 ± 5.4 (range 1-30) mg. Fludrocortisone dosage was increased in fewer cases (7/54 during the first trimester, 9/64 during the second trimester, and 9/62 cases during the third trimester). Overall, an adrenal crisis was reported in 9/128 (7%) pregnancies. Cesarean section was the most frequent mode of delivery at 58% (69/118). Fetal complications were reported in 3/120 (3%) and minor maternal complications in 15/120 (13%) pregnancies without fatal outcomes. CONCLUSIONS This survey confirms good maternal and fetal outcome in women with AI managed in specialized endocrine centers. An emphasis on careful endocrine follow-up and repeated patient education is likely to have reduced the risk of adrenal crisis and resulted in positive outcomes.
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Affiliation(s)
- Christina Bothou
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
| | - Gurpreet Anand
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
| | - Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| | - Khyatisha Seejore
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds, UK
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Andreas Ebbehoj
- Department of Clinical Medicine, Department of Endocrinology and Diabetes, Aarhus University, Aarhus, Denmark
| | - Emma G Ward
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds, UK
| | - Rosa Maria Paragliola
- Unit of Endocrinology, Università Cattolica del Sacro Cuore – Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Klaus Badenhoop
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital, Frankfurt, Germany
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Inflammation and Infection Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne Oksnes
- Endocrinology in Charlottenburg, Berlin, Germany
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Jonas Liesvei, Bergen, Norway
| | - Daniela Esposito
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska, University Hospital, Gothenburg, Sweden
| | - Ragnhildur Bergthorsdottir
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska, University Hospital, Gothenburg, Sweden
| | - William Drake
- Department of Endocrinology, St Bartholomew’s Hospital, London, UK
| | - Jeanette Wahlberg
- Department of Endocrinology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Nicole Reisch
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Stefanie Hahner
- Department of Internal Medicine I, Endocrinology and Diabetes Unit, University Hospital of Würzburg, University of Würzburg, Germany
| | - Simon Pearce
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter Trainer
- The Christie NHS Foundation, MAHSC, Wilmslow Road, Manchester, UK
| | | | | | - Åse B Sævik
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Jonas Liesvei, Bergen, Norway
| | - Eystein Husebye
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Jonas Liesvei, Bergen, Norway
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Inflammation and Infection Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gesine Meyer
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital, Frankfurt, Germany
| | - Salvatore M Corsello
- Unit of Endocrinology, Università Cattolica del Sacro Cuore – Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Robert Murray
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds, UK
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Felix Beuschlein
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
- Correspondence and Reprint Requests: Prof. Felix Beuschlein, MD, Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland. E-mail:
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Arlt W, Baldeweg SE, Pearce SHS, Simpson HL. ENDOCRINOLOGY IN THE TIME OF COVID-19: Management of adrenal insufficiency. Eur J Endocrinol 2020; 183:G25-G32. [PMID: 32379699 PMCID: PMC7938015 DOI: 10.1530/eje-20-0361] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/20/2020] [Indexed: 01/08/2023]
Abstract
We provide guidance on prevention of adrenal crisis during the global COVID-19 crisis, a time with frequently restricted access to the usual level of healthcare. Patients with adrenal insufficiency are at an increased risk of infection, which may be complicated by developing an adrenal crisis; however, there is currently no evidence that adrenal insufficiency patients are more likely to develop a severe course of disease. We highlight the need for education (sick day rules, stringent social distancing rules), equipment (sufficient glucocorticoid supplies, steroid emergency self-injection kit) and empowerment (steroid emergency card, COVID-19 guidelines) to prevent adrenal crises. In patients with adrenal insufficiency developing an acute COVID-19 infection, which frequently presents with continuous high fever, we suggest oral stress dose cover with 20 mg hydrocortisone every 6 h. We also comment on suggested dosing for patients who usually take modified release hydrocortisone or prednisolone. In patients with adrenal insufficiency showing clinical deterioration during an acute COVID-19 infection, we advise immediate (self-)injection of 100 mg hydrocortisone intramuscularly, followed by continuous i.v. infusion of 200 mg hydrocortisone per 24 h, or until this can be established, and administration of 50 mg hydrocortisone every 6 h. We also advise on doses for infants and children.
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Affiliation(s)
- Wiebke Arlt
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Correspondence should be addressed to W Arlt;
| | - Stephanie E Baldeweg
- Department of Diabetes and Endocrinology, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Medicine, University College London, London, UK
| | - Simon H S Pearce
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Endocrinology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Helen L Simpson
- Department of Diabetes and Endocrinology, University College London Hospitals NHS Foundation Trust, London, UK
- Genetics and Genomic Medicine, University College London Great Ormond Street Institute for Child Health, London, UK
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Rushworth RL, Torpy DJ, Falhammar H. Adrenal crises in older patients. Lancet Diabetes Endocrinol 2020; 8:628-639. [PMID: 32559478 DOI: 10.1016/s2213-8587(20)30122-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 12/21/2022]
Abstract
Adrenal crises are severe manifestations of adrenal insufficiency that result in hospital admission and incur a risk of cardiovascular events, acute renal injury, and death. Evidence from population-based studies indicate that adults older than 60 years have the highest adrenal insufficiency incidence, contribute to the highest number of adrenal crises, and have the highest age-specific incidence of adrenal crisis, which doubles between the age groups of 60-69 years and 80 years or older. Older patients might be more susceptible to adrenal crises because of a higher prevalence of comorbidities and a consequently higher risk of acute illness. This susceptibility might be compounded by shortfalls in the implementation of prevention strategies for adrenal crisis, because of individual and social factors that increase with age. Although little research has focused on adrenal crisis prevention in older patients, it seems logical that a timely diagnosis of adrenal insufficiency and the use of consensus driven adrenal crisis prevention and attenuation strategies might reduce adrenal crises in patients older than 60 years old.
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Affiliation(s)
- Ruth L Rushworth
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Gaudino R, Pecoraro L, Martini L, Salvottini C, Antoniazzi F, Piacentini G, Cavarzere P. 21-hydroxylase-deficient congenital adrenal hyperplasia classic form therapy knowledge and management: targeted educational intervention for pediatricians. Minerva Pediatr (Torino) 2020; 73:285-287. [PMID: 32241101 DOI: 10.23736/s2724-5276.20.05594-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Rossella Gaudino
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy -
| | - Luca Pecoraro
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Lucia Martini
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Chiara Salvottini
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Franco Antoniazzi
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Giorgio Piacentini
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Paolo Cavarzere
- Unit of Pediatrics, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
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Therapie des klassischen 21‑Hydroxylase-Mangel-Adrenogenitalen Syndroms (AGS) im Kindes- und Jugendalter. JOURNAL FÜR KLINISCHE ENDOKRINOLOGIE UND STOFFWECHSEL 2019. [DOI: 10.1007/s41969-019-00083-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Heinrich DA, Adolf C, Holler F, Lechner B, Schneider H, Riester A, Nirschl N, Sturm L, Wang X, Ladurner R, Seidensticker M, Bidlingmaier M, Beuschlein F, Reincke M. Adrenal Insufficiency After Unilateral Adrenalectomy in Primary Aldosteronism: Long-Term Outcome and Clinical Impact. J Clin Endocrinol Metab 2019; 104:5658-5664. [PMID: 31225874 DOI: 10.1210/jc.2019-00996] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/17/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Primary aldosteronism (PA) represents a secondary form of arterial hypertension that can be cured by surgery. Evidence of adrenal insufficiency (AI) was recently found in patients with PA who had undergone unilateral adrenalectomy (uADX). OBJECTIVE To study the incidence and long-term outcome of postoperative AI after uADX for PA. DESIGN Prospective registry study (August 2014 until the end of 2018). SETTING Tertiary referral center. PATIENTS One hundred consecutive patients undergoing uADX for PA were included. All patients underwent postoperative ACTH stimulation testing. INTERVENTION Postoperative ACTH stimulation testing to identify patients with AI. MAIN OUTCOME MEASURES Incidence of patients with postoperative AI and definition of long-term outcome. RESULTS Twenty-seven percent of patients developed postoperative AI. Of these, 48% had postoperative ACTH stimulation serum cortisol levels ≤13.5 µg/dL (severe AI); 52% were classified into the group with moderate AI (stimulated serum cortisol levels: 13.5 to 17 µg/dL). Patients with severe AI required significantly longer hydrocortisone replacement therapy than the moderate group (median [25th, 75th percentiles]: 353 [294, 476] days; 95% CI: 284 to 322 days; vs 74 [32, 293] days; 95% CI: 11 to 137 days; P = 0.016). One patient with severe AI was hospitalized for an acute adrenal crisis. With a cumulative follow-up of 14.5 years, this produced an incidence rate of 6.9 adrenal crises per 100 patient-years. CONCLUSION We suggest performing postoperative ACTH stimulation tests in all patients who undergo uADX for PA.
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Affiliation(s)
- Daniel A Heinrich
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Christian Adolf
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Finn Holler
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Benjamin Lechner
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Holger Schneider
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Nina Nirschl
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Lisa Sturm
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Xiao Wang
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Roland Ladurner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Campus Innenstadt, Klinikum der Universität München, LMU München, Munich, Germany
| | - Max Seidensticker
- Klinik und Poliklinik für Radiologie, Klinikum der Universität München, LMU München, Munich, Germany
| | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitäts-Spital Zürich, Zurich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
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Goubar T, Torpy DJ, McGrath S, Rushworth RL. Prehospital Management of Acute Addison Disease: Audit of Patients Attending a Referral Hospital in a Regional Area. J Endocr Soc 2019; 3:2194-2203. [PMID: 31723718 PMCID: PMC6839527 DOI: 10.1210/js.2019-00263] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/11/2019] [Indexed: 11/19/2022] Open
Abstract
Context Adrenal crisis (AC) causes morbidity and mortality in patients with Addison disease [primary adrenal insufficiency (PAI)]. Patient-initiated stress dosing (oral or parenteral hydrocortisone) is recommended to avert ACs. Although these should be effective, the continued incidence of ACs remains largely unexplained. Methods Audit of all attendances between 2000 and 2017 of adult patients with treated PAI to one large regional referral center in New South Wales, Australia. Measurements were those taken on arrival at hospital. Results There were 252 attendances by 56 patients with treated PAI during the study period. Women comprised 60.7% (n = 34) of the patients. The mean age of attendees was 53.7 (19.6) years. Nearly half (45.2%, n = 114) of the patients had an infection. There were 61 (24.2%) ACs diagnosed by the treating clinician. Only 17.9% (n = 45) of the hospital presentations followed any form of stress dosing. IM hydrocortisone was used prior to presentation 7 (2.8%) attendances only. Among patients with a clinician-diagnosed AC, only 32.8% (n = 20) had used stress dosing before presentation. Vomiting was reported by 47.6% (n = 120) of the patients but only 33 (27.5%) of these attempted stress dosing and 5 patients with vomiting used IM hydrocortisone. The number of prior presentations was an independent predictor of use of stress doses [1.05 (1.01, 1.09)]. Conclusion Dose-escalation strategies are not used universally or correctly by unwell patients with PAI; many patients do not use IM or subcutaneous hydrocortisone injections. Previous hospital treatment increases the likelihood of stress dosing, and hospital attendance offers the opportunity for reinforcement of prevention strategies.
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Affiliation(s)
- Thomas Goubar
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, North Terrace, Adelaide, Australia
| | | | - R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, Australia
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Abstract
Fertility rates in classic congenital adrenal hyperplasia caused by 21-hydroxylase deficiency are substantially decreased for various reasons, including hormonal, anatomic, psychosocial, and psychosexual causes. However, fecundity is comparable with the general population. Under optimal hormone replacement, the course and outcome of pregnancies is also good. This article summarizes successful gestational management, including preconceptional considerations, adjustment of hormone replacement during pregnancy, delivery and lactation, as well as the prevention of adrenal crises. In nonclassic 21-hydroxylase deficiency, preconceptional low-dose hydrocortisone replacement normalizes the otherwise increased miscarriage rate. Pregnancy reports in rarer forms of congenital adrenal hyperplasia are summarized as well.
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Affiliation(s)
- Nicole Reisch
- Medizinische Klinik IV, Department of Endocrinology, Klinikum der Universität München, Ziemssenstraße 1, München 80336, Germany.
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Rushworth RL, Chrisp GL, Torpy DJ. The use of medical identification jewellery in adults with adrenal insufficiency in Australia. Clin Endocrinol (Oxf) 2019; 91:41-47. [PMID: 30963602 DOI: 10.1111/cen.13985] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/28/2019] [Accepted: 04/06/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Hydrocortisone stress dosing during illness can prevent adrenal crises (AC) in patients with adrenal insufficiency (AI). When patients cannot communicate, medical identification jewellery may facilitate parenteral hydrocortisone provision but patient adoption rates are not known. DESIGN A cross-sectional analysis of Australian medical identification jewellery subscription data. PATIENTS Patients with AI aged 20 years and over with an active subscription to a large medical jewellery provider. MEASUREMENTS Subscription rates by AI subtype, geographic area, age and gender. RESULTS There were 1955 patients with AI and an active subscription in the database, corresponding to a subscription rate of 105.79/million or approximately one-third of the AI population. The subscription rate was substantially higher in primary AI (60.72/million) than secondary AI (23.16/million), corresponding to approximately 60.7% and 11.6% of the estimated population prevalence of each disorder, respectively. There was substantial variation in use by state/territory, with the highest subscribing state having a rate of over four times that of the lowest (P < 0.001). Women comprised 64.8% (n = 1266) of the group. Subscription also varied by age, being highest in the 60-69 year age group (165.15/million) and lowest in those aged 30-39 years (47.23/million) (P < 0.001). Few patients (4.8%, n = 94) mentioned, either in their record or on their jewellery, the need for urgent parenteral hydrocortisone in the event of severe illness. CONCLUSIONS Medical jewellery is a component of AC risk reduction. However, subscription appears to be underutilised in the Australian AI population, especially among patients with secondary AI. Urgent treatment recommendations should be inscribed on the jewellery.
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Affiliation(s)
- Rosemary Louise Rushworth
- School of Medicine Sydney, The University of Notre Dame, Australia, Sydney, New South Wales, Australia
| | - Georgina L Chrisp
- School of Medicine Sydney, The University of Notre Dame, Australia, Sydney, New South Wales, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
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Eyal O, Levin Y, Oren A, Zung A, Rachmiel M, Landau Z, Schachter-Davidov A, Segev-Becker A, Weintrob N. Adrenal crises in children with adrenal insufficiency: epidemiology and risk factors. Eur J Pediatr 2019; 178:731-738. [PMID: 30806790 DOI: 10.1007/s00431-019-03348-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/10/2019] [Accepted: 02/12/2019] [Indexed: 02/21/2023]
Abstract
The aim of the study was to assess the epidemiology and risk factors of adrenal crises (AC) in children with adrenal insufficiency (AI). Children diagnosed with AI between 1990 and 2017 at four Israeli pediatric endocrinology units were studied. Demographic and clinical data were retrieved retrospectively from their files. The study population consisted of 120 children (73 boys, 47 girls) and comprised 904 patient years. Median age at diagnosis was 0.3 years (0-17.5). Thirty-one AC events in 26 children occurred during the study period, accounting for a frequency of 3.4 crises/100 patient years. Fifty-two percent of AC events occurred at presentation. The significant risk factors for developing AC were the following: younger age at diagnosis (P = 0.003), primary AI vs. secondary AI (P = 0.016), specific diagnosis of autoimmune AI, adrenal hypoplasia congenita and salt wasting congenital adrenal hyperplasia (P < 0.001), mineralocorticoid treatment (P < 0.001), and recurrent hospital admissions (P > 0.001). After applying a stepwise logistic regression model, only the group of diagnoses, including salt wasting CAH, AHC, and Addison's disease, remained significant predictor of AC (OR 17.5, 95% CI 4.7-64.9, P < 0.001). There was no AC-associated mortality during the study period.Conclusions: Since significant percent of AC events occurred at presentation, measures to increase the awareness to signs and symptoms of AI among primary care physicians should be taken. Efforts to prevent AC should be focused on younger patients, especially those with primary AI. What Is Known: • Diagnosis and long-term management of pediatric patients with adrenal insufficiency (AI) remain a challenge. • Adrenal crises (AC) pose life-threatening emergencies in affected youngsters. Studies on the rate and risk factors of AC in children with AI are scarce, and they were done mainly on children with congenital adrenal hyperplasia (CAH). What Is New: • The rate of AC was relatively low and there was no AC-associated mortality during the study period. • Children with primary AI were at higher risk for AC than children with secondary AI. Specifically, children with salt wasting CAH, adrenal hypoplasia congenita, and Addison's disease at the highest risk.
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Affiliation(s)
- Ori Eyal
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel. .,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Yair Levin
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Asaf Oren
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Amnon Zung
- Pediatric Endocrinology Unit, Kaplan Medical Center, Rehovot, Israel.,The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Marianna Rachmiel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Endocrinology Unit, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Zohar Landau
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Endocrinology Unit, Wolfson Medical Center, Holon, Israel
| | - Anita Schachter-Davidov
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Anat Segev-Becker
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Naomi Weintrob
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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45
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Burger-Stritt S, Bachmann L, Kurlbaum M, Hahner S. Emergency treatment of adrenal crisis with prednisone suppositories: a bioequivalence study in female patients with Addison's disease. Endocr Connect 2019; 8:425-434. [PMID: 30952111 PMCID: PMC6454300 DOI: 10.1530/ec-19-0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/18/2019] [Indexed: 12/02/2022]
Abstract
Objective Patients with adrenal insufficiency (AI) need to adapt their glucocorticoid replacement under stressful conditions to prevent adrenal crisis (AC). Prednisone (PN) suppositories are used for emergency treatment. Pharmacokinetics of 100 mg PN suppositories after vaginal or rectal administration was evaluated. Design Single-center, open-label, sequence-randomized, cross-over, bioequivalence study. Methods Twelve females with primary AI were included. Comparison of pharmacokinetics after vaginal and rectal administration of 100 mg PN suppositories. Main outcome measures: bioequivalence (Cmax: maximum plasma concentration of prednisolone; AUC0 -360: area under the plasma concentration curve of prednisolone from administration to 360 min), adrenocorticotropin (ACTH) levels, safety and tolerability. Comparison of ACTH-suppressive effect with subcutaneous and intramuscular administration of 100 mg hydrocortisone. Results Vaginal administration of PN suppositories was not bioequivalent to rectal administration: Cmax and AUC0-360 were significantly lower after vaginal compared to rectal administration: 22 ng/mL (109%) vs 161 ng/mL (28%), P < 0.001; 4390 ng/mL * min (116%) vs 40,302 ng/mL * min (26%), P < 0.001; (mean (coefficient of variation), respectively). A suppression of ACTH by >50% of baseline values was observed 149 min (32%) after rectal PN administration; after vaginal PN administration, the maximum decrease within 360 min was only 44%. Adverse events were more frequent after vaginal administration and mainly attributable to the glucocorticoid deficit due to inadequate vaginal absorption. The ACTH-suppressive effect was more pronounced after parenteral hydrocortisone compared to rectal or vaginal PN. Conclusion Vaginal administration of PN suppositories in the available form is not useful for prevention of AC. Pharmacokinetics after rectal use of PN show inferiority compared to available data on parenteral glucocorticoids. In adrenal emergencies, hydrocortisone injection should be the first choice.
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Affiliation(s)
- Stephanie Burger-Stritt
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Linda Bachmann
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Max Kurlbaum
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Stefanie Hahner
- Endocrinology and Diabetes Unit, Department of Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
- Correspondence should be addressed to S Hahner:
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46
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Dineen R, Thompson CJ, Sherlock M. Adrenal crisis: prevention and management in adult patients. Ther Adv Endocrinol Metab 2019; 10:2042018819848218. [PMID: 31223468 PMCID: PMC6566489 DOI: 10.1177/2042018819848218] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/04/2019] [Indexed: 12/24/2022] Open
Abstract
Adrenal crisis is an acute life-threatening emergency contributing to the excess mortality that is reported in patients with adrenal insufficiency. The incidence of adrenal crisis is estimated to be 8 per 100 patient years in patients with adrenal insufficiency. Patients with adrenal crisis present systemically unwell with nonspecific signs and symptoms often leading to misdiagnosis and delayed treatment. An adrenal crisis may be the first presentation of adrenal insufficiency or can occur in patients who have been established on glucocorticoid replacement therapy. Infections are the major precipitating factor, but other causes include physical stress such as a surgical procedure or trauma, forgetting or discontinuing glucocorticoid therapy, pronounced physical activity, and psychological stress. The emergency treatment involves prompt recognition and administration of parenteral hydrocortisone, rehydration and management of electrolyte abnormalities. Prevention is centred around patient education. All patients should be educated on stress dosing and parenteral glucocorticoid administration. They should carry a steroid dependency alert card and wear a medical alert bracelet or similar identification. Despite many improvements in the management of patients with adrenal insufficiency, adrenal crisis continues to occur and represents a major source of morbidity, mortality and distress for patients. Improved patient and clinician education and measures to facilitate parenteral hydrocortisone self-administration in impending crisis are central to the management of this life-threatening event.
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Affiliation(s)
- Rosemary Dineen
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
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47
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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 554] [Impact Index Per Article: 92.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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48
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Chrisp GL, Maguire AM, Quartararo M, Falhammar H, King BR, Munns CF, Torpy DJ, Hameed S, Rushworth RL. Variations in the management of acute illness in children with congenital adrenal hyperplasia: An audit of three paediatric hospitals. Clin Endocrinol (Oxf) 2018; 89:577-585. [PMID: 30086199 DOI: 10.1111/cen.13826] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/02/2018] [Accepted: 08/02/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Episodes of acute adrenal insufficiency (AI)/adrenal crises (AC) are a serious consequence of congenital adrenal hyperplasia (CAH). This study aimed to assess morbidity from acute illness in CAH and identify factors associated with use of IV hydrocortisone, admission and diagnosis of an AC. METHOD An audit of acute illness presentations among children with CAH to paediatric hospitals in New South Wales, Australia, between 2000 and 2015. RESULTS There were 321 acute presentations among 75 children with CAH. Two-thirds (66.7%, n = 214) of these resulted in admission and 49.2% (n = 158) of the patients received intravenous (IV) hydrocortisone. An AC was diagnosed in (9.0%). Prior to presentation, 64.2% (n = 206) had used oral stress dosing and 22.1% (n = 71) had been given intramuscular (IM) hydrocortisone. Vomiting was recorded in 61.1% (n = 196), 32.7% (n = 64) of whom had used IM hydrocortisone. Admission, AC diagnosis and use of stress dosing varied significantly between hospitals. IM use varied from 7.0% in one metropolitan hospital to 45.8% in the regional hospital. Children aged up to 12 months had the lowest levels of stress dosing and IV hydrocortisone administration. Higher numbers of prior hospital attendances for acute illness were associated with increased use of IM hydrocortisone. CONCLUSION Prehospital and in-hospital management of children with CAH can vary between health services. Children under 12 months have lower levels of stress dosing prior to hospital than other age groups. Experience with acute episodes improves self-management of CAH in the context of acute illness in educated patient populations.
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Affiliation(s)
- Georgina L Chrisp
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
| | - Ann M Maguire
- The Children's Hospital, Westmead, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Maria Quartararo
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research and Royal Darwin Hospital, Tiwi, Northern Territory, Australia
| | - Bruce R King
- John Hunter Children's Hospital, Newcastle, New South Wales, Australia
- University of Newcastle, Newcastle, New South Wales, Australia
| | - Craig F Munns
- The Children's Hospital, Westmead, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Shihab Hameed
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Children's Hospital, Randwick, New South Wales, Australia
- School of Women's and Children's Health, University of New South Wales, Kensington, New South Wales, Australia
| | - R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
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49
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Rushworth RL, Torpy DJ, Stratakis CA, Falhammar H. Adrenal Crises in Children: Perspectives and Research Directions. Horm Res Paediatr 2018; 89:341-351. [PMID: 29874655 DOI: 10.1159/000481660] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/20/2017] [Indexed: 11/19/2022] Open
Abstract
Adrenal crises (AC) are life-threatening physiological disturbances that occur at a rate of 5-10/100 patient years in patients with adrenal insufficiency (AI). Despite their seriousness, there is a paucity of information on the epidemiology of AC events in the paediatric population specifically, as most investigations have focused on AI and ACs in adults. Improved surveillance of AC-related morbidity and mortality should improve the delineation of AC risk overall and among different subgroups of paediatric patients with AI. Valid incidence measures are essential for this purpose and also for the evaluation of interventions aimed at reducing adverse health outcomes from ACs. However, the absence of an agreed AC definition limits the potential benefit of research and surveillance in this area. While approaches to the treatment and prevention of ACs have much in common across the lifespan, there are important differences between children and adults with regards to the physiological, psychological, and social milieu in which these events occur. Education is considered to be an essential element of AC prevention but studies have shown that ACs occur even among well-educated patients, suggesting that new strategies may be needed. In this review, we examine the current knowledge regarding AC events in children with AI; assess the existing definitions of an AC and offer a new definition for use in research and the clinic; and suggest areas for further investigation that are aimed at reducing the incidence and health impact of ACs in the paediatric age group.
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Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Menzies School of Health Research and Royal Darwin Hospital, Tiwi, Northwest Territories, Australia
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50
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Ishii T, Adachi M, Takasawa K, Okada S, Kamasaki H, Kubota T, Kobayashi H, Sawada H, Nagasaki K, Numakura C, Harada S, Minamitani K, Sugihara S, Tajima T. Incidence and Characteristics of Adrenal Crisis in Children Younger than 7 Years with 21-Hydroxylase Deficiency: A Nationwide Survey in Japan. Horm Res Paediatr 2018; 89:166-171. [PMID: 29455197 DOI: 10.1159/000486393] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 12/18/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS We aimed to evaluate the incidence and characteristics of adrenal crisis in Japanese children with 21-hydroxylase deficiency (21-OHD). METHODS We conducted a retrospective nationwide survey for the councilors of the Japanese Society for Pediatric Endocrinology (JSPE) regarding adrenal crisis in children under 7 years with 21-OHD, admitted to hospitals from 2011 through 2016. We defined adrenal crisis as the acute impairment of general health due to glucocorticoid deficiency with at least two of symptoms, signs, or biochemical abnormalities. RESULTS The councilors of the JSPE in 83 institutions responded to this survey (response rate, 60.1%). Data analyses of 378 patients with 1,101.4 person-years (PYs) revealed that 67 patients (17.7%) experienced at least 1 episode of hospital admission for adrenal crisis at the median age of 2 years. The incidence of adrenal crisis was calculated as 10.9 per 100 PYs (95% confidence interval [CI] 9.6-12.2). Infections were the most common precipitating factors, while no factor was observed in 12.5%. Hypoglycemia occurred concomitantly in 27.4%. One patient died from severe hypoglycemia, resulting in a mortality rate of 0.09 per 100 PYs (95% CI 0.0-0.2). CONCLUSION Adrenal crisis is not rare and can be accompanied by disastrous hypoglycemia in children with 21-OHD.
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Affiliation(s)
- Tomohiro Ishii
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Masanori Adachi
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Kei Takasawa
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoshi Okada
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Hotaka Kamasaki
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takuo Kubota
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hironori Kobayashi
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Shimane University Faculty of Medicine, Shimane, Japan
| | - Hirotake Sawada
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Reproductive and Developmental Medicine, University of Miyazaki, Miyazaki, Japan
| | - Keisuke Nagasaki
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Division of Pediatrics, Department of Homeostatic Regulation and Development, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Chikahiko Numakura
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan
| | - Shohei Harada
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Child Studies, Seitoku University, Matsudo, Japan
| | - Kanshi Minamitani
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Shigetaka Sugihara
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Toshihiro Tajima
- The Committee on Mass Screening, Japanese Society for Pediatric Endocrinology, Kyoto, Japan.,Department of Pediatrics, Jichi Medical University Tochigi Childrens Medical Center, Shimotsuke, Japan
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