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Jørgensen NT, Boesen VB, Borresen SW, Christoffersen T, Jørgensen NR, Plomgaard P, Christoffersen C, Watt T, Feldt-Rasmussen U, Klose M. Dual-release hydrocortisone improves body composition and the glucometabolic profile in patients with secondary adrenal insufficiency. Endocrine 2024; 84:1182-1192. [PMID: 38345683 PMCID: PMC11208214 DOI: 10.1007/s12020-024-03711-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/21/2024] [Indexed: 06/27/2024]
Abstract
PURPOSE Studies have suggested improved metabolic profiles in patients with adrenal insufficiency treated with dual-release hydrocortisone (DR-HC) compared with conventional hydrocortisone (C-HC). This study investigates the effect of DR-HC compared with C-HC treatment on five health variables: diurnal salivary cortisol/cortisone, body composition, bone health, glucose metabolism, lipids, and blood pressure. METHODS Prospective study of 27 participants (24 men) with secondary adrenal insufficiency with measurements during stable C-HC and 16 weeks after treatment switch to DR-HC. OUTCOMES Diurnal salivary-cortisol/cortisone, body composition assessed by Dual-Energy X-ray absorptiometry scan, bone status indices (serum type I N-terminal procollagen [PINP], collagen type I cross-linked C-telopeptide [CTX], osteocalcin, receptor activator kappa-B [RANK] ligand, osteoprotegerin, and sclerostin), lipids, haemoglobin A1c (HbA1c), and 24-hour blood pressure. RESULTS After the switch to DR-HC, the diurnal salivary-cortisol area under the curve (AUC) decreased non-significantly (mean difference: -55.9 nmol/L/day, P = 0.06). The salivary-cortisone-AUC was unchanged. Late-evening salivary-cortisol and cortisone were lower (-1.6 and -1.7 nmol/L, P = 0.002 and 0.004). Total and abdominal fat mass (-1.5 and -0.5 kg, P = 0.003 and 0.02), HbA1c (-1.2 mmol/mol, P = 0.02), and osteocalcin decreased (-7.0 µg/L, P = 0.03) whereas sclerostin increased (+41.1 pg/mL, P = 0.0001). The remaining bone status indices, lipids, and blood pressure were unchanged. CONCLUSION This study suggests that switching to DR-HC leads to lower late-evening cortisol/cortisone exposure and a more favourable metabolic profile and body composition. In contrast, decreased osteocalcin with increasing sclerostin might indicate a negative impact on bones. CLINICAL TRIAL REGISTRATION EudraCT201400203932.
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Affiliation(s)
- Nanna Thurmann Jørgensen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Victor Brun Boesen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Stina Willemoes Borresen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Thea Christoffersen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Niklas Rye Jørgensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Peter Plomgaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christina Christoffersen
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Torquil Watt
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Marianne Klose
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
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Gasco V, Giannelli J, Campioni L, Arvat E, Ghigo E, Grottoli S, Maccario M, Giordano R. Benefits of dual-release hydrocortisone treatment on central adiposity and health-related quality of life in secondary adrenal insufficiency. J Endocrinol Invest 2023; 46:587-597. [PMID: 36251244 PMCID: PMC9938071 DOI: 10.1007/s40618-022-01940-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/12/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Patients with secondary adrenal insufficiency (SAI) have an increased morbidity and an impaired health-related quality of life (HRQoL), which seems to primarily depend on the sub-optimal replacement of hypoadrenalism with standard glucocorticoid (GC) therapy, and on the inadequate correction of other associated pituitary deficiencies. A dual-release hydrocortisone (DR-HC) formulation has shown to exert positive effects on morbidity and HRQoL, mainly in patients with primary adrenal insufficiency. We assessed the variations of anthropometric and metabolic parameters and HRQoL in patients with SAI after switching from cortisone acetate (CA) or hydrocortisone (HC) to DR-HC. METHODS Twenty-one patients (17 M, 4 F) treated with CA (n = 16; 25 mg/day twice a day) or HC (n = 5; 20 mg/day three times a day), were evaluated for waist circumference, BMI, fasting glucose, HbA1c, insulin, HOMA-IR index, serum lipids, electrolytes, blood pressure and HRQoL at baseline, at 3, 6 and 12 months after switching from CA/HC to DR-HC. RESULTS The study showed a significant reduction of waist circumference and BMI (p = 0.04, for both), after 3 and 6months of DR-HC treatment, respectively. No significant changes were observed for fasting glucose, insulin, HOMA-IR index, HbA1c, total cholesterol, triglycerides, LDL cholesterol, electrolytes, and blood pressure. However, HDL cholesterol significantly decreased (p = 0.003). An improvement of AddiQoL total score was observed during DR-HC treatment (p = 0.01), mainly for the category "emotions". No predictors resulted for these changes. CONCLUSION DR-HC treatment provides some benefits in patients with SAI, reducing central adiposity and improving HRQoL; however, worsening of HDL cholesterol is observed during treatment with DR-HC.
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Affiliation(s)
- V Gasco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - J Giannelli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - L Campioni
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - E Arvat
- Division of Oncological Endocrinology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - E Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - S Grottoli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - M Maccario
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - R Giordano
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences and Department of Clinical and Biological Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
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Puglisi S, Rossini A, Tabaro I, Cannavò S, Ferrau' F, Ragonese M, Borretta G, Pellegrino M, Dughera F, Parisi A, Latina A, Pia A, Terzolo M, Reimondo G. What factors have impact on glucocorticoid replacement in adrenal insufficiency: a real-life study. J Endocrinol Invest 2021; 44:865-872. [PMID: 32779106 PMCID: PMC7946659 DOI: 10.1007/s40618-020-01386-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/02/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The impact of patient's characteristics on glucocorticoid (GC) replacement therapy in adrenal insufficiency (AI) is poorly evaluated. Aims of this study were to assess the influence of sex and body weight on GC dosing and to describe the choice of GC in AI of different etiologies. METHODS We retrospectively evaluated hydrocortisone (HC) equivalent total daily dose (HC-TDD) and per-kg-daily dose (HC-KDD) in 203 patients (104 primary AI [pAI], 99 secondary AI [sAI]) followed up for ≥ 12 months. They were treated with HC, modified-release HC (MRHC) or cortisone acetate (CA) and fludrocortisone acetate (FCA) in pAI. RESULTS At baseline, CA was preferred both in pAI and sAI; at last visit, MRHC was most used in pAI (49%) and CA in sAI (73.7%). Comparing the last visit with baseline, in pAI, HC-TDD and HC-KDD were significantly lower (p = 0.04 and p = 0.006, respectively), while FCA doses increased during follow-up (p = 0.02). The reduction of HC-TDD and HC-KDD was particularly relevant for pAI women (p = 0.04 and p = 0.002, respectively). In sAI patients, no change of HC-KDD and HC-TDD was observed, and we found a correlation between weight and HC-TDD in males (r 0.35, p = 0.02). CONCLUSIONS Our real-life study demonstrated the influence of etiology of AI on the type of GC used, a weight-based tailoring in sAI, a likely overdosage of GC treatment in pAI women at the start of treatment and the possibility to successfully increase FCA avoiding GC over-treatment. These observations could inform the usual clinical practice.
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Affiliation(s)
- S Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy.
| | - A Rossini
- Endocrinology and Diabetes Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - I Tabaro
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - S Cannavò
- Department of Human Pathology 'G.Barresi', University of Messina, Messina, Italy
| | - F Ferrau'
- Department of Human Pathology 'G.Barresi', University of Messina, Messina, Italy
| | - M Ragonese
- Department of Human Pathology 'G.Barresi', University of Messina, Messina, Italy
| | - G Borretta
- Division of Endocrinology, AO S. Croce E Carle, Cuneo, Italy
| | - M Pellegrino
- Division of Endocrinology, AO S. Croce E Carle, Cuneo, Italy
| | - F Dughera
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - A Parisi
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - A Latina
- Division of Endocrinology, AO S. Croce E Carle, Cuneo, Italy
| | - A Pia
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - M Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - G Reimondo
- Internal Medicine, Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
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Choudhury S, Tan T, Lazarus K, Meeran K. The use of prednisolone versus dual-release hydrocortisone in the treatment of hypoadrenalism. Endocr Connect 2021; 10:R66-R76. [PMID: 33449916 PMCID: PMC7983484 DOI: 10.1530/ec-20-0473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/06/2021] [Indexed: 02/03/2023]
Abstract
The introduction of adrenocortical extract in 1930 improved the life expectancy of hyhpoadrenal patients, with further increases seen after the introduction of cortisone acetate from 1948. Most patients are now treated with synthetic hydrocortisone, and incremental advances have been made with optimisation of daily dosing and the introduction of multidose regimens. There remains a significant mortality gap between individuals with treated hypoadrenalism and the general population. It is unclear whether this gap is a result of glucocorticoid over-replacement, under-replacement or loss of the circadian and ultradian rhythm of cortisol secretion, with the risk of detrimental excess glucocorticoid exposure at later times in the day. The way forwards will involve replacement of the diurnal cortisol rhythm with better glucocorticoid replacement regimens. The steroid profile produced by both prednisolone and dual-release hydrocortisone (Plenadren), provide a smoother glucocorticoid profile of cortisol than standard oral multidose regimens of hydrocortisone and cortisone acetate. The individualisation of prednisolone doses and lower bioavailability of Plenadren offer reductions in total steroid exposure. Although there is emerging evidence of both treatments offering better cardiometabolic outcomes than standard glucocorticoid replacement regimens, there is a paucity of evidence involving very low dose prednisolone (2-4 mg daily) compared to the larger doses (~7.5 mg) historically used. Data from upcoming clinical studies on prednisolone will therefore be of key importance in informing future practice.
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Affiliation(s)
- Sirazum Choudhury
- Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, Commonwealth Building, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Tricia Tan
- Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, Commonwealth Building, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Katharine Lazarus
- Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, Commonwealth Building, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Karim Meeran
- Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, Commonwealth Building, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Correspondence should be addressed to K Meeran:
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Bannon CAM, Border D, Hanson P, Hattersley J, Weickert MO, Grossman A, Randeva HS, Barber TM. Early Metabolic Benefits of Switching Hydrocortisone to Modified Release Hydrocortisone in Adult Adrenal Insufficiency. Front Endocrinol (Lausanne) 2021; 12:641247. [PMID: 33776936 PMCID: PMC7992002 DOI: 10.3389/fendo.2021.641247] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 02/09/2021] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To compare metabolic effects of modified release hydrocortisone (MR-HC) with standard hydrocortisone (HC) therapies in adults with Adrenal Insufficiency (AI). METHODS Adult patients (n = 12) with AI, established on HC therapy, were recruited from Endocrinology clinics at University Hospitals Coventry and Warwickshire (UHCW), UK. Baseline (HC) metabolic assessments included fasting serum HbA1C, lipid and thyroid profiles, accurate measures of body composition (BodPod), and 24-h continuous measures of energy expenditure including Sleeping Metabolic Rate (SMR) using indirect calorimetry within the Human Metabolism Research Unit, UHCW. All participants then switched HC to MR-HC with repeat (MR-HC) metabolic assessments at 3 months. Paired-sample t-tests were used for data comparisons between HC and MR-HC assessments: P-value <0.05 was considered significant. RESULTS Following exclusion of 2 participants, analyses were based on 10 participants. Compared with baseline HC data, following 3 months of MR-HC therapy mean fat mass reduced significantly by -3.2 kg (95% CI: -6.0 to -0.4). Mean (SD) baseline HC fat mass vs repeat MR-HC fat mass: 31.9 kg (15.2) vs 28.7 kg (12.8) respectively, P = 0.03. Mean SMR increased significantly by +77 kcal/24 h (95% CI: 10-146). Mean (SD) baseline HC SMR vs repeat MR-HC SMR: 1,517 kcal/24 h (301) vs 1,594 kcal/24 h (344) respectively, P = 0.03. Mean body fat percentage reduced significantly by -3.4% (95% CI: -6.5 to -0.2). Other measures of body composition, energy expenditure, and biochemical analytes were equivalent between HC and MR-HC assessments. CONCLUSIONS In adults with AI, switching from standard HC to MR-HC associates with early metabolic benefits of reduced fat mass and increased SMR.
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Affiliation(s)
- Christopher A. M. Bannon
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Daniel Border
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Petra Hanson
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - John Hattersley
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Faculty of Health & Life Sciences, Centre of Applied Biological & Exercise Sciences, Coventry University, Coventry, United Kingdom
| | - Martin O. Weickert
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Faculty of Health & Life Sciences, Centre of Applied Biological & Exercise Sciences, Coventry University, Coventry, United Kingdom
| | - Ashley Grossman
- Neuroendocrine Tumour Unit, Royal Free Hospital, London, United Kingdom
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Harpal S. Randeva
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Faculty of Health & Life Sciences, Centre of Applied Biological & Exercise Sciences, Coventry University, Coventry, United Kingdom
| | - Thomas M. Barber
- Warwickshire Institute for the Study of Diabetes Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- NIHR CRF Human Metabolism Research Unit, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- *Correspondence: Thomas M. Barber,
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Kraus AU, Penna-Martinez M, Shoghi F, Meyer G, Badenhoop K. Monocytic Cytokines in Autoimmune Polyglandular Syndrome Type 2 Are Modulated by Vitamin D and HLA-DQ. Front Immunol 2020; 11:583709. [PMID: 33365026 PMCID: PMC7750404 DOI: 10.3389/fimmu.2020.583709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/30/2020] [Indexed: 12/16/2022] Open
Abstract
Context Autoimmune polyglandular syndrome (APS-2: autoimmune Addison’s disease or type 1 diabetes) is conferred by predisposing HLA molecules, vitamin D deficiency, and heritable susceptibility. Organ destruction is accompanied by cytokine alterations. We addressed the monocytic cytokines of two distinct APS-2 cohorts, effects of vitamin D and HLA DQ risk. Methods APS-2 patients (n = 30) and healthy controls (n = 30) were genotyped for HLA DQA1/DQB1 and their CD14+ monocytes stimulated with IL1β and/or 1,25(OH)2D3 for 24 h. Immune regulatory molecules (IL-6, IL-10, IL-23A, IL-15, CCL-2, PD-L1), vitamin D pathway gene transcripts (CYP24A1, CYP27B1, VDR), and CD14 were analyzed by enzyme-linked immunosorbent assay and RTqPCR. Results Pro-inflammatory CCL-2 was higher in APS-2 patients than in controls (p = 0.001), whereas IL-6 showed a trend – (p = 0.1). In vitro treatment with 1,25(OH)2D3 reduced proinflammatory cytokines (IL-6, CCL-2, IL-23A, IL-15) whereas anti-inflammatory cytokines (IL-10 and PD-L1) rose both in APS-type 1 diabetes and APS-Addison´s disease. Patients with adrenal autoimmunity showed a stronger response to vitamin D. Expression of IL-23A and vitamin D pathway genes VDR and CYP27B1 varied by HLA genotype and was lower in healthy individuals with high-risk HLA (p = 0.0025; p = 0.04), while healthy controls with low-risk HLA showed a stronger IL-10 and CD14 expression (p = 0.01; p = 0.03). Conclusion 1,25(OH)2D3 regulates the monocytic response in APS-2 disorders type 1 diabetes or Addison´s disease. The monocytic cytokine profile of individuals carrying HLA high-risk alleles is proinflammatory, enhances polyglandular autoimmunity and can be targeted by vitamin D.
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Affiliation(s)
- Anna U Kraus
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Marissa Penna-Martinez
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Firouzeh Shoghi
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Gesine Meyer
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Klaus Badenhoop
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany
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Bannon CA, Gallacher D, Hanson P, Randeva HS, Weickert MO, Barber TM. Systematic review and meta-analysis of the metabolic effects of modified-release hydrocortisone versus standard glucocorticoid replacement therapy in adults with adrenal insufficiency. Clin Endocrinol (Oxf) 2020; 93:637-651. [PMID: 32621327 DOI: 10.1111/cen.14275] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/01/2020] [Accepted: 06/22/2020] [Indexed: 12/29/2022]
Abstract
CONTEXT Published studies exploring the metabolic effects of Modified-Release Hydrocortisone (MR-HC) replacement in patients with adrenal insufficiency (AI). OBJECTIVE To compare metabolic effects of MR-HC with Standard Glucocorticoid (SG) replacement in adults with AI. Randomized control trials (RCTs) were meta-analysed; non-RCT studies described narratively with critical appraisal. DATA SOURCES PubMed/Medline, EMBASE, CINAHL and CENTRAL were searched to identify relevant articles, published before Aug 2019. STUDY SELECTION All study types that reported metabolic profile (including anthropometric, glucose and lipid-related parameters), on patients switched from SG to MR-HC replacement. Following independent screening from two reviewers, 390 studies were identified, of which 9 studies were included for review (RCT, n = 2; non-RCT, n = 7). DATA EXTRACTION Two independent reviewers assessed each paper for bias and data extraction. RESULTS Meta-analysis from RCTs (n = 2), 104 patients were switched from SG to MR-HC replacement. Combining treatment effects, at 3-months post-therapy switch there was significant reduction in body weight (-0.82 kg; 95% CI: -1.24 kg to -0.40 kg; P < .001) and HbA1c (-0.13%; 95% CI: -0.214% to -0.045%; P = .003). In the sub-group with Diabetes Mellitus (DM), reduction in HbA1C was more pronounced (-0.52%; 95% CI: -0.82% to -0.23%; P < .001). Non-RCT studies showed improved anthropometric measures and glucose metabolism up to 48-months following switch from SG to MR-HC replacement. CONCLUSIONS In adults with AI, replacement with MR-HC associates with significant improvements in anthropometric measurements and HbA1c compared with SG replacement, particularly those with DM.
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Affiliation(s)
- Christopher A Bannon
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Daniel Gallacher
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Petra Hanson
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Harpal S Randeva
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, UK
- Centre of Applied Biological & Exercise Sciences, Faculty of Health & Life Sciences, Coventry University, Coventry, UK
| | - Martin O Weickert
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, UK
- Centre of Applied Biological & Exercise Sciences, Faculty of Health & Life Sciences, Coventry University, Coventry, UK
| | - Thomas M Barber
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals Coventry and Warwickshire, Coventry, UK
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Esposito D, Bobbio E, Di Fraia R, Mone P, Accardo G, De Bellis A, Iorio S, Esposito K, Marfella R, Johannsson G, Ragnarsson O, Pasquali D. Patients with adrenal insufficiency have cardiovascular features associated with hypovolemia. Endocrine 2020; 70:412-420. [PMID: 32813212 PMCID: PMC7581570 DOI: 10.1007/s12020-020-02458-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Patients with adrenal insufficiency (AI) have excess mortality and morbidity, mainly due to cardiovascular (CV) diseases. The mechanisms for this is unclear. OBJECTIVE To assess CV structure and function in AI patients on conventional replacement therapy and after switching to once-daily, modified-release hydrocortisone (OD-HC) in comparison with healthy matched controls. METHODS This was a retrospective analysis of 17 adult AI patients (11 with primary AI, 6 with secondary AI) on stable replacement with cortisone acetate [median (minimum, maximum) 33.5 (12.5-50) mg] and, if needed, fludrocortisone [0.1 (0.05-0.2) mg], and 17 healthy matched controls. Ten patients were switched to an equivalent dose of OD-HC. Data from echocardiography, 24 h Holter-ECG and 24 h blood pressure monitoring were collected at baseline and 6 months after the switch to OD-HC. RESULTS At baseline, AI patients had smaller left ventricular diastolic diameter (47.1 ± 4.2 vs. 51.6 ± 2.3 mm; P = 0.001) and left atrial diameter (34.9 ± 4.7 vs. 38.2 ± 2.6 cm; P = 0.018), and a higher ejection fraction (62.5 ± 6.9% vs. 56.0 ± 4.7%; P = 0.003) than controls. AI patients had lower nocturnal systolic and diastolic blood pressure than controls (108 ± 15 mmHg vs. 117 ± 8 mmHg; P = 0.038 and 65 ± 9 mmHg vs. 73 ± 7 mmHg; P = 0.008, respectively). After the switch to OD-HC, nocturnal diastolic blood pressure normalised. No significant changes were observed in echocardiographic and Holter-ECG parameters following the switch. CONCLUSIONS AI patients on conventional treatment display cardiovascular abnormalities that could be related to hypovolemia. Switch to OD-HC seems to have beneficial effect on blood pressure profile, but no effect on cardiovascular structure and function.
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Affiliation(s)
- 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.
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Emanuele Bobbio
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Rosa Di Fraia
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Pasquale Mone
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giacomo Accardo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Annamaria De Bellis
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Sergio Iorio
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Katherine Esposito
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Gudmundur Johannsson
- 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
| | - Oskar Ragnarsson
- 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
| | - Daniela Pasquali
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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Kiko N, Kalhan A. Comparison of Various Glucocorticoid Replacement Regimens Used in Chronic Adrenal Insufficiency: A Systematic Review. DUBAI DIABETES AND ENDOCRINOLOGY JOURNAL 2020. [DOI: 10.1159/000508321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
<b><i>Objective:</i></b> Patients with adrenal insufficiency require life-long glucocorticoid replacement therapy. Hydrocortisone (15–30 mg/day) and prednisolone (3–7.5 mg/day) are the preferred agents used although there is a lack of consensus among endocrinologists regarding the impact of different steroid regimens on quality of life, bone metabolism, cardiometabolic outcomes, adrenal crisis and infections. We carried out a retrospective systematic review of the literature to compare the efficacy and side effects of various glucocorticoid replacement regimens in patients with chronic adrenal insufficiency. <b><i>Methods:</i></b> We searched PubMed, Cochrane Reviews and Google Scholar databases up to March 14, 2019, for studies evaluating various clinical outcomes with glucocorticoid replacement therapy. The abstracts and full studies were appraised and data extracted from the eligible studies. The quality of evidence was evaluated and risk of bias carried out. <b><i>Results:</i></b> A total of 47 studies including 9 randomised controlled trials (RCTs) and 38 observational studies were evaluated in this systematic review. Prednisolone therapy was observed to be safe as well as efficacious as hydrocortisone although a higher dose was associated with an increased risk of cardiovascular (CV) disease. A lower hydrocortisone dose (15–20 mg/day) was associated with a reduction of blood pressure and improved clinical outcomes although this observation was based on a solitary RCT. Modified release hydrocortisone was observed to reduce the risk of CV disease based upon results from 2 of the RCTs. However, there was no conclusive evidence of benefit of modified release hydrocortisone and continuous subcutaneous hydrocortisone infusion in improving subjective health status. <b><i>Conclusion:</i></b> Prednisolone therapy remains a safe and efficacious alternative to hydrocortisone although there are concerns of dyslipidaemia and CV disease with higher doses. There is limited level I evidence suggestive of a positive effect of modified release hydrocortisone on CV and metabolic outcomes, particularly weight reduction.
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Dineen R, Martin-Grace J, Thompson CJ, Sherlock M. The management of glucocorticoid deficiency: Current and future perspectives. Clin Chim Acta 2020; 505:148-159. [DOI: 10.1016/j.cca.2020.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 01/10/2023]
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Isidori AM, Arnaldi G, Boscaro M, Falorni A, Giordano C, Giordano R, Pivonello R, Pozza C, Sbardella E, Simeoli C, Scaroni C, Lenzi A. Towards the tailoring of glucocorticoid replacement in adrenal insufficiency: the Italian Society of Endocrinology Expert Opinion. J Endocrinol Invest 2020; 43:683-696. [PMID: 31773582 DOI: 10.1007/s40618-019-01146-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/11/2019] [Indexed: 11/28/2022]
Abstract
CONTEXT Glucocorticoid (GC) replacement therapy in patients with adrenal insufficiency (AI) is life saving. After over 50 years of conventional GC treatment, novel formulations are now entering routine clinical practice. METHODS Given the spectrum of medications currently available and new insights into the understanding of AI, the authors reviewed relevant medical literature with emphasis on original studies, prospective observational data and randomized controlled trials performed in the past 35 years. The Expert Opinion of a panel of selected endocrinologists was sought to answer specific clinical questions. The objective was to provide an evidence-supported guide, for the use of GC in various settings from university hospitals to outpatient clinics, that offers specific advice tailored to the individual patient. RESULTS The Panel reviewed available GC replacement therapies, comprising short-acting, intermediate and long-acting oral formulations, subcutaneous formulations and the novel modified-release hydrocortisone. Advantages and disadvantages of these formulations were reviewed. CONCLUSIONS In the Panel's opinion, achieving the optimal GC timing and dosing is needed to improve the outcome of AI. No-single formulation offers the best option for every patients. Recent data suggest that more emphasis should be given to the timing of intake. Tailoring of GS should be attempted in all patients-by experts-on a case-by-case basis. The Panel identified specific subgroups of AI patients that could be help by this process. Long-term studies are needed to confirm the short-term benefits associated with the modified-release GCs. The impact of GC tailoring has yet to be proven in terms of hospitalization rate, morbidity and mortality.
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Affiliation(s)
- A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - G Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Azienda Ospedaliero-Universitaria, Università Politecnica delle Marche, Ancona, Italy
| | - M Boscaro
- UOC Endocrinologia, Dipartimento di Medicina DIMED, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - A Falorni
- Dipartimento di Medicina, Università di Perugia, Perugia, Italy
| | - C Giordano
- Section of Diabetology, Endocrinology and Metabolism, PROMISE, University of Palermo, Palermo, Italy
| | - R Giordano
- Department of Clinical and Biological Sciences, Division of Endocrinology, Diabetes and Metabolism-Department of Medical Sciences, University of Turin, Turin, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - C Pozza
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - C Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - C Scaroni
- UOC Endocrinologia, Dipartimento di Medicina DIMED, Azienda Ospedaliera-Università di Padova, Padua, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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Mongioì LM, Condorelli RA, Barbagallo F, La Vignera S, Calogero AE. Dual-release hydrocortisone for treatment of adrenal insufficiency: a systematic review. Endocrine 2020; 67:507-515. [PMID: 31927751 DOI: 10.1007/s12020-020-02187-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 01/03/2020] [Indexed: 12/18/2022]
Abstract
Dual-release hydrocortisone is a new hydrocortisone formulation developed to improve the pharmacokinetic and the pharmacodynamic profiles and patient compliance. The aim of this review is to summarize the main knowledge on dual-release hydrocortisone, with particular attention to pharmacokinetics, metabolic and health-related quality-of-life aspects, bone health and drug safety.
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Affiliation(s)
- Laura Maria Mongioì
- Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - Rosita Angela Condorelli
- Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - Federica Barbagallo
- Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - Sandro La Vignera
- Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - Aldo Eugenio Calogero
- Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy.
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Guarnotta V, Di Stefano C, Santoro A, Ciresi A, Coppola A, Giordano C. Dual-release hydrocortisone vs conventional glucocorticoids in adrenal insufficiency. Endocr Connect 2019; 8:853-862. [PMID: 31252397 PMCID: PMC6599082 DOI: 10.1530/ec-19-0176] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/04/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Dual-release hydrocortisone (DR-HC) improves metabolism in patients with adrenal insufficiency. The aims of this study were to compare the cardiovascular and metabolic effects of conventional glucocorticoids (GCs) vs. DR-HC and of high vs. low doses of GCs, after 48 months of observation. METHODS We selected 27 patients on hydrocortisone (mean dose 17.5 ± 4.2 mg/day) and 20 patients on cortisone acetate (mean dose 37.5 ± 12.1 mg/day) who maintained this treatment (group A) and 53 patients switched to DR-HC (mean dose 22 ± 4.8 mg/day) (group B). At baseline and after 48 months, clinical and metabolic parameters and Framingham Risk Score (FRS) were obtained. RESULTS After 48 months, patients in group A had a significant increase from baseline in BMI (P < 0.001), waist circumference (P = 0.001), systolic blood pressure (P = 0.001), LDL cholesterol (P = 0.018), HbA1c (P = 0.020) and FRS (P = 0.002). By contrast, patients in group B had a significant decrease in BMI (P = 0.002), waist circumference (P = 0.015), diastolic blood pressure (P = 0.031), total (P = 0.006) and LDL cholesterol (P = 0.005), HbA1c (P < 0.001) and FRS (P = 0.015) compared to baseline. No significant differences between high and low doses of both conventional GCs and DR-HC were observed. CONCLUSIONS DR-HC is associated with an improvement of metabolic parameters and cardiovascular risk compared to conventional GCs, which are associated with a worsening of these parameters, regardless of the dose used.
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Affiliation(s)
- V Guarnotta
- Dipartimento di Promozione della Salute, Materno – Infantile, Medicina Interna e Specialistica di Eccellenza ‘G. D’Alessandro’ (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - C Di Stefano
- Dipartimento di Promozione della Salute, Materno – Infantile, Medicina Interna e Specialistica di Eccellenza ‘G. D’Alessandro’ (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - A Santoro
- Dipartimento di Promozione della Salute, Materno – Infantile, Medicina Interna e Specialistica di Eccellenza ‘G. D’Alessandro’ (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - A Ciresi
- Dipartimento di Promozione della Salute, Materno – Infantile, Medicina Interna e Specialistica di Eccellenza ‘G. D’Alessandro’ (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - A Coppola
- Dipartimento di Promozione della Salute, Materno – Infantile, Medicina Interna e Specialistica di Eccellenza ‘G. D’Alessandro’ (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - C Giordano
- Dipartimento di Promozione della Salute, Materno – Infantile, Medicina Interna e Specialistica di Eccellenza ‘G. D’Alessandro’ (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
- Correspondence should be addressed to C Giordano:
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Guarnotta V, Mineo MI, Radellini S, Pizzolanti G, Giordano C. Dual-release hydrocortisone improves hepatic steatosis in patients with secondary adrenal insufficiency: a real-life study. Ther Adv Endocrinol Metab 2019; 10:2042018819871169. [PMID: 31489172 PMCID: PMC6713956 DOI: 10.1177/2042018819871169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 07/31/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Conventional glucocorticoid treatment has a significant impact on liver in patients with adrenal insufficiency. Dual-release hydrocortisone (DR-HC) provides physiological cortisol exposure, leading to an improvement in anthropometric and metabolic parameters. We aimed to evaluate the effects of 12-month DR-HC treatment on the hepatic steatosis index (HSI), a validated surrogate index of hepatic steatosis, in patients with secondary adrenal insufficiency (SAI). METHODS A total of 45 patients with hypopituitarism, 22 with hypogonadism, hypothyroidism, ACTH, and GH deficiencies, and 23 with hypogonadism, hypothyroidism, and ACTH deficiency, on replacement therapy for all the pituitary deficiencies, were switched from conventional hydrocortisone to DR-HC. At baseline and after 12 months, glucose and insulin levels, surrogate estimates of insulin sensitivity, and hepatic steatosis were evaluated through ultrasonography and HSI. RESULTS At diagnosis, ultrasonography documented steatosis in 31 patients (68.8%) while 33 (73.3%) showed high HSI. Hydrocortisone (HC) dose (β = 1.231, p = 0.010), insulin resistance index (HOMA-IR) (β = 1.431, p = 0.002), and insulin sensitivity index (ISI)-Matsuda (β = -1.389, p = 0.034) were predictors of HSI at baseline. After 12 months of DR-HC, a significant decrease in body mass index (BMI) (p = 0.008), waist circumference (WC) (p = 0.010), fasting insulin (p = 0.041), HOMA-IR (p = 0.047), HSI (p < 0.001) and number of patients with HSI ⩾36 (p = 0.003), and a significant increase in sodium (p < 0.001) and ISI-Matsuda (p = 0.031) were observed. HOMA-IR (β = 1.431, p = 0.002) and ISI-Matsuda (β = -9.489, p < 0.001) were identified as independent predictors of HSI at 12 months. CONCLUSIONS In adults with SAI, DR-HC is associated with an improvement in HSI, regardless of the dose used, mainly related to an improvement in insulin sensitivity.
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Affiliation(s)
- Valentina Guarnotta
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Sicilia, Italy
| | - Mariagrazia Irene Mineo
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Sicilia, Italy
| | - Stefano Radellini
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Sicilia, Italy
| | - Giuseppe Pizzolanti
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Sicilia, Italy
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Ceccato F, Selmin E, Sabbadin C, Dalla Costa M, Antonelli G, Plebani M, Barbot M, Betterle C, Boscaro M, Scaroni C. Improved salivary cortisol rhythm with dual-release hydrocortisone. Endocr Connect 2018; 7:965-974. [PMID: 30300536 PMCID: PMC6182219 DOI: 10.1530/ec-18-0257] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION AND AIM The purpose of replacement therapy in adrenal insufficiency (AI) is mimicking endogenous cortisol levels as closely as possible: dual release hydrocortisone (DR-HC) has been introduced to replicate the circadian cortisol rhythm. Multiple daily saliva collections could be used to assess the cortisol rhythm during real life: our aim was to study the salivary cortisol profile in AI. MATERIALS AND METHODS We prospectively evaluated, in an observational study, 18 adult outpatients with AI (11 primary and 7 secondary AI), switched from conventional treatment (conv-HC, 25 mg/day) to the same dose of DR-HC. We collected six samples of saliva in a day, measuring cortisol (F) and cortisone (E) with LC-MS/MS. Forty-three matched healthy subjects served as controls. RESULTS F levels were similar in the morning (and higher than controls) in patients treated with conv-HC or DR-HC; otherwise F levels and exposure were lower in the afternoon and evening in patients with DR-HC, achieving a cortisol profile closer to healthy controls. Daily cortisol exposure, measured with area under the curve, was lower with DR-HC. Morning F and E presented sensitivity and specificity >90% to diagnose AI (respectively threshold of 3 and 9.45 nmol/L). Total cholesterol and HbA1c levels reduced with DR-HC. CONCLUSIONS Salivary cortisol daily curve could be used as a new tool to assess the cortisol profiles in patients treated with conv-HC and DR-HC. A lower daily cortisol exposure was achieved with DR-HC (despite the same HC dose), especially in the afternoon-evening.
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Affiliation(s)
- Filippo Ceccato
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, Padova, Italy
- Correspondence should be addressed to F Ceccato:
| | - Elisa Selmin
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Chiara Sabbadin
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Miriam Dalla Costa
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Giorgia Antonelli
- Laboratory MedicineDepartment of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Laboratory MedicineDepartment of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Corrado Betterle
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Marco Boscaro
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, Padova, Italy
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Guarnotta V, Ciresi A, Pillitteri G, Giordano C. Improved insulin sensitivity and secretion in prediabetic patients with adrenal insufficiency on dual-release hydrocortisone treatment: a 36-month retrospective analysis. Clin Endocrinol (Oxf) 2018; 88:665-672. [PMID: 29368442 DOI: 10.1111/cen.13554] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/12/2018] [Accepted: 01/17/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Dual-release hydrocortisone (DR-HC) provides physiological cortisol exposure, leading to an improvement of anthropometric and metabolic parameters. The aim of the study was to evaluate the effects of DR-HC on insulin secretion and sensitivity and cardiometabolic risk, indirectly expressed by the visceral adiposity index (VAI). DESIGN AND PATIENTS Retrospective analysis of 49 patients, 13 with primary and 36 with secondary adrenal insufficiency (AI), respectively, on conventional glucocorticoid treatment at baseline and switched to DR-HC for 36 months. Overall, 24 patients had AI-pre-diabetes (impaired fasting glucose, impaired glucose tolerance and the combination), and 25 had AI-normal glucose tolerance (NGT). MEASUREMENTS Clinical and metabolic parameters, including VAI, insulin secretion and sensitivity indexes (fasting insulinaemia, AUC2 h insulinaemia , oral disposition index [Dio] and ISI-Matsuda), were evaluated. RESULTS In patients with AI-NGT and AI-prediabetes, a significant decrease in BMI (P = .017 and P < .001), waist circumference (P = .008 and P < .001), HbA1c (P = .034 and P = .001) and a significant increase in HDL-C (P = .036 and P = .043) was, respectively, observed. In addition, in prediabetic patients, only we found a significant decrease in insulinaemia (P = .014), AUC2 h insulinaemia (P = .038) and VAI (P = .001), in concomitance with a significant increase in DIo (P = .041) and ISI-Matsuda (P = .038). CONCLUSIONS Long-term DR-HC therapy is associated with an improvement in insulin secretion and sensitivity in patients with prediabetes. However, all patients appear to benefit from the treatment in terms of improvement of metabolic and anthropometric parameters. Larger studies are required to confirm our preliminary data.
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Affiliation(s)
- Valentina Guarnotta
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Palermo, Italy
| | - Alessandro Ciresi
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Palermo, Italy
| | - Giuseppe Pillitteri
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Palermo, Italy
| | - Carla Giordano
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Palermo, Italy
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Machado MC, Fragoso MCBV, Moreira AC, Boguszewski CL, Vieira Neto L, Naves LA, Vilar L, Araújo LAD, Musolino NRC, Miranda PAC, Czepielewski MA, Gadelha MR, Bronstein MD, Ribeiro-Oliveira A. A review of Cushing's disease treatment by the Department of Neuroendocrinology of the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:87-105. [PMID: 29694638 PMCID: PMC10118687 DOI: 10.20945/2359-3997000000014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 10/02/2017] [Indexed: 11/23/2022]
Abstract
The treatment objectives for a patient with Cushing's disease (CD) are remission of hypercortisolism, adequate management of co-morbidities, restoration of the hypothalamic-pituitary-adrenal axis, preservation of fertility and pituitary function, and improvement of visual defects in cases of macroadenomas with suprasellar extension. Transsphenoidal pituitary surgery is the main treatment option for the majority of cases, even in macroadenomas with low probability of remission. In cases of surgical failure, another subsequent pituitary surgery might be indicated in cases with persistent tumor imaging at post surgical magnetic resonance imaging (MRI) and/or pathology analysis of adrenocorticotropic hormone-positive (ACTH+) positive pituitary adenoma in the first procedure. Medical treatment, radiotherapy and adrenalectomy are the other options when transsphenoidal pituitary surgery fails. There are several options of medical treatment, although cabergoline and ketoconazole are the most commonly used alone or in combination. Novel treatments are also addressed in this review. Different therapeutic approaches are frequently needed on an individual basis, both before and, particularly, after surgery, and they should be individualized. The objective of the present review is to provide the necessary information to achieve a more effective treatment for CD. It is recommended that patients with CD be followed at tertiary care centers with experience in treating this condition.
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Affiliation(s)
- Márcio Carlos Machado
- Unidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Maria Candida Barisson Vilares Fragoso
- Unidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Ayrton Custódio Moreira
- Divisão de Endocrinologia e Metabologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - César Luiz Boguszewski
- Serviço de Endocrinologia e Metabologia (SEMPR), Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Leonardo Vieira Neto
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Luciana A Naves
- Serviço de Endocrinologia, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, DF, Brasil
| | - Lucio Vilar
- Serviço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Pernambuco, Recife, PE, Brasil
| | | | - Nina Rosa Castro Musolino
- Divisão de Neurocirurgia Funcional, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | - Mauro A Czepielewski
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Monica R Gadelha
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Marcello Delano Bronstein
- Unidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Antônio Ribeiro-Oliveira
- Serviço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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Isidori AM, Venneri MA, Graziadio C, Simeoli C, Fiore D, Hasenmajer V, Sbardella E, Gianfrilli D, Pozza C, Pasqualetti P, Morrone S, Santoni A, Naro F, Colao A, Pivonello R, Lenzi A. Effect of once-daily, modified-release hydrocortisone versus standard glucocorticoid therapy on metabolism and innate immunity in patients with adrenal insufficiency (DREAM): a single-blind, randomised controlled trial. Lancet Diabetes Endocrinol 2018; 6:173-185. [PMID: 29229498 DOI: 10.1016/s2213-8587(17)30398-4] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/09/2017] [Accepted: 10/12/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Conventional treatment of patients with adrenal insufficiency involves administration of glucocorticoids multiple times a day and has been associated with weight gain and metabolic impairment. The optimal glucocorticoid replacement therapy for these patients is highly debated because of the scarcity of evidence from randomised trials. We aimed to establish whether the timing and pharmacokinetics of glucocorticoid replacement therapy affect the metabolism and immune system of patients with adrenal insufficiency. METHODS We did a single-blind randomised controlled trial at two reference university hospitals in Italy. Eligible patients (aged 18-80 years) with adrenal insufficiency were on conventional glucocorticoid therapy and had been stable for at least 3 months before enrolment. Patients were randomly assigned (1:1) with a computer-generated random sequence stratified by type of adrenal insufficiency and BMI to continue conventional glucocorticoid therapy (standard treatment group) or to switch to an equivalent dose of once-daily, modified-release oral hydrocortisone (switch treatment group). Outcome assessors were masked to treatment allocation. The primary outcome was bodyweight change from baseline to 24 weeks. Secondary outcomes included immune cell profiles, susceptibility to infections, and quality of life. Efficacy analyses included all patients who received at least one dose of the study drug. This trial is registered with ClinicalTrials.gov, NCT02277587. FINDINGS Between March 1, 2014, and June 30, 2016, 89 patients with adrenal insufficiency were randomly assigned to continue standard glucocorticoid therapy (n=43) or to switch to once-daily, modified-release hydrocortisone (n=46). At 24 weeks, bodyweight reduction was superior in patients in the once-daily hydrocortisone group compared with those in the standard treatment group (-2·1 kg [95% CI -4·0 to -0·3] vs 1·9 kg [-0·1 to 3·9]; treatment difference -4·0 kg, 95% CI -6·9 to -1·1; p=0·008). Additionally, patients in the once-daily hydrocortisone group had more normal immune cell profiles, reduced susceptibility to infections, and improved quality of life compared with the standard glucocorticoid therapy group. We observed no difference in frequency or severity of adverse events between the two intervention groups, although a lower cumulative number of recurrent upper respiratory tract infections was observed with once-daily hydrocortisone than with standard treatment (17 vs 38; p=0·016). Most adverse events were mild; three serious adverse events occurred in each group, of which one adverse advent (arthritis) in the switch treatment group could be considered drug related. INTERPRETATION Patients with adrenal insufficiency on conventional glucocorticoid replacement therapy multiple times a day exhibit a pro-inflammatory state and weakened immune defence. Restoration of a more physiological circadian glucocorticoid rhythm by switching to a once-daily, modified-release regimen reduces bodyweight, normalises the immune cell profile, reduces recurrent infections, and improves the quality of life of patients with adrenal insufficiency. FUNDING Italian Ministry of University and Research.
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Affiliation(s)
- Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - Mary Anna Venneri
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Graziadio
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Daniela Fiore
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Carlotta Pozza
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Patrizio Pasqualetti
- Service of Medical Statistics and Information Technology, Fatebenefratelli Foundation for Health Research and Education, Rome, Italy
| | - Stefania Morrone
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Angela Santoni
- Department of Molecular Medicine, Pasteur Institute-Cenci Bolognetti Foundation, Sapienza University of Rome, Rome, Italy
| | - Fabio Naro
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
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19
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Esposito D, Pasquali D, Johannsson G. Primary Adrenal Insufficiency: Managing Mineralocorticoid Replacement Therapy. J Clin Endocrinol Metab 2018; 103:376-387. [PMID: 29156052 DOI: 10.1210/jc.2017-01928] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/10/2017] [Indexed: 12/28/2022]
Abstract
CONTEXT Mineralocorticoid (MC) replacement therapy in patients with primary adrenal insufficiency (PAI) was introduced more than 60 years ago. Still, there are limited data on how MC substitution should be optimized, because MC dosing regimens have only been systematically investigated in a few studies. We review the management of current standard MC replacement therapy in PAI and its plausible impact on outcome. DESIGN Using PubMed, we conducted a systematic review of the literature from 1939 to 2017, with the following keywords: adrenal insufficiency, MC deficiency, aldosterone, cardiovascular disease, hypertension, and heart failure. RESULTS The current standard treatment consists of fludrocortisone (FC) given once daily in the morning, aiming at normotension, normokalemia, and plasma renin activity in the upper normal range. Available data suggest that patients with PAI may be underreplaced with FC as symptoms and signs indicating chronic MC underreplacement, such as salt craving and postural dizziness persist, in many treated patients with PAI. Data acquired from large registry-based studies show that glucocorticoid doses for replacement in PAI are higher than those estimated from endogenous production. Glucocorticoid overreplacement may reduce the need of MC replacement but may also be a consequence of inadequate MC replacement. CONCLUSIONS The commonly used MC replacement in PAI may not be adequate in some patients. Insufficient MC substitution may be responsible for poor cardiometabolic outcome and the failure to restore well-being adequately in patients with PAI. Well-designed studies oriented at optimizing MC replacement therapy are urgently needed.
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Affiliation(s)
- 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
- Department of Medical, Surgical, Neurological, Metabolic Sciences, and Aging, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Daniela Pasquali
- Department of Medical, Surgical, Neurological, Metabolic Sciences, and Aging, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Gudmundur Johannsson
- 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
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20
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Mongioì LM, Condorelli RA, La Vignera S, Calogero AE. Dual-release hydrocortisone treatment: glycometabolic profile and health-related quality of life. Endocr Connect 2018; 7:211-219. [PMID: 29233815 PMCID: PMC5793805 DOI: 10.1530/ec-17-0368] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 12/12/2017] [Indexed: 12/02/2022]
Abstract
OBJECTIVE Adrenal insufficiency (AI) is a chronic condition associated with increased mortality and morbidity. The treatment of AI in the last years has been object of important changes due to the development of a dual-release preparation of hydrocortisone. It differs from previous therapeutic strategy as it contemplates a once-daily tablet that allows more closely mimicking the physiological circadian cortisol rhythm. The aim of the study was to evaluate the effects of dual-release hydrocortisone treatment on the glycometabolic profile and health-related quality of life of patients with AI. DESIGN AND METHODS In this clinical open trial, we enrolled ten patients with primary AI (41 ± 2.67 years) and nine patients with AI secondary to hypopituitarism (53.2 ± 17.7 years). We evaluated the glycometabolic profile before and 3, 6, 9 and 12 months after dual-release hydrocortisone administration. We also evaluated health-related quality of life, estimated by the AddiQol questionnaire. The mean dose administered of dual-release hydrocortisone was 28.33 ± 6.68 mg/day. RESULTS One female hypopituitary patient dropped out from the study. After 12 months of treatment, the mean dosage administered of dual-release hydrocortisone was significantly lower (P < 0.05) and all patients reported improved quality of life and well-being. The glycometabolic profile improved and the glycosylated hemoglobin decreased significantly in patients with primary AI (6.25 ± 0.2 vs 5.35 ± 0.17, P < 0.05). In contrast, hypopituitary patients had worse glycometabolic profile and a trend toward hypertriglyceridemia. CONCLUSIONS Dual-release hydrocortisone treatment improved the quality of life of patients with AI, and it allowed a decrease of cortisol dosage administered in the absence of side effects. The glycometabolic profile worsened in hypopituitary patients.
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Affiliation(s)
- L M Mongioì
- Department of Clinical and Experimental MedicineUniversity of Catania, Catania, Italy
| | - R A Condorelli
- Department of Clinical and Experimental MedicineUniversity of Catania, Catania, Italy
| | - S La Vignera
- Department of Clinical and Experimental MedicineUniversity of Catania, Catania, Italy
| | - A E Calogero
- Department of Clinical and Experimental MedicineUniversity of Catania, Catania, Italy
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21
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Mazziotti G, Formenti AM, Frara S, Roca E, Mortini P, Berruti A, Giustina A. MANAGEMENT OF ENDOCRINE DISEASE: Risk of overtreatment in patients with adrenal insufficiency: current and emerging aspects. Eur J Endocrinol 2017; 177:R231-R248. [PMID: 28583942 DOI: 10.1530/eje-17-0154] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/31/2017] [Accepted: 06/05/2017] [Indexed: 01/17/2023]
Abstract
The effects of long-term replacement therapy of adrenal insufficiency (AI) are still a matter of controversy. In fact, the established glucocorticoid replacement regimens do not completely reproduce the endogenous hormonal production and the monitoring of AI treatment may be a challenge for the lack of reliable clinical and biochemical markers. Consequently, several AI patients are frequently exposed to relative glucocorticoid excess potentially leading to develop chronic complications, such as diabetes mellitus, dyslipidemia, hypertension and fragility fractures with consequent impaired QoL and increased mortality risk. This review deals with the pathophysiological and clinical aspects concerning the over-replacement therapy of primary and secondary AI.
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Affiliation(s)
- G Mazziotti
- Endocrinology Unit, ASST, Carlo Poma, Mantua, Italy
| | - A M Formenti
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - S Frara
- Chair of Endocrinology, San Raffaele Vita-Salute University, Milan, Italy
| | - E Roca
- Chair of Medical Oncology, University of Brescia, Brescia, Italy
| | - P Mortini
- Chair of Neurosurgery, San Raffaele Vita-Salute University, Milan, Italy
| | - A Berruti
- Chair of Medical Oncology, University of Brescia, Brescia, Italy
| | - A Giustina
- Chair of Endocrinology, San Raffaele Vita-Salute University, Milan, Italy
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22
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Khan U, Lakhani OJ. Management of Primary Adrenal Insufficiency: Review of Current Clinical Practice in a Developed and a Developing Country. Indian J Endocrinol Metab 2017; 21:781-783. [PMID: 28989892 PMCID: PMC5628554 DOI: 10.4103/ijem.ijem_193_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Treatment of primary adrenal insufficiency (PAI) requires lifelong hormone replacement with glucocorticoids (GCs) and mineralocorticoids. Impaired quality of life and increased standardized mortality ratio in these patients emphasize the importance of tailoring therapy to individual needs. Role of education is paramount in improving patient compliance and in anticipating and preventing adrenal crises. Although discovery of synthetic GCs was a major breakthrough in treatment of patients with this life-threatening condition, management of PAI continues to be challenging. The obstacles for clinicians appear to vary widely across the globe. While optimization and individualization of therapy after diagnosis of PAI remain the main challenges for clinicians in the developed world, doctors in a developing country face problems at almost every stage from the diagnosis to the treatment and follow-up of these patients; cost of therapy, lack of resources, and funding are the main hindrances. Adherence to therapy and patient education are found to be common issues in most parts of the world. This commentary highlights the challenges from both developed and developing country's perspective in treating PAI; it also provides an update on current management scenario and future treatment options.
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Affiliation(s)
- Uzma Khan
- Department of Endocrinology and Metabolic Medicine, Queen's Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom
| | - Om J. Lakhani
- Department of Endocrinology, Zydus Hospital, Ahmedabad, Gujarat, India
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23
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Nilsson AG, Bergthorsdottir R, Burman P, Dahlqvist P, Ekman B, Engström BE, Ragnarsson O, Skrtic S, Wahlberg J, Achenbach H, Uddin S, Marelli C, Johannsson G. Long-term safety of once-daily, dual-release hydrocortisone in patients with adrenal insufficiency: a phase 3b, open-label, extension study. Eur J Endocrinol 2017; 176:715-725. [PMID: 28292927 PMCID: PMC5425941 DOI: 10.1530/eje-17-0067] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/10/2017] [Accepted: 03/14/2017] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To investigate the long-term safety and tolerability of a once-daily, dual-release hydrocortisone (DR-HC) tablet as oral glucocorticoid replacement therapy in patients with primary adrenal insufficiency (AI). DESIGN Prospective, open-label, multicenter, 5-year extension study of DR-HC conducted at five university clinics in Sweden. METHODS Seventy-one adult patients diagnosed with primary AI who were receiving stable glucocorticoid replacement therapy were recruited. Safety and tolerability outcomes included adverse events (AEs), intercurrent illness episodes, laboratory parameters and vital signs. Quality of life (QoL) was evaluated using generic questionnaires. RESULTS Total DR-HC exposure was 328 patient-treatment years. Seventy patients reported 1060 AEs (323 per 100 patient-years); 85% were considered unrelated to DR-HC by the investigator. The most common AEs were nasopharyngitis (70%), fatigue (52%) and gastroenteritis (48%). Of 65 serious AEs reported by 32 patients (20 per 100 patient-years), four were considered to be possibly related to DR-HC: acute AI (n = 2), gastritis (n = 1) and syncope (n = 1). Two deaths were reported (fall from height and subarachnoid hemorrhage), both considered to be unrelated to DR-HC. From baseline to 5 years, intercurrent illness episodes remained relatively stable (mean 2.6-5.4 episodes per patient per year), fasting plasma glucose (0.7 mmol/L; P < 0.0001) and HDL cholesterol (0.2 mmol/L; P < 0.0001) increased and patient-/investigator-assessed tolerability improved. QoL total scores were unchanged but worsening physical functioning was recorded (P = 0.008). CONCLUSIONS In the first prospective study evaluating the long-term safety of glucocorticoid replacement therapy in patients with primary AI, DR-HC was well tolerated with no safety concerns observed during 5-year treatment.
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Affiliation(s)
- Anna G Nilsson
- Department of EndocrinologySahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ragnhildur Bergthorsdottir
- Department of EndocrinologySahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pia Burman
- Department of EndocrinologySkåne University Hospital Malmö, University of Lund, Lund, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical MedicineUmeå University, Umeå, Sweden
| | - Bertil Ekman
- Departments of Endocrinology and Medical and Health SciencesLinköping University, Linköping, Sweden
| | - Britt Edén Engström
- Department of Medical SciencesEndocrinology and Metabolism, University Hospital, Uppsala, Sweden
| | - Oskar Ragnarsson
- Department of EndocrinologySahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stanko Skrtic
- Department of EndocrinologySahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- AstraZeneca R&DMölndal, Sweden
| | - Jeanette Wahlberg
- Departments of Endocrinology and Medical and Health SciencesLinköping University, Linköping, Sweden
| | | | | | | | - Gudmundur Johannsson
- Department of EndocrinologySahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Correspondence should be addressed to G Johannsson;
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24
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Oster H, Challet E, Ott V, Arvat E, de Kloet ER, Dijk DJ, Lightman S, Vgontzas A, Van Cauter E. The Functional and Clinical Significance of the 24-Hour Rhythm of Circulating Glucocorticoids. Endocr Rev 2017; 38:3-45. [PMID: 27749086 PMCID: PMC5563520 DOI: 10.1210/er.2015-1080] [Citation(s) in RCA: 294] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/21/2016] [Indexed: 02/07/2023]
Abstract
Adrenal glucocorticoids are major modulators of multiple functions, including energy metabolism, stress responses, immunity, and cognition. The endogenous secretion of glucocorticoids is normally characterized by a prominent and robust circadian (around 24 hours) oscillation, with a daily peak around the time of the habitual sleep-wake transition and minimal levels in the evening and early part of the night. It has long been recognized that this 24-hour rhythm partly reflects the activity of a master circadian pacemaker located in the suprachiasmatic nucleus of the hypothalamus. In the past decade, secondary circadian clocks based on the same molecular machinery as the central master pacemaker were found in other brain areas as well as in most peripheral tissues, including the adrenal glands. Evidence is rapidly accumulating to indicate that misalignment between central and peripheral clocks has a host of adverse effects. The robust rhythm in circulating glucocorticoid levels has been recognized as a major internal synchronizer of the circadian system. The present review examines the scientific foundation of these novel advances and their implications for health and disease prevention and treatment.
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Affiliation(s)
- Henrik Oster
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Etienne Challet
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Volker Ott
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Emanuela Arvat
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - E Ronald de Kloet
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Derk-Jan Dijk
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Stafford Lightman
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Alexandros Vgontzas
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
| | - Eve Van Cauter
- Medical Department I (H.O., V.O.), University of Lübeck, 23562 Lübeck, Germany; Institute for Cellular and Integrative Neuroscience (E.C.), Centre National de la Recherche Scientifique (CNRS) UPR 3212, University of Strasbourg, 67084 Strasbourg, France; Division of Endocrinology, Diabetology and Metabolism (E.A.), Department of Internal Medicine, University of Turin, 10043 Turin, Italy; Department of Endocrinology and Metabolic Disease (E.R.d.K.), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; Surrey Sleep Research Center (D.-J.D.), Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XP, United Kingdom; Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology (S.L.), University of Bristol, Bristol BS8 1TH, United Kingdom; Sleep Research and Treatment Center (A.V.), Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033; and Sleep, Metabolism, and Health Center (E.V.C.), Department of Medicine, University of Chicago, Chicago, Illinois 60637
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Nicolaides NC, Charmandari E, Kino T, Chrousos GP. Stress-Related and Circadian Secretion and Target Tissue Actions of Glucocorticoids: Impact on Health. Front Endocrinol (Lausanne) 2017; 8:70. [PMID: 28503165 PMCID: PMC5408025 DOI: 10.3389/fendo.2017.00070] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 03/24/2017] [Indexed: 12/13/2022] Open
Abstract
Living organisms are highly complex systems that must maintain a dynamic equilibrium or homeostasis that requires energy to be sustained. Stress is a state in which several extrinsic or intrinsic disturbing stimuli, the stressors, threaten, or are perceived as threatening, homeostasis. To achieve homeostasis against the stressors, organisms have developed a highly sophisticated system, the stress system, which provides neuroendocrine adaptive responses, to restore homeostasis. These responses must be appropriate in terms of size and/or duration; otherwise, they may sustain life but be associated with detrimental effects on numerous physiologic functions of the organism, leading to a state of disease-causing disturbed homeostasis or cacostasis. In addition to facing a broad spectrum of external and/or internal stressors, organisms are subject to recurring environmental changes associated with the rotation of the planet around itself and its revolution around the sun. To adjust their homeostasis and to synchronize their activities to day/night cycles, organisms have developed an evolutionarily conserved biologic system, the "clock" system, which influences several physiologic functions in a circadian fashion. Accumulating evidence suggests that the stress system is intimately related to the circadian clock system, with dysfunction of the former resulting in dysregulation of the latter and vice versa. In this review, we describe the functional components of the two systems, we discuss their multilevel interactions, and we present how excessive or prolonged activity of the stress system affects the circadian rhythm of glucocorticoid secretion and target tissue effects.
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Affiliation(s)
- Nicolas C. Nicolaides
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, ’Aghia Sophia’ Children’s Hospital, Athens, Greece
- Division of Endocrinology and Metabolism, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- *Correspondence: Nicolas C. Nicolaides,
| | - Evangelia Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, ’Aghia Sophia’ Children’s Hospital, Athens, Greece
- Division of Endocrinology and Metabolism, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Tomoshige Kino
- Division of Experimental Genetics, Sidra Medical and Research Center, Doha, Qatar
| | - George P. Chrousos
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, ’Aghia Sophia’ Children’s Hospital, Athens, Greece
- Division of Endocrinology and Metabolism, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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Abstract
Sheehan syndrome or postpartum hypopituitarism is a condition characterized by hypopituitarism due to necrosis of the pituitary gland. The initial insult is caused by massive postpartum haemorrhage (PPH), leading to impaired blood supply to the pituitary gland, which has become enlarged during pregnancy. Small sella turcica size, vasospasms (caused by PPH) and/or thrombosis (associated with pregnancy or coagulation disorders) are predisposing factors; autoimmunity might be involved in the progressive worsening of pituitary functions. Symptoms are caused by a decrease or absence of one or more of the pituitary hormones, and vary, among others, from failure to lactate and nonspecific symptoms (such as fatigue) to severe adrenal crisis. In accordance with the location of hormone-secreting cells relative to the vasculature, the secretion of growth hormone and prolactin is most commonly affected, followed by follicle-stimulating hormone and luteinizing hormone; severe necrosis of the pituitary gland also affects the secretion of thyroid-stimulating hormone and adrenocorticotropic hormone. Symptoms usually become evident years after delivery, but can, in rare cases, develop acutely. The incidence of Sheehan syndrome depends, to a large extent, on the occurrence and management of PPH. Sheehan syndrome is an important cause of hypopituitarism in developing countries, but has become rare in developed countries. Diagnosis is based on clinical manifestations combined with a history of severe PPH; hormone levels and/or stimulation tests can confirm clinical suspicion. Hormone replacement therapy is the only available management option so far.
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Affiliation(s)
- Züleyha Karaca
- Department of Endocrinology, Erciyes University Medical School, 38039, Kayseri, Turkey
| | - Bashir A Laway
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, India
| | - Hatice S Dokmetas
- Department of Endocrinology, Istanbul Medipol University Medical School, Istanbul, Turkey
| | - Hulusi Atmaca
- Department of Endocrinology, Ondokuz Mayıs University Medical School, Samsun, Turkey
| | - Fahrettin Kelestimur
- Department of Endocrinology, Erciyes University Medical School, 38039, Kayseri, Turkey
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Johannsson G. Improving glucocorticoid replacement in patients with adrenal insufficiency. Endocrine 2016; 52:405-7. [PMID: 27041094 DOI: 10.1007/s12020-016-0929-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/15/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.
- Department of Endocrinology, Sahlgrenska University Hospital, Grona straket 8, 413 45, Göteborg, Sweden.
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Therapeutic innovations in endocrine diseases - Part 2: Modified-release glucocorticoid compounds: What good do they provide to the adrenal insufficient patient? Presse Med 2016; 45:e205-10. [PMID: 27260966 DOI: 10.1016/j.lpm.2016.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Intensive researches on modified-release hydrocortisone compounds developed in the last decade have paved the way for obtaining near-physiological glucocorticoid replacement in the adrenal insufficient patient. The dual-release Duocort (Plenadren) allows a unique morning intake and closely mimics the circadian rhythm of cortisol secretion, except for the progressive nocturnal increase and the morning cortisol peak observed in healthy subjects. Duocort treatment during a 6-month period was associated with favorable changes in weight, blood pressure and glycemic control in patients with diabetes mellitus. Chronocort, a multiparticulate formulation with sustained-release properties replaces endogenous cortisol in a near-physiologic manner and fully restores the end of night cortisol peak. A twice-daily Chronocort regimen was effective in controlling androgen excess in adults with CAH. Recently, the new multiparticulate formulation Infacort was designed for the treatment of adrenal insufficiency during infancy. Long term effectiveness and safety studies are needed until these promising hydrocortisone formulations become routine therapeutic tools in adrenal insufficiency.
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Abstract
Adrenal insufficiency, a rare disorder which is characterized by the inadequate production or absence of adrenal hormones, may be classified as primary adrenal insufficiency in case of direct affection of the adrenal glands or secondary adrenal insufficiency, which is mostly due to pituitary or hypothalamic disease. Primary adrenal insufficiency affects 11 of 100,000 individuals. Clinical symptoms are mainly nonspecific and include fatigue, weight loss, and hypotension. The diagnostic test of choice is dynamic testing with synthetic ACTH. Patients suffering from chronic adrenal insufficiency require lifelong hormone supplementation. Education in dose adaption during physical and mental stress or emergency situations is essential to prevent life-threatening adrenal crises. Patients with adrenal insufficiency should carry an emergency card and emergency kit with them.
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Affiliation(s)
- A Pulzer
- Medizinische Klinik und Poliklinik I, Schwerpunkt Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - S Burger-Stritt
- Medizinische Klinik und Poliklinik I, Schwerpunkt Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - S Hahner
- Medizinische Klinik und Poliklinik I, Schwerpunkt Endokrinologie und Diabetologie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
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Webb EA, Krone N. Current and novel approaches to children and young people with congenital adrenal hyperplasia and adrenal insufficiency. Best Pract Res Clin Endocrinol Metab 2015; 29:449-68. [PMID: 26051302 DOI: 10.1016/j.beem.2015.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Congenital adrenal hyperplasia (CAH) represents a group of autosomal recessive conditions leading to glucocorticoid deficiency. CAH is the most common cause of adrenal insufficiency (AI) in the paediatric population. The majority of the other forms of primary and secondary adrenal insufficiency are rare conditions. It is critical to establish the underlying aetiology of each specific condition as a wide range of additional health problems specific to the underlying disorder can be found. Following the introduction of life-saving glucocorticoid replacement sixty years ago, steroid hormone replacement regimes have been refined leading to significant reductions in glucocorticoid doses over the last two decades. These adjustments are made with the aim both of improving the current management of children and young persons and of reducing future health problems in adult life. However despite optimisation of existing glucocorticoid replacement regimens fail to mimic the physiologic circadian rhythm of glucocorticoid secretion, current efforts therefore focus on optimising replacement strategies. In addition, in recent years novel experimental therapies have been developed which target adrenal sex steroid synthesis in patients with CAH aiming to reduce co-morbidities associated with sex steroid excess. These developments will hopefully improve the health status and long-term outcomes in patients with congenital adrenal hyperplasia and adrenal insufficiency.
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Affiliation(s)
- Emma A Webb
- School of Clinical & Experimental Medicine, University of Birmingham, Institute of Biomedical Research, Birmingham B15 2TT, UK.
| | - Nils Krone
- School of Clinical & Experimental Medicine, University of Birmingham, Institute of Biomedical Research, Birmingham B15 2TT, UK.
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Quinkler M, Miodini Nilsen R, Zopf K, Ventz M, Øksnes M. Modified-release hydrocortisone decreases BMI and HbA1c in patients with primary and secondary adrenal insufficiency. Eur J Endocrinol 2015; 172:619-26. [PMID: 25656494 DOI: 10.1530/eje-14-1114] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Patients with adrenal insufficiency (AI) have impaired health-related quality of life (HRQoL), which is thought to be in part due to unphysiological glucocorticoid replacement therapy. The aim was to compare once-daily hydrocortisone (HC) dual-release tablet (modified-release) with conventional HC therapy regarding clinical data and HRQoL. DESIGN AND METHODS We conducted an open, prospective trial at one endocrine center. There were 15 of 26 patients with primary AI, nine of 18 patients with secondary AI, and six congenital adrenal hyperplasia patients switched to modified-release HC therapy by their own decision. We evaluated clinical outcome and disease-specific HRQoL by using AddiQoL questionnaire at baseline and at follow-up (median 202 days (85-498)). RESULTS Patients on modified-release HC (n=30) showed significant decreases in BMI (26.0±0.75-25.6±0.71, P for change=0.006) and HbA1c (6.04±0.29-5.86±0.28, P for change=0.005), whereas patients remaining on conventional HC (n=20) showed no change in these parameters (P for interaction=0.029 and 0.017 respectively). No significant change in AddiQoL score were found in the modified-release HC group (83.8 baseline and 84.9 at follow-up; P for change=0.629). In the conventional HC group, there was a significant decrease in scores (84.0 baseline and 80.9 at follow-up; P for change=0.016), with a between-treatment P for interaction of 0.066. The fatigue subscore of AddiQoL showed the same pattern with a significant decrease (P for change=0.024) in patients on conventional HC therapy (P for interaction=0.116). CONCLUSIONS Modified-release HC decreases BMI and HbA1c compared with conventional HC treatment. In addition, it seems to stabilize HRQoL over time.
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Affiliation(s)
- Marcus Quinkler
- Endocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, GermanyClinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyCentre for Clinical ResearchHaukeland University Hospital, Bergen, NorwayDepartment of Clinical ScienceUniversity of Bergen, Bergen, NorwayDepartment of MedicineHaukeland University Hospital, Bergen, Norway Endocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, GermanyClinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyCentre for Clinical ResearchHaukeland University Hospital, Bergen, NorwayDepartment of Clinical ScienceUniversity of Bergen, Bergen, NorwayDepartment of MedicineHaukeland University Hospital, Bergen, Norway
| | - Roy Miodini Nilsen
- Endocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, GermanyClinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyCentre for Clinical ResearchHaukeland University Hospital, Bergen, NorwayDepartment of Clinical ScienceUniversity of Bergen, Bergen, NorwayDepartment of MedicineHaukeland University Hospital, Bergen, Norway
| | - Kathrin Zopf
- Endocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, GermanyClinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyCentre for Clinical ResearchHaukeland University Hospital, Bergen, NorwayDepartment of Clinical ScienceUniversity of Bergen, Bergen, NorwayDepartment of MedicineHaukeland University Hospital, Bergen, Norway
| | - Manfred Ventz
- Endocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, GermanyClinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyCentre for Clinical ResearchHaukeland University Hospital, Bergen, NorwayDepartment of Clinical ScienceUniversity of Bergen, Bergen, NorwayDepartment of MedicineHaukeland University Hospital, Bergen, Norway
| | - Marianne Øksnes
- Endocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, GermanyClinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyCentre for Clinical ResearchHaukeland University Hospital, Bergen, NorwayDepartment of Clinical ScienceUniversity of Bergen, Bergen, NorwayDepartment of MedicineHaukeland University Hospital, Bergen, Norway Endocrinology in CharlottenburgStuttgarter Platz 1, 10627 Berlin, GermanyClinical EndocrinologyCharité Campus Mitte, Charité University Medicine Berlin, Berlin, GermanyCentre for Clinical ResearchHaukeland University Hospital, Bergen, NorwayDepartment of Clinical ScienceUniversity of Bergen, Bergen, NorwayDepartment of MedicineHaukeland University Hospital, Bergen, Norway
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Leliavski A, Dumbell R, Ott V, Oster H. Adrenal Clocks and the Role of Adrenal Hormones in the Regulation of Circadian Physiology. J Biol Rhythms 2014; 30:20-34. [DOI: 10.1177/0748730414553971] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The mammalian circadian timing system consists of a master pacemaker in the suprachiasmatic nucleus (SCN) and subordinate clocks that disseminate time information to various central and peripheral tissues. While the function of the SCN in circadian rhythm regulation has been extensively studied, we still have limited understanding of how peripheral tissue clock function contributes to the regulation of physiological processes. The adrenal gland plays a special role in this context as adrenal hormones show strong circadian secretion rhythms affecting downstream physiological processes. At the same time, they have been shown to affect clock gene expression in various other tissues, thus mediating systemic entrainment to external zeitgebers and promoting internal circadian alignment. In this review, we discuss the function of circadian clocks in the adrenal gland, how they are reset by the SCN and may further relay time-of-day information to other tissues. Focusing on glucocorticoids, we conclude by outlining the impact of adrenal rhythm disruption on neuropsychiatric, metabolic, immune, and malignant disorders.
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Affiliation(s)
- Alexei Leliavski
- Chronophysiology Group, Medical Department, University of Lübeck, Germany
| | - Rebecca Dumbell
- Chronophysiology Group, Medical Department, University of Lübeck, Germany
| | - Volker Ott
- Institute of Neuroendocrinology, University of Lübeck, Germany
| | - Henrik Oster
- Chronophysiology Group, Medical Department, University of Lübeck, Germany
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Russell GM, Lightman SL. Can side effects of steroid treatments be minimized by the temporal aspects of delivery method? Expert Opin Drug Saf 2014; 13:1501-13. [DOI: 10.1517/14740338.2014.965141] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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