Recovery of hypothalamo-pituitary-adrenal axis suppression during treatment with inhaled corticosteroids for childhood asthma

Baseline and peak cortisol response to the low dose short Synacthen test relates to indication for testing, age and sex

Objective

To review the outcomes of a simplified low dose Synacthen test (LDSST) performed in a tertiary endocrine service over seven years, and to examine for relationships between cortisol measurements and indication for testing, age and sex.

Design

Retrospective, observational study of LDSST performed in 2008 – 2014 (N=335) and 2016-2020 (N=160).

Methods

LDSST were performed by endocrine nurses. Synacthen 500ng/1.73m 2 administered as IV bolus, sampling at 0, 15, 25 and 35 minutes.

Results

Mean (± 1SD) baseline cortisol was 221 ± 120 nmol/L, peak 510 ± 166nmol/L and increment 210 ± 116 nmol/L. 336 (70%) of patients had a normal response (baseline cortisol >100nmol/L, peak >450nmol/L), 78 (16%) a suboptimal response (peak cortisol 350-450nmol/L) and were prescribed hydrocortisone to during periods of stress only, 67 (14%) an abnormal response (baseline <100nmol/L or peak <350nmol/L) and were prescribed daily hydrocortisone. Basal, peak and incremental increases in cortisol were higher in females (p=0.03, p<0.001, p=0.03 respectively). Abnormal results occurred most frequently in patients treated previously with pharmacological doses of glucocorticoids or structural brain abnormalities (p<0.0001).

Discussion

There are concerns that the specificity of the LDSST is poor. The low prevalence and strong association of abnormal results with indication for testing, suggests that over diagnosis occurred infrequently in this clinical setting.

Research on the establishment of chronic stress-induced premature ovarian failure the rat model and effects of Chinese medicine Muniziqi treatment

The purposes of this study were to establish and to explore the biological basis of the chronic stress-induced premature ovarian failure (POF) model and to explore the therapeutic effects of the traditional Chinese medicine Muniziqi. Sexually matured female Sprague-Dawley rats were fed with spinach and cilantro in cold and wet conditions for about 20 weeks until a chronic stress (CS) model was established. The CS rats were divided into a POF stress model group and a stress model group according to weekly biological characteristics and hormone level detection ( luteinizing hormone [LH], follicle stimulating hormone [FSH], and estrogen [E2]). To investigate the therapeutic effect of Muniziqi, the POF disease stress model group was divided into the high-, medium-, and low-drug intervention groups. The results showed that chronic stresses (special food, cold, damp) can lead to POF disease. The traditional Chinese medicine Muniziqi could not only improve the reproductive hormone level disorder, but also improve the function of the hypothalamus-pituitary-ovarian axis. The underlying mechanism may be a change in the E2, LH, and FSH hormone levels in serum and lower expression of ovarian premature aging-related protein PFN-1.

The Challenges of Cortisol Replacement Therapy in Childhood: Observations from a Case Series of Children Treated with Modified-Release Hydrocortisone

BACKGROUND

Hydrocortisone is the preferred treatment for adrenal insufficiency in childhood. A small minority of children experience low cortisol concentrations and symptoms of cortisol insufficiency, poorly responsive to modifications in dosing. We speculated that treatment with modified-release hydrocortisone Plenadren^® may be beneficial in these selected patients.

OBJECTIVE

The aim of this article was to report cortisol profiles during treatment with standard formulation hydrocortisone and Plenadren, and growth and weight gain during treatment with Plenadren in selected children with adrenal insufficiency.

PATIENTS AND METHODS

Data are reported as median (range). Eight patients (5 male) age 11.0 years (8.8-13.3), with adrenal insufficiency for 4.3 years (2.2-10.0) were treated with Plenadren in doses derived from cortisol concentrations measured during treatment with standard formulation hydrocortisone.

RESULTS

Plasma cortisol was 262 nmol/L (114-654) 2 h after the morning dose (hydrocortisone dose 6.1 mg/m² [4.3-7.1]) of standard formulation hydrocortisone. After 4 h, cortisol concentration was 81 nmol/L (56-104) and was < 100 nmol/L in six patients. Two hours after Plenadren administration (hydrocortisone dose 12.1 mg/m² [8.3-17.6]), plasma cortisol concentration was 349 nmol/L (150-466), and after 4 h it was 239 nmol/L (99-375) and < 100 nmol/L in one patient. Six hours after the Plenadren dose, cortisol concentration was < 100 nmol/L in four patients and after 8 h cortisol concentration was < 100 nmol/L in seven patients (sample not obtained in one patient). Six patients elected to continue treatment with Plenadren. After 4.2 years (2.7-6.0), change in height standard deviation score (SDS) was 0.1 SD (- 0.2 to 0.2) and body mass index SDS was 0.3 SD (0-1.1).

CONCLUSION

Smoother cortisol profiles and more sustained cortisol exposure were achieved during treatment with Plenadren, which was the preferred treatment in most patients. Robust clinical trials are required to determine the place of this medication in paediatric practice.