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Flokas ME, Yang L, Middleton KR, Kollender S, Parker M, Sukin C, Persky RW, Merke DP. CAHQL: A patient reported outcome instrument to assess health-related quality of life in congenital adrenal hyperplasia. J Clin Endocrinol Metab 2024:dgae309. [PMID: 38706369 DOI: 10.1210/clinem/dgae309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/08/2024] [Accepted: 05/02/2024] [Indexed: 05/07/2024]
Abstract
CONTEXT Measuring health-related quality of life (HRQoL) is a crucial aspect of evaluating health care outcomes. Patients with congenital adrenal hyperplasia (CAH) often self-report deficiencies in HRQoL. OBJECTIVE The aim of our study was to develop a disease-specific patient reported outcome (PRO) instrument to evaluate the HRQoL of patients >16 years old with classic congenital adrenal hyperplasia (CAH). DESIGN, SETTING AND OUTCOMES Following the FDA guidelines for developing PRO instruments, we developed a conceptual framework for the instrument. A preliminary instrument was created after interviewing a representative sample of 12 patients with CAH between 16 to 68 years old and 3 parents, and obtaining expert feedback from 4 endocrinologists. The instrument was edited after cognitive interviews with 6 patients. Internal consistency of the instrument was evaluated using Cronbach's alpha. Validity was assessed by comparing the scores of our instrument with scores from widely used validated instruments for HRQoL and PRO not specific to CAH. RESULTS Sixty-nine patients 16 to 75 years old participated in validating our preliminary instrument. The final questionnaire consists of 44 questions within 7 domains: General Health, Adrenal Insufficiency, Glucocorticoid Excess, Physical Functioning, Mental Health and Cognition, Social Functioning, and Sexual Functioning, with acceptable internal consistency (Chronbach's alpha≥0.6) and validity (r = -0.350 to 0.866). CONCLUSION CAHQL is the first validated PRO instrument to capture disease specific HRQoL outcomes in CAH. In addition to its anticipated use in the clinical setting, the instrument could be used to assess the efficacy of novel treatments in development.
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Affiliation(s)
- Myrto Eleni Flokas
- Children's National Hospital, Washington, DC 20010, USA
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892-1932, USA
| | - Li Yang
- National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
| | | | - Sarah Kollender
- National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
| | - Megan Parker
- National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
| | - Charles Sukin
- National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
| | - Rebecca Wood Persky
- Children's National Hospital, Washington, DC 20010, USA
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892-1932, USA
| | - Deborah P Merke
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892-1932, USA
- National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
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Kolli V, Frucci E, da Cunha IW, Iben JR, Kim SA, Mallappa A, Li T, Faucz FR, Kebebew E, Nilubol N, Quezado MM, Merke DP. Evidence of the Role of Inflammation and the Hormonal Environment in the Pathogenesis of Adrenal Myelolipomas in Congenital Adrenal Hyperplasia. Int J Mol Sci 2024; 25:2543. [PMID: 38473790 DOI: 10.3390/ijms25052543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Adrenal myelolipomas (AML) are composed of mature adipose and hematopoietic components. They represent approximately 3 percent of adrenal tumors and are commonly found in patients with congenital adrenal hyperplasia (CAH). CAH provides a unique environment to explore AML pathogenesis. We aimed to evaluate the role of the immune system and hormones that accumulate in poorly controlled CAH in the development of AML. When compared to normal adrenal tissue, CAH-affected adrenal tissue and myelolipomas showed an increased expression of inflammatory cells (CD68, IL2Rbeta), stem cells (CD117) B cells (IRF4), and adipogenic markers (aP2/FABP4, AdipoQ, PPARγ, Leptin, CideA), and immunostaining showed nodular lymphocytic accumulation. Immunohistochemistry staining revealed a higher density of inflammatory cells (CD20, CD3, CD68) in CAH compared to non-CAH myelolipomas. In vitro RNA-sequencing studies using NCI-H295R adrenocortical cells with exogenous exposure to ACTH, testosterone, and 17-hydroxyprogesterone hormones, showed the differential expression of genes involved in cell cycle progression, phosphorylation, and tumorigenesis. Migration of B-lymphocytes was initiated after the hormonal treatment of adrenocortical cells using the Boyden chamber chemotaxis assay, indicating a possible hormonal influence on triggering inflammation and the development of myelolipomas. These findings demonstrate the important role of inflammation and the hormonal milieu in the development of AML in CAH.
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Affiliation(s)
- Vipula Kolli
- National Institutes of Health Clinical Center, 10 Center Drive, Bethesda, MD 20892, USA
| | - Emily Frucci
- National Institutes of Health Clinical Center, 10 Center Drive, Bethesda, MD 20892, USA
| | - Isabela Werneck da Cunha
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD 20892, USA
- D'Or Institute for Research and Education (IDOR), São Paulo 05403, Brazil
| | - James R Iben
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Sun A Kim
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD 20892, USA
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, 10 Center Drive, Bethesda, MD 20892, USA
| | - Tianwei Li
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Fabio Rueda Faucz
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Electron Kebebew
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | | | - Martha M Quezado
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD 20892, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center, 10 Center Drive, Bethesda, MD 20892, USA
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
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Javaid R, Sinaii N, Kollender S, Desai J, Moon A, Merke DP. Course of COVID-19 infection in patients with congenital adrenal hyperplasia. Front Endocrinol (Lausanne) 2024; 15:1348130. [PMID: 38405151 PMCID: PMC10884314 DOI: 10.3389/fendo.2024.1348130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/23/2024] [Indexed: 02/27/2024] Open
Abstract
Context Patients with primary adrenal insufficiency due to congenital adrenal hyperplasia (CAH) are at risk for adrenal crisis during infectious illnesses. Increased risk of infection including COVID-19 has been variably reported. Objective To evaluate COVID-19 illness outcomes and stress dose practices in a large cohort of patients with CAH during the first two years of the pandemic and compare observations of COVID-19 infection in patients with CAH to the general USA population. Methods Between March 2020 and November 2022, patients with CAH followed at the National Institutes of Health Clinical Center were queried about COVID-19 infection during their routine visits. Cases of COVID-19 were compared to controls. COVID-19 infection rates and symptoms were compared to general USA population data from the Centers for Disease Control and Prevention. Results Of 168 patient visits, there were 54 (32%) cases of COVID-19 infection, and 15 (28%) were pediatric. Overall an association was found between acquiring COVID-19 and obesity (p=0.018), and adults acquiring COVID-19 were on lower doses of fludrocortisone (p=0.008). Fewer cases of COVID-19 infection were reported in those receiving hydrocortisone or modified-release hydrocortisone compared to longer acting glucocorticoids (p=0.0018). In our CAH population, the pattern of COVID-19 infection rates and COVID-related symptomatology were similar to those observed in the general USA population. Most patients with the presumed alpha variant reported anosmia and ageusia, while gastrointestinal symptoms were commonly reported during the delta and omicron waves. Stress dosing occurred in 30/54 cases, and 7 received parenteral hydrocortisone. Two hospitalizations occurred; one pediatric and one adult, both with co-morbidities. There were 5 emergency room visits and no reported deaths. Conclusion Patients with CAH with close follow-up do not appear to be at increased risk of acquiring COVID-19 or to have a more severe course of COVID-19 compared to the general USA population. Obesity may increase risk of acquiring COVID-19 in patients with CAH, and overall infection risk may be lower in those receiving short-acting and circadian glucocorticoid replacement therapy. Established age-appropriate guidelines for stress dosing during infectious illnesses should be used for patients with CAH and COVID-19. COVID-19 specific guidelines are not indicated. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT00250159.
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Affiliation(s)
- Rida Javaid
- Department of Pediatrics, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Ninet Sinaii
- Biostatistics and Epidemiology Service, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Sarah Kollender
- Department of Pediatrics, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Jay Desai
- Department of Pediatrics, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Amy Moon
- Department of Pediatrics, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Deborah P. Merke
- Department of Pediatrics, National Institutes of Health Clinical Center, Bethesda, MD, United States
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
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Flokas ME, Wakim P, Kollender S, Sinaii N, Merke DP. Gonadotropin-Releasing Hormone Agonist Therapy and Longitudinal Bone Mineral Density in Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2024; 109:498-504. [PMID: 37643900 PMCID: PMC10795903 DOI: 10.1210/clinem/dgad514] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 08/31/2023]
Abstract
CONTEXT Children with congenital adrenal hyperplasia (CAH) are at risk for early puberty. Gonadotropin-releasing hormone analog (GnRHa) is frequently used and can decrease bone mineral density (BMD). OBJECTIVE Our aim was to investigate the effect of GnRHa therapy on BMD in a longitudinal study of patients with CAH spanning both childhood and adulthood. DESIGN AND SETTING Sixty-one patients with classic CAH due to 21-hydroxylase deficiency (20 treated with GnRHa) were followed with dual-energy X-ray absorptiometry (DXA) scans at puberty onset, attainment of adult height, and during early adulthood. MAIN OUTCOME MEASURES Whole body, lumbar spine, femoral neck, total hip, and distal radius BMD z-score at adult height. Longitudinal BMD and adult height were also assessed. RESULTS Twenty patients received GnRHa for an average of 4.5 ± 2 years. There were no differences in BMD between GnRHa-treated and -untreated groups at adult height for all sites. Overall, the follow-up DXA during early adulthood showed decreases in BMD z-scores for whole body (P = .01), lumbar spine (P < .0001), femoral neck (P = .06), total hip (P = .009), and distal radius (P = .05). GnRHa treatment correlated with improved height outcomes compared to predicted height at puberty onset after adjusting for midparental height (P = .02). Patients in both groups achieved similar adult height. CONCLUSION In children with CAH, GnRHa does not compromise BMD. However, BMD decreases with time and during the second and third decades of life is a possible effect of chronic supraphysiologic glucocorticoids. Children with CAH who experience early puberty benefit from GnRHa treatment as evidenced by the positive effect on height.
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Affiliation(s)
- Myrto Eleni Flokas
- Children's National Hospital, Washington, DC 20010, USA
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892-1932, USA
| | - Paul Wakim
- The National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
| | - Sarah Kollender
- The National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
| | - Ninet Sinaii
- The National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
| | - Deborah P Merke
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892-1932, USA
- The National Institutes of Health Clinical Center, Bethesda, MD 20892-1932, USA
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Ernst M, Cogo-Moreira H, Desai J, Merke DP. Sexual dimorphism in anxiety is programmed in-utero by sex-steroids: Proof of concept using a disease-model and stress responses to COVID pandemic. Psychiatry Res 2024; 331:115623. [PMID: 38064910 PMCID: PMC10872369 DOI: 10.1016/j.psychres.2023.115623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/16/2023] [Accepted: 11/20/2023] [Indexed: 01/02/2024]
Abstract
Sex differences in the psychological impact of the COVID-19 pandemic have been consistently reported, showing disproportionally high rates of anxiety/distress in women relative to men. The mechanisms underlying this sexual dimorphism remain unclear. The present study queries the potential protective role of early hyperandrogenism on brain development. A natural model of sex-steroids abnormality, classic congenital adrenal hyperplasia (CAH), was used to test this question. CAH is characterized by adrenal androgen overproduction in utero (prenatal) through the neonatal critical developmental period. An online survey collected information on subjective responses to the COVID-19 pandemic. Matched on demographic variables, 60 adults carrying a diagnosis of classic CAH and 240 adults from the general population (non-CAH) were compared on levels of anxiety/distress in the first year of the COVID-19 pandemic (May 2020-April 2021). Structural Equation Modeling was used to test the modulation by CAH status of Sex effects on anxiety/distress. Results revealed lower levels of anxiety/distress in the female CAH group compared to the other 3 groups (male CAH, female non-CAH, and male non-CAH). This finding suggests that pre-neonatal hyperandrogenism might impact the development of neural circuits underlying anxiety processes, in a way that enhances resilience to chronic stress.
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Affiliation(s)
- Monique Ernst
- National Institute of Mental Health, Bethesda, MD, USA.
| | - Hugo Cogo-Moreira
- Department of Education, ICT and Learning, Østfold University College, Norway
| | - Jay Desai
- National Institutes of Health Clinical Center US, USA
| | - Deborah P Merke
- National Institute of Mental Health, Bethesda, MD, USA; National Institutes of Health Clinical Center US, USA; Eunice Kennedy Shriver National Institute of Child Health and Human Development US, USA.
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Sarafoglou K, Merke DP, Reisch N, Claahsen-van der Grinten H, Falhammar H, Auchus RJ. Interpretation of Steroid Biomarkers in 21-Hydroxylase Deficiency and Their Use in Disease Management. J Clin Endocrinol Metab 2023; 108:2154-2175. [PMID: 36950738 PMCID: PMC10438890 DOI: 10.1210/clinem/dgad134] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/07/2023] [Indexed: 03/24/2023]
Abstract
The most common form of congenital adrenal hyperplasia is 21-hydroxylase deficiency (21OHD), which in the classic (severe) form occurs in roughly 1:16 000 newborns worldwide. Lifelong treatment consists of replacing cortisol and aldosterone deficiencies, and supraphysiological dosing schedules are typically employed to simultaneously attenuate production of adrenal-derived androgens. Glucocorticoid titration in 21OHD is challenging as it must balance the consequences of androgen excess vs those from chronic high glucocorticoid exposure, which are further complicated by interindividual variability in cortisol kinetics and glucocorticoid sensitivity. Clinical assessment and biochemical parameters are both used to guide therapy, but the specific purpose and goals of each biomarker vary with age and clinical context. Here we review the approach to medication titration for children and adults with classic 21OHD, with an emphasis on how to interpret adrenal biomarker values in guiding this process. In parallel, we illustrate how an understanding of the pathophysiologic and pharmacologic principles can be used to avoid and to correct complications of this disease and consequences of its management using existing treatment options.
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Affiliation(s)
- Kyriakie Sarafoglou
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN 55454, USA
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, USA
| | - Deborah P Merke
- Department of Pediatrics, National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, 80336 Munich, Germany
| | - Hedi Claahsen-van der Grinten
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, SE-17176, Stockholm, Sweden
| | - Richard J Auchus
- Departments of Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Lao Q, Burkardt DD, Kollender S, Faucz FR, Merke DP. Congenital adrenal hyperplasia due to two rare CYP21A2 variant alleles, including a novel attenuated CYP21A1P/CYP21A2 chimera. Mol Genet Genomic Med 2023:e2195. [PMID: 37157918 DOI: 10.1002/mgg3.2195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/05/2023] [Accepted: 04/25/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase (21OH) deficiency is an autosomal recessive inborn error of cortisol biosynthesis, with varying degrees of aldosterone production. There is a continuum of phenotypes which generally correlate with genotype and the expected residual 21OH activity of the less severely impaired allele. CYP21A1P/CYP21A2 chimeric genes caused by recombination between CYP21A2 and its highly homologous CYP21A1P pseudogene are common in CAH and typically associated with salt-wasting CAH, the most severe form. Nine chimeras have been described (CH-1 to CH-9). AIMS The aim of this study was to genetically evaluate two variant alleles carried by a 22-year-old female with the non-salt-wasting simple virilizing form of CAH and biallelic 30-kb deletions. METHODS The haplotypes of the CYP21A2 heterozygous variants, as well as the chimeric junction sites, were determined by Sanger sequencing TA clones of an allele-specific PCR product. RESULTS Genetic testing revealed two rare CYP21A1P/CYP21A2 chimeras: allele 1 matches the previously described CAH CH-1 chimera but without the P30L variant, and allele 2, termed here as novel CAH CH-10, has a junction site between c.293-37 and c.29314, which is expected to retain partial 21OH activity. CONCLUSION These two variant alleles further document the complex nature of RCCX modules and highlight that not all CYP21A1P/CYP21A2 chimera severely impair 21OH activity.
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Affiliation(s)
- Qizong Lao
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | | | - Sarah Kollender
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Fabio R Faucz
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders of steroidogenesis of the adrenal cortex, most commonly due to 21-hydroxylase deficiency caused by mutations in the CYP21A2 gene. Although women with CAH have decreased fecundity, they are able to conceive; thus, if pregnancy is not desired, contraception options should be offered. If fertility is desired, women with classic CAH should first optimize glucocorticoid treatment, followed by ovulation induction medications and gonadotropins if needed. Due to the possible pregnancy complications and implications on the offspring, preconception genetic testing and counseling with a high-risk obstetrics specialist is recommended. For couples trying to avoid having a child with CAH, care with a reproductive endocrinology and infertility specialist to utilize in vitro fertilization can be offered, with or without preimplantation genetic testing for monogenic disorders. Prenatal screening and diagnosis options during pregnancy include maternal serum cell free-DNA for sex of the baby, and chorionic villus sampling and amniocentesis for diagnosis of CAH. Pregnant women with classic CAH need glucocorticoids to be adjusted during the pregnancy, at the time of delivery, and postpartum, and should be monitored for adrenal crisis. Maternal and fetal risks may include chorioamnionitis, maternal hypertension, gestational diabetes, cesarean section, and small for gestational age infants. This review on CAH due to 21-hydroxylase deficiency highlights reproductive health including genetic transmission, contraception options, glucocorticoid management, fertility treatments, as well as testing, antenatal monitoring, and management during pregnancy, delivery, and postpartum.
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Affiliation(s)
- Jacqueline Yano Maher
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Staff Clinician, 10 Central Drive, Room 8N248, Bethesda, MD, 20892, USA
| | - Veronica Gomez-Lobo
- Director of Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Central Drive, Room 8N248, Bethesda, MD, 20892, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Central Drive, Room 1-2740, Bethesda, MD, 20892, USA.
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Lao Q, Zhou K, Parker M, Faucz FR, Merke DP. Pseudogene TNXA Variants May Interfere with the Genetic Testing of CAH-X. Genes (Basel) 2023; 14:genes14020265. [PMID: 36833192 PMCID: PMC9956258 DOI: 10.3390/genes14020265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023] Open
Abstract
CAH-X is a hypermobility-type Ehlers-Danlos syndrome connective tissue dysplasia affecting approximately 15% of patients with 21-hydroxylase deficiency (21-OHD) congenital adrenal hyperplasia (CAH) due to contiguous deletion of CYP21A2 and TNXB genes. The two most common genetic causes of CAH-X are CYP21A1P-TNXA/TNXB chimeras with pseudogene TNXA substitution for TNXB exons 35-44 (CAH-X CH-1) and TNXB exons 40-44 (CAH-X CH-2). A total of 45 subjects (40 families) from a cohort of 278 subjects (135 families of 21-OHD and 11 families of other conditions) were found to have excessive TNXB exon 40 copy number as measured by digital PCR. Here, we report that 42 subjects (37 families) had at least one copy of a TNXA variant allele carrying a TNXB exon 40 sequence, whose overall allele frequency was 10.3% (48/467). Most of the TNXA variant alleles were in cis with either a normal (22/48) or an In2G (12/48) CYP21A2 allele. There is potential interference with CAH-X molecular genetic testing based on copy number assessment, such as with digital PCR and multiplex ligation-dependent probe amplification, since this TNXA variant allele might mask a real copy number loss in TNXB exon 40. This interference most likely happens amongst genotypes of CAH-X CH-2 with an in trans normal or In2G CYP21A2 allele.
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Affiliation(s)
- Qizong Lao
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
- Correspondence: ; Tel.: +1-301-451-7168
| | - Kiet Zhou
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - Megan Parker
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - Fabio R. Faucz
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
| | - Deborah P. Merke
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
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Tschaidse L, Reisch N, Arlt W, Brac de la Perriere A, Linden Hirschberg A, Juul A, Mallappa A, Merke DP, Newell-Price JDC, Perry CG, Prete A, Rees DA, Stikkelbroeck NMML, Touraine PA, Coope H, Porter J, Ross RJM, Quinkler M. Modified-release hydrocortisone is associated with lower plasma renin activity in patients with salt-wasting congenital adrenal hyperplasia. Eur J Endocrinol 2023; 188:6991929. [PMID: 36654495 DOI: 10.1093/ejendo/lvac006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/06/2022] [Accepted: 11/30/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Poorly controlled salt-wasting (SW) congenital adrenal hyperplasia (CAH) patients often require high 9α-fluorocortisol doses as they show high levels of 17-hydroxyprogesterone (17OHP), which is a mineralocorticoid (MC)-receptor antagonist. DESIGN We investigated the renin-angiotensin-aldosterone system in patients with SW-CAH receiving twice daily modified-release hydrocortisone (MR-HC, Efmody) compared with standard glucocorticoid (GC) therapy. METHODS Data were analyzed from the 6-month, phase 3 study of MR-HC (n = 42) versus standard GC therapy (n = 41). MC replacement therapy remained unchanged throughout the study. Blood pressure, serum potassium, serum sodium, plasma renin activity (PRA), and serum 17OHP and androstenedione concentrations were analyzed at baseline, 4, 12, and 24 weeks. RESULTS The median serum 17OHP in the morning was significantly lower on MR-HC compared with standard GC at 24 weeks (2.5 nmol L-1 (IQR 8.3) versus 10.5 nmol L-1 (IQR 55.2), P = .001). PRA decreased significantly from baseline to 24 weeks in patients on MR-HC (0.83 ng L-1 s-1 (IQR 1.0) to 0.48 ng L-1 s-1 (IQR 0.61), P = .012) but not in patients on standard GC (0.53 ng L-1 s-1 (IQR 0.66) to 0.52 ng L-1 s-1 (IQR 0.78), P = .613). Serum sodium concentrations increased from baseline to 24 weeks in patients on MR-HC (138.8 ± 1.9 mmol L-1 to 139.3 ± 1.8 mmol L-1, P = .047), but remained unchanged on standard GC (139.8 ± 1.6 mmol L-1 to 139.3 ± 1.9 mmol L-1, P = .135). No significant changes were seen in systolic and diastolic blood pressure and serum potassium levels. CONCLUSION 6 months of MR-HC therapy decreased PRA and increased sodium levels indicating a greater agonist action of the 9α-fluorocortisol dose, which may be due to the decreased levels of the MC-receptor antagonist 17OHP.
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Affiliation(s)
- Lea Tschaidse
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Nicole Reisch
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, United Kingdom
| | - Aude Brac de la Perriere
- Hospices Civils de Lyon, Fédération d'Endocrinologie, Groupement hospitalier Est, Bron Cedex, France
| | - Angelica Linden Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet and Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Juul
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ashwini Mallappa
- AstraZeneca, Gaithersburg, Maryland, United States
- National Institutes of Health Clinical Center, Bethesda, Maryland, United States
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland, United States
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, United States
| | | | - Colin G Perry
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Alessandro Prete
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, United Kingdom
| | - D Aled Rees
- Neuroscience and Mental Health Research Institute, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | | | - Philippe A Touraine
- University Hospitals Pitié Salpêtrière - Charles Foix, Center for Rare Endocrine and Gynecological Disorders, Paris, France
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Merke DP, Mallappa A, Arlt W, De La Perriere AB, Hirschberg AL, Juul A, Newell-Price JDC, Perry CG, Prete A, Rees A, Reisch N, Stikkelbroeck M, Touraine PA, Coope HJ, Porter J, Ross RJ. RF09 | PSAT70 Comparison of Prednisolone Versus Modified-release Hydrocortisone (Efmody) in the Treatment of Congenital Adrenal Hyperplasia (CAH). J Endocr Soc 2022. [DOI: 10.1210/jendso/bvac150.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Abstract
Background
Prednisolone and prednisone have a longer plasma elimination half-life after oral administration than hydrocortisone: 2.1 to 3.5 vs ∼1.5hrs1,2. For this reason, prednis(ol)one has been used in Congenital Adrenal Hyperplasia (CAH) by giving a dose in the evening to try to prevent the overnight rise in adrenal androgens. Modified-release hydrocortisone (MRHC) capsules, (Efmody, Diurnal Ltd, Cardiff UK), replicate the cortisol diurnal rhythm and improve the control of CAH compared to standard glucocorticoid therapy3. This post-hoc sub-analysis examines CAH control in MRHC treated patients switched from prednis(ol)one.
Methods
We reviewed the data of all patients taking prednis(ol)one in the randomised study of standard treatment versus MRHC3: 39 classic CAH patients on prednis(ol)one (alone or combined with hydrocortisone) (36 prednisolone; 3 prednisone) were randomised either to continue prednis(ol)one or switched to MRHC at the same hydrocortisone dose equivalent (HDE=prednisolone dose x5). Patients were assessed after 4 weeks following which blinded dose titration according to 17OHP and A4 control was performed to bring 17OHP into the optimal range (<36 nmol/l) and A4 into the reference range. After 24 weeks, 31 patients from the prednis(ol)one prior therapy group participated in an ongoing MHRC single arm extension study with 28 patients completing 18 months follow up. Control of CAH was defined as a 0900h 17OHP <36 nmol/l.
Results
Median baseline dose (HDE) was 30mg (n=39), androgen control was 56%. In patients randomised to MRHC (n=18), 39% were controlled at baseline and 94% at 4 weeks without dose adjustment. At 24 weeks, after androgen-control guided titration, the HDE dose in the prednis(ol)one group was 34mg, and in the MRHC group 27.5mg, with control being 71% and 94%, respectively. Percentage inhibition of 9am 17OHP from the levels at baseline to that at 24 weeks in the prednis(ol)one group was 32% and in the MRHC group 91%. In this study period there were no adrenal crises in the MRHC group and one in the prednis(ol)one group. MRHC-treated patients in the extension study were further titrated according to clinician assessment, at interim analysis the median MRHC dose was 20mg (median reduction 10mg) and 82% of patients were controlled at 18 months (n=28). In the ongoing extension study of all patients on MRHC (221 patient years), there were 12 adrenal crises in 5 patients (5.4/100 patient years).
Conclusions
Control of CAH is better on MRHC than prednisolone: 94% vs 39%; and the dose of MRHC can be down titrated to an adrenal replacement dose whilst maintaining control in the majority (82%) of patients.
References
1. Pickup ME. Clin Pharmacokinet 1979 4 111-128; 2. Toothaker RD. J Pharm Sci 1982 71 573-576; 3. Merke DP. JCEM 2021 106 e2063-e2077.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 1:05 p.m., Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
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Zenno A, Cohen A, Babcock H, Moon A, Santhanam P, Desai J, Joyal E, Manoli I, Merke DP. ODP408 Elevated DHEAS and Acute Hair Loss in an Adult Male with Trichorhinophalangeal Syndrome Type 1: a Case of Male PCOS. J Endocr Soc 2022. [PMCID: PMC9625333 DOI: 10.1210/jendso/bvac150.1364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Male androgenic alopecia is a common cause of hair loss in both men and women. Although genetic and hormonal factors likely play a role, the etiology is mostly unknown. PCOS is a highly heritable disease with elevated prevalence of reproductive abnormalities in first-degree relatives (FDRs) of patients with PCOS, which may be due to an underlying genetic defect in steroidogenesis. A recent meta-analysis revealed that male FDRs of patients with PCOS had significantly increased levels of DHEAS compared with controls. We present a young adult male who developed acute hair loss with biochemical evidence of hyperandrogenism. Clinical Case A 21-year-old man presented for evaluation of hyperandrogenism after experiencing progressive loss of posterior patch of hair over 3 weeks. He also endorsed acne, intermittent headaches, striae, and difficulty losing weight for the past 2 years. He denied facial rounding, vision changes, and use of glucocorticoids or supplements. Physical examination was notable for height of 67 inches, BMI 30.5 mg/m 2, BP 120/78, recession of the frontotemporal and occipital hairline, sparse posterior scalp hair, bulbous nose, long philtrum, mild facial acne, 2, 3 toe syndactyly, and thin purple striae on bilateral flanks and axillae. Labs revealed elevated DHEAS 1065.7 mcg/dL (ref. 238.4-539.3) and normal 8 AM total testosterone of 382 ng/dL (240-871). Cosyntropin stimulation test revealed baseline cortisol level of 10.6 mcg/dL with ACTH of 22.2 pg/mL (5-46) and 60-minute cortisol level of 24.8 mcg/dL, 17-OH progesterone level 81 ng/dL (18-164), and 17-OH pregnenolone 1040 ng/dL (55-455). Workup for Cushing's revealed multiple normal midnight salivary cortisol levels and mild intermittent elevation of 24-hour urinary free cortisol levels. CT scan of the adrenals was negative for a mass. Exome sequencing revealed a heterozygous de novo pathogenic variant (c.1614_1615delTCinsAT: p. C538X) in the TRPS1 gene (NM_0141112.2). Family history was significant for a 20-year-old sister with PCOS and elevated DHEAS of 443 ug/dL (51-321). Mid-parental height was 69.6 inches. Conclusion Trichorhinophalangeal syndrome Type 1 (TRPS1) is a rare genetic disorder characterized by hair, craniofacial, and skeletal abnormalities such as androgenetic alopecia, bulbous nasal tip, and cone-shaped epiphyses. To our knowledge, the hair findings in TRPS are not associated with hyperandrogenism which prompted further investigation. Evaluation for endocrine causes of hyperandrogenism such as Cushing's disease, congenital adrenal hyperplasia, and adrenal tumor were negative. However, our patient's elevated DHEAS is likely due to male PCOS, as previously described in male FDRs of patients with PCOS. Thus, genetic susceptibility to PCOS and rare genetic syndromes should be considered in the differential diagnosis of young men with clinical and biochemical evidence of hyperandrogenism. Reference: Shan D et al. Reproductive Health in First-degree relatives of Patients with Polycystic Ovarian Syndrome: a Review and Meta-analysis. JCEM. 2022 Jan;107(1); 273-295. Presentation: No date and time listed
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Walzer D, Turcu AF, Jha S, Abel BS, Auchus RJ, Merke DP, Brown RJ. Excess 11-Oxygenated Androgens in Women With Severe Insulin Resistance Are Mediated by Adrenal Insulin Receptor Signaling. J Clin Endocrinol Metab 2022; 107:2626-2635. [PMID: 35696182 PMCID: PMC9387696 DOI: 10.1210/clinem/dgac365] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Syndromes of severe insulin resistance (SIR) include insulin receptoropathy, in which all signaling downstream of the insulin receptor is lost, and lipodystrophy, in which some signaling pathways are impaired and others preserved. Women with SIR commonly have ovarian hyperandrogenemia; adrenal-derived 11-oxygenated androgens, produced by CYP11B1, have not been studied. OBJECTIVE We aimed to evaluate classic pathway androgens (androstenedione, testosterone) and 11-oxygenated androgens in women with SIR and hyperandrogenemia, and to elucidate the role of insulin receptor signaling for 11-oxygenated androgen production by comparing lipodystrophy and receptoropathy. METHODS Steroid hormones were quantified using LC-MS/MS in a cross-sectional study of 18 women with hyperandrogenemia and SIR (11 lipodystrophy, 7 receptoropathy) and 23 controls. To assess ovarian vs adrenal origin, steroids were compared in receptoropathy patients with (Ovary+) vs without (Ovary-) ovarian function. RESULTS Compared with controls, classic androgens were elevated in both lipodystrophy and receptoropathy, and 11-oxygenated androgens were increased in lipodystrophy (2.9-fold higher 11β-hydroxyandrostenedione (11OHA4), 2.4-fold higher 11-ketoandrostenedione (11KA4), 3.6-fold higher 11-ketotestosterone (11KT); P < 0.01), but not receptoropathy. Product-to-precursor ratios for CYP11B1 conversion of androstenedione to 11OHA4 were similar in lipodystrophy and controls but decreased in receptoropathy (6.5-fold lower than control; P = 0.001). Classic androgens were elevated in Ovary + but not Ovary- patients. CONCLUSIONS 11-Oxygenated androgens are elevated in lipodystrophy but not receptoropathy. In SIR, insulin receptor signaling is necessary for adrenal hyperandrogenemia but not ovarian hyperandrogenemia; excess classic androgens are derived from the ovaries. Insulin receptor signaling increases adrenal 19-carbon steroid production, which may have implications for more common disorders of mild IR.
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Affiliation(s)
- Dalia Walzer
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Smita Jha
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Brent S Abel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Deborah P Merke
- The National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Rebecca J Brown
- Correspondence: Rebecca J. Brown, Building 10, Room 6-5940, 10 Center Dr., Bethesda, MD 20892, USA.
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Flippo C, Kolli V, Andrew M, Berger S, Bhatti T, Boyce AM, Casella D, Collins MT, Délot E, Devaney J, Hewitt SM, Kolon T, Mallappa A, White PC, Merke DP, Dauber A. Precocious Puberty in a Boy with Bilateral Leydig Cell Tumors due to a Somatic Gain-of-Function LHCGR Variant. J Endocr Soc 2022; 6:bvac127. [DOI: 10.1210/jendso/bvac127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Context
Autosomal dominant and rarely de novo gain-of-function variants in the LHCGR gene are associated with precocious male puberty, while somatic LHCGR variants have been found in isolated Leydig cell adenomas and Leydig cell hyperplasia. Bilateral diffuse Leydig cell tumor formation in peripheral precocious male puberty has not been reported.
Case Description
We present a boy with gonadotropin-independent precocious puberty and rapid virilization beginning in infancy resistant to standard therapy. Treatment with abiraterone in addition to letrozole and bicalutamide proved effective. Bilateral diffuse Leydig cell tumors were identified at age 5 years.
Results
Whole genome sequencing of tumor and blood samples was performed. The patient was confirmed to have bilateral, diffuse Leydig cell tumors harboring the somatic, gain-of-function p.Asp578His variant in the LHCGR gene. Digital droplet PCR of the LHCGR variant performed in tumor and blood samples detected low-levels of this same variant in the blood.
Conclusions
We report a young boy with severe gonadotropin-independent precocious puberty beginning in infancy who developed bilateral diffuse Leydig cell tumors at age 5 years due to a somatic gain-of-function p.Asp578His variant in LHCGR. The gain-of-function nature of the LHCGR variant and the developmental timing of the somatic mutation likely play a role in the risk of tumor formation. Abiraterone (a CYP17A1 inhibitor), in combination with an anti-androgen, aromatase inhibitor and glucocorticoid, appears to be an effective therapy for severe peripheral precocious puberty in boys.
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Affiliation(s)
- Chelsi Flippo
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health , Bethesda, MD
- Division of Endocrinology, Children’s National Hospital , Washington, DC
| | - Vipula Kolli
- National Institutes of Health Clinical Center , Bethesda, MD
| | - Melissa Andrew
- Division of Endocrinology, Children’s National Hospital , Washington, DC
| | - Seth Berger
- Center for Genetic Medicine Research & Rare Disease Institute, Children's National Hospital , Washington, DC
| | - Tricia Bhatti
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania , Philadelphia, PA
| | - Alison M Boyce
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health , Bethesda, MD
| | - Daniel Casella
- Division of Pediatric Urology, Children's National Hospital , Washington, DC
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health , Bethesda, MD
| | - Emmanuèle Délot
- Center for Genetic Medicine Research, Children's National Research Institute and Department of Genomics and Precision Medicine, George Washington University , Washington, D.C
| | | | - Stephen M Hewitt
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health , Bethesda, MD
| | - Thomas Kolon
- Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania , Philadelphia, PA
| | | | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center , Dallas TX
| | - Deborah P Merke
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health , Bethesda, MD
- National Institutes of Health Clinical Center , Bethesda, MD
| | - Andrew Dauber
- Division of Endocrinology, Children’s National Hospital , Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, 2300 I St. NW , Washington, DC
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Abstract
Treatment for congenital adrenal hyperplasia (CAH) was introduced in the 1950s following the discovery of the structure and function of adrenocortical hormones. Although major advances in molecular biology have delineated steroidogenic mechanisms and the genetics of CAH, management and treatment of this condition continue to present challenges. Management is complicated by a combination of comorbidities that arise from disease-related hormonal derangements and treatment-related adverse effects. The clinical outcomes of CAH can include life-threatening adrenal crises, altered growth and early puberty, and adverse effects on metabolic, cardiovascular, bone and reproductive health. Standard-of-care glucocorticoid formulations fall short of replicating the circadian rhythm of cortisol and controlling efficient adrenocorticotrophic hormone-driven adrenal androgen production. Adrenal-derived 11-oxygenated androgens have emerged as potential new biomarkers for CAH, as traditional biomarkers are subject to variability and are not adrenal-specific, contributing to management challenges. Multiple alternative treatment approaches are being developed with the aim of tailoring therapy for improved patient outcomes. This Review focuses on challenges and advances in the management and treatment of CAH due to 21-hydroxylase deficiency, the most common type of CAH. Furthermore, we examine new therapeutic developments, including treatments designed to replace cortisol in a physiological manner and adjunct agents intended to control excess androgens and thereby enable reductions in glucocorticoid doses.
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Affiliation(s)
- Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, MD, USA.
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 132] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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Torky A, Sinaii N, Jha S, Desai J, El-Maouche D, Mallappa A, Merke DP. Cardiovascular Disease Risk Factors and Metabolic Morbidity in a Longitudinal Study of Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2021; 106:e5247-e5257. [PMID: 33677504 PMCID: PMC8864751 DOI: 10.1210/clinem/dgab133] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Indexed: 02/04/2023]
Abstract
CONTEXT Patients with congenital adrenal hyperplasia (CAH) are exposed to hyperandrogenism and supraphysiologic glucocorticoids, both of which can increase risk of metabolic morbidity. OBJECTIVE Our aim was to evaluate cardiovascular and metabolic morbidity risk in a longitudinal study of patients with CAH spanning both childhood and adulthood. DESIGN AND SETTING Patients with classic CAH followed for a minimum of 5 years during both childhood and adulthood (n = 57) at the National Institutes of Health were included and compared with the US general population using NHANES data. MAIN OUTCOME MEASURES Obesity, hypertension, insulin resistance, fasting hyperglycemia, and dyslipidemia. RESULTS Compared to the US population, patients with CAH had higher (P < 0.001) prevalence of obesity, hypertension, insulin resistance, fasting hyperglycemia, and low high-density lipoprotein (HDL) during childhood and obesity (P = 0.024), hypertension (P<0.001), and insulin resistance (P < 0.001) during adulthood. In our cohort, obesity, hypertension, fasting hyperglycemia, and hypertriglyceridemia began prior to age 10. During childhood, increased mineralocorticoid dose was associated with hypertension (P = 0.0015) and low HDL (P = 0.0021). During adulthood, suppressed androstenedione was associated with hypertension (P = 0.002), and high low-density lipoprotein (P = 0.0039) whereas suppressed testosterone (P = 0.003) was associated with insulin resistance. Elevated 17-hydroxyprogesterone, possibly reflecting poor disease control, was protective against high cholesterol (P = 0.0049) in children. Children whose mothers were obese (maternal obesity) had increased risk of obesity during adulthood (P = 0.0021). Obesity, in turn, contributed to the development of hypertension, insulin resistance, and hypertriglyceridemia in adulthood. CONCLUSION Patients with CAH develop metabolic morbidity at a young age associated with treatment-related and familial factors. Judicious use of glucocorticoid and mineralocorticoid is warranted.
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Affiliation(s)
- Ahmed Torky
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health, Bethesda, MD, USA
| | - Smita Jha
- National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Jay Desai
- National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Diala El-Maouche
- National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA
- Division of Endocrinology & Metabolism, George Washington University, Washington, DC,USA
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Deborah P Merke
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
- National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA
- Correspondence: Deborah P Merke, MD, 10 Center Drive, Room 3-2750, Bethesda, MD 20892-1932.
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Turcu AF, Mallappa A, Nella AA, Chen X, Zhao L, Nanba AT, Byrd JB, Auchus RJ, Merke DP. 24-Hour Profiles of 11-Oxygenated C 19 Steroids and Δ 5-Steroid Sulfates during Oral and Continuous Subcutaneous Glucocorticoids in 21-Hydroxylase Deficiency. Front Endocrinol (Lausanne) 2021; 12:751191. [PMID: 34867794 PMCID: PMC8636728 DOI: 10.3389/fendo.2021.751191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background Optimal management of androgen excess in 21-hydroxylase deficiency (21OHD) remains challenging. 11-oxygenated-C19 steroids (11-oxyandrogens) have emerged as promising biomarkers of disease control, but data regarding their response to treatment are lacking. Objective To compare the dynamic response of a broad set of steroids to both conventional oral glucocorticoids (OG) and circadian cortisol replacement via continuous subcutaneous hydrocortisone infusion (CSHI) in patients with 21OHD based on 24-hour serial sampling. Participants and Methods We studied 8 adults (5 women), ages 19-43 years, with poorly controlled classic 21OHD who participated in a single-center open-label phase I-II study comparing OG with CSHI. We used mass spectrometry to measure 15 steroids (including 11-oxyandrogens and Δ5 steroid sulfates) in serum samples obtained every 2 h for 24 h after 3 months of stable OG, and 6 months into ongoing CSHI. Results In response to OG therapy, androstenedione, testosterone (T), and their four 11-oxyandrogen metabolites:11β-hydroxyandrostenedione, 11-ketoandrostenedione, 11β-hydroxytestosterone and 11-ketotestosterone (11KT) demonstrated a delayed decline in serum concentrations, and they achieved a nadir between 0100-0300. Unlike DHEAS, which had little diurnal variation, pregnenolone sulfate (PregS) and 17-hydoxypregnenolone sulfate peaked in early morning and declined progressively throughout the day. CSHI dampened the early ACTH and androgen rise, allowing the ACTH-driven adrenal steroids to return closer to baseline before mid-day. 11KT concentrations displayed the most consistent difference between OG and CSHI across all time segments. While T was lowered by CSHI as compared with OG in women, T increased in men, suggesting an improvement of the testicular function in parallel with 21OHD control in men. Conclusion 11-oxyandrogens and PregS could serve as biomarkers of disease control in 21OHD. The development of normative data for these promising novel biomarkers must consider their diurnal variability.
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Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, United States
| | - Ashwini Mallappa
- Pediatric Service, National Institutes of Health (NIH) Clinical Center, Bethesda, MD, United States
| | - Aikaterini A Nella
- Division of Pediatric Diabetes and Endocrinology, Baylor College of Medicine, Houston, TX, United States
| | - Xuan Chen
- School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Lili Zhao
- School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Aya T Nanba
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, United States
| | - James Brian Byrd
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, United States
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, United States
| | - Deborah P Merke
- Pediatric Service, National Institutes of Health (NIH) Clinical Center, Bethesda, MD, United States
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
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Sarafoglou K, Barnes CN, Huang M, Imel EA, Madu IJ, Merke DP, Moriarty D, Nakhle S, Newfield RS, Vogiatzi MG, Auchus RJ. Tildacerfont in Adults With Classic Congenital Adrenal Hyperplasia: Results from Two Phase 2 Studies. J Clin Endocrinol Metab 2021; 106:e4666-e4679. [PMID: 34146101 PMCID: PMC8530725 DOI: 10.1210/clinem/dgab438] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Congenital adrenal hyperplasia due to 21-hydroxylase deficiency (21OHD) is typically treated with lifelong supraphysiologic doses of glucocorticoids (GCs). Tildacerfont, a corticotropin-releasing factor type-1 receptor antagonist, may reduce excess androgen production, allowing for GC dose reduction. OBJECTIVE Assess tildacerfont safety and efficacy. DESIGN AND SETTING Two Phase 2 open-label studies. PATIENTS Adults with 21OHD. INTERVENTION Oral tildacerfont 200 to 1000 mg once daily (QD) (n = 10) or 100 to 200 mg twice daily (n = 9 and 7) for 2 weeks (Study 1), and 400 mg QD (n = 11) for 12 weeks (Study 2). MAIN OUTCOME MEASURE Efficacy was evaluated by changes from baseline at 8 am in adrenocorticotropic hormone (ACTH), 17-hydroxyprogesterone (17-OHP), and androstenedione (A4) according to baseline A4 ≤ 2× upper limit of normal (ULN) or A4 > 2× ULN. Safety was evaluated using adverse events (AEs) and laboratory assessments. RESULTS In Study 1, evaluable participants with baseline A4 > 2× ULN (n = 11; 19-67 years, 55% female) had reductions from baseline in ACTH (-59.4% to -28.4%), 17-OHP (-38.3% to 0.3%), and A4 (-24.2% to -18.1%), with no clear dose response. In Study 2, participants with baseline A4 > 2× ULN (n = 5; 26-63 years, 40% female) had ~80% maximum mean reductions in biomarker levels. ACTH and A4 were normalized for 60% and 40%, respectively. In both studies, participants with baseline A4 ≤ 2× ULN maintained biomarker levels. AEs (in 53.6% of patients overall) included headache (7.1%) and upper respiratory tract infection (7.1%). CONCLUSIONS For patients with 21OHD, up to 12 weeks of oral tildacerfont reduced or maintained key hormone biomarkers toward normal.
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Affiliation(s)
- Kyriakie Sarafoglou
- Department of Pediatrics, Division of Endocrinology, University of Minnesota Medical School; and Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | - Chris N Barnes
- Spruce Biosciences, Inc., Daly City, CA, USA
- Correspondence: Chris N. Barnes, PhD, Spruce Biosciences, 2001 Junipero Serra Blvd, Suite 640, Daly City, CA 94014, USA.
| | | | - Erik A Imel
- Department of Medicine, Division of Endocrinology and Metabolism, Indiana University School of Medicine, Indianapolis, IN; USA
- Department of Pediatrics, Section of Endocrinology and Diabetology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Deborah P Merke
- National Institutes of Health Clinical Center, and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | | | | | - Ron S Newfield
- Pediatric Endocrinology, University of California San Diego and Rady Children’s Hospital San Diego, San Diego, CA, USA
| | - Maria G Vogiatzi
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI and Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA
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Kolli V, da Cunha IW, Kim S, Iben JR, Mallappa A, Li T, Gaynor A, Coon SL, Quezado MM, Merke DP. Morphologic and Molecular Characterization of Adrenals and Adrenal Rest Affected by Congenital Adrenal Hyperplasia. Front Endocrinol (Lausanne) 2021; 12:730947. [PMID: 34616364 PMCID: PMC8488225 DOI: 10.3389/fendo.2021.730947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/26/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction Adrenocortical hyperplasia and adrenal rest tumor (ART) formation are common in congenital adrenal hyperplasia (CAH). Although driven by excessive corticotropin, much is unknown regarding the morphology and transformation of these tissues. Our study objective was to characterize CAH-affected adrenals and ART and compare with control adrenal and gonadal tissues. Patients/Methods CAH adrenals, ART and control tissues were analyzed by histology, immunohistochemistry, and transcriptome sequencing. We investigated protein expression of the ACTH receptor (MC2R), steroidogenic (CYP11B2, CYP11B1, CYB5A) and immune (CD20, CD3, CD68) biomarkers, and delta-like 1 homolog (DLK1), a membrane bound protein broadly expressed in fetal and many endocrine cells. RNA was isolated and gene expression was analyzed by RNA sequencing (RNA-seq) followed by principle component, and unsupervised clustering analyses. Results Based on immunohistochemistry, CAH adrenals and ART demonstrated increased zona reticularis (ZR)-like CYB5A expression, compared to CYP11B1, and CYP11B2, markers of zona fasciculata and zona glomerulosa respectively. CYP11B2 was mostly absent in CAH adrenals and absent in ART. DLK1 was present in CAH adrenal, ART, and also control adrenal and testis, but was absent in control ovary. Increased expression of adrenocortical marker MC2R, was observed in CAH adrenals compared to control adrenal. Unlike control tissues, significant nodular lymphocytic infiltration was observed in CAH adrenals and ART, with CD20 (B-cell), CD3 (T-cell) and CD68 (macrophage/monocyte) markers of inflammation. RNA-seq data revealed co-expression of adrenal MC2R, and testis-specific INSL3, HSD17B3 in testicular ART indicating the presence of both gonadal and adrenal features, and high expression of DLK1 in ART, CAH adrenals and control adrenal. Principal component analysis indicated that the ART transcriptome was more similar to CAH adrenals and least similar to control testis tissue. Conclusions CAH-affected adrenal glands and ART have similar expression profiles and morphology, demonstrating increased CYB5A with ZR characteristics and lymphocytic infiltration, suggesting a common origin that is similarly affected by the abnormal hormonal milieu. Immune system modulators may play a role in tumor formation of CAH.
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Affiliation(s)
- Vipula Kolli
- National Institutes of Health Clinical Center, Bethesda, MD, United States
| | | | - SunA Kim
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, United States
| | - James R. Iben
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Tianwei Li
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Alison Gaynor
- National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Steven L. Coon
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Martha M. Quezado
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, United States
| | - Deborah P. Merke
- National Institutes of Health Clinical Center, Bethesda, MD, United States
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
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21
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Lao Q, Merke DP. Letter to the Editor from Lao and Merke: "Ehlers-Danlos Syndrome: Molecular and Clirnical Characterization of TNXA/TNXB Chimeras in Congenital Adrenal Hyperplasia". J Clin Endocrinol Metab 2021; 106:e2835-e2836. [PMID: 33901292 PMCID: PMC8427707 DOI: 10.1210/clinem/dgab280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Indexed: 01/01/2023]
Affiliation(s)
- Qizong Lao
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
- Correspondence: Qizong Lao PhD, 10 Center Drive, Room B1B58, Bethesda, MD 20892–1932, USA.
| | - Deborah P Merke
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
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Merke DP, Auchus RJ, Sarafoglou K, Geffner ME, Kim MS, Escandon RD, Bharucha KN, Shaywitz AJ, Eclov R, Beard CW, Fur SL, Bougneres PF. Design of a Phase 1/2 Open-Label, Dose-Escalation Study of the Safety and Efficacy of Gene Therapy in Adults With Classic Congenital Adrenal Hyperplasia (CAH) Due to 21-hydroxylase Deficiency Through Administration of an Adeno-Associated Virus (AAV) Serotype 5-Based Recombinant Vector Encoding the Human CYP21A2 Gene. J Endocr Soc 2021. [DOI: 10.1210/jendso/bvab048.165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
The CYP21A2 gene, which encodes the 21-hydroxylase enzyme, plays a critical role in glucocorticoid (GC) and mineralocorticoid synthesis by the adrenal cortex. CYP21A2 pathogenic variants cause 21-hydroxylase deficiency (21OHD), the most common type of CAH, characterized by variable degrees of adrenal insufficiency and androgen excess. Standard treatment of classic 21OHD consists of daily doses of GC and mineralocorticoid. However, suppressive GC doses are often required to reduce androgen excess, and it is often not possible to dose exogenous GC in a manner that provides adequate disease control while avoiding overtreatment. Disease-related and treatment-related comorbidities are common and include life-threatening adrenal crises, impaired growth and development during childhood, adult short stature, virilization in females, subfertility in both sexes, obesity and cardiovascular risk factors, and decreased bone mineral density. Novel treatment approaches are needed to address these challenges and a treatment that restores the ability of the adrenals to produce cortisol and aldosterone in a physiologically-regulated manner would be particularly helpful.
Here we present the design and rationale of a clinical trial using BBP-631, an AAV5 gene replacement therapy for adults with classic CAH due to 21-OHD. This treatment approach is based on the demonstration that a single intravenous administration of BBP-631 corrects the enzyme deficiency in the H2-aw18 CYP21-/- CAH mouse model of 21OHD, including response to stress. This correction was robust, dose-dependent and durable. BBP-631 treatment also resulted in robust and durable expression of the human CYP21A2 transgene in the non-human primate adrenal cortex. BBP-631 appears to be safe and well-tolerated in mice with 21-OHD, healthy mice and non-human primates. Taken together, these data support initiating clinical trials in adults with classic CAH due to 21-OHD.
The trial will sequentially enroll individuals in up to 3 successive dose-escalation cohorts. Each subject will receive a single dose of BBP-631 and safety will be assessed prior to dose escalation. Endogenous production rates of adrenal steroids (cortisol, 17-hydroxyprogesterone, androstenedione) will be determined pre- and post- dose, and their concentrations assessed over a 1-year period after which subjects will roll over into an extension study for at least 4 years. The Phase 1 study will determine the tolerability of a single dose of BBP-631. The magnitude and durability of BBP-631 and effects on adrenal steroids, ACTH and, where relevant, aldosterone levels will be monitored. The ability of BBP-631 to allow tapering of GC doses will also be explored. This first in human study of gene therapy for CAH represents a milestone in the development of novel and improved treatment approaches for patients with classic CAH.
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Affiliation(s)
| | | | | | | | - Mimi S Kim
- Children’s Hospital of Los Angeles, Los Angeles, CA, USA
| | | | | | - Adam J Shaywitz
- BridgeBio Gene Therapy/Adrenas Therapeutics, Palo Alto, CA, USA
| | - Rachel Eclov
- BridgeBio Gene Therapy/Adrenas Therapeutics, Palo Alto, CA, USA
| | - Clayton W Beard
- BridgeBio Gene Therapy/Adrenas Therapeutics, Palo Alto, CA, USA
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23
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Auchus RJ, Merke DP, Madu IJ, Nakhle S, Sarafoglou K, Huang M, Moriarty D, Barnes C, Newfield RS. Tildacerfont for the Treatment of Patients With Classic Congenital Adrenal Hyperplasia: Results From a 12-Week Phase 2 Clinical Trial in Adults With Classic CAH. J Endocr Soc 2021. [PMCID: PMC8090554 DOI: 10.1210/jendso/bvab048.1011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21-OHD) is an autosomal recessive disorder characterized by insufficient cortisol production resulting in excess adrenocorticotropic hormone (ACTH) and adrenal androgen production. Standard-of-care therapy with glucocorticoids (GC) is suboptimal due to the difficulty of balancing control of the ACTH-driven androgen excess against the serious long-term side effects associated with chronic supraphysiologic GC exposure. Tildacerfont, a second-generation corticotropin-releasing factor type-1 (CRF1) receptor antagonist, lowers excess ACTH, and thus has the potential to reduce adrenal androgen production and to allow for GC dosing closer to physiologic doses. A prior study demonstrated that tildacerfont was effective in reducing ACTH, 17-hydroxyprogesterone (17-OHP) and androstenedione (A4) after 2 weeks of therapy. Here we report results from an open-label 12-week extension study. Methods: Subjects met either of the following criteria: 1) completion of prior study or 2) treatment naïve to tildacerfont with 17-OHP >800 ng/dL while on a stable GC regimen (excluding dexamethasone). Subjects were treated with oral tildacerfont at 400 mg once daily for 12 weeks. Efficacy and safety parameters were assessed at baseline through Week 12. Results: Subject characteristics (n=8) are as follows: median (range) age was 44.5 years (26-67 years; 5 females), median (range) body mass index 30.8 kg/m2 (22-41 kg/m2). In month 3, in the participants with poor control of disease at baseline (elevations in all key biomarkers: ACTH, 17-OHP, and A4) (n=5), maximum mean percentage reductions for ACTH, 17-OHP and A4 were 84%, 82%, and 79%, respectively. In this subgroup, 60% of subjects achieved ACTH normalization and 40% achieved A4 normalization during treatment. Tildacerfont treatment maintained, and did not suppress, biomarkers in participants with good control of disease at baseline (A4 below upper limit of normal) (n=3). Overall, tildacerfont was well tolerated with no serious adverse events. Conclusions: This is the first study of 12 weeks’ duration for a novel, non-steroidal mechanism-of-action agent for the treatment of 21-OHD. Results of this study show that tildacerfont was generally well-tolerated and effective in achieving meaningful reductions in ACTH and A4 in poorly controlled patients over 12 weeks. In addition, this is the first, non-steroidal therapeutic to show evidence of ACTH and A4 normalization over 12 weeks of therapy. Longer term future studies will evaluate whether treatment with tildacerfont can achieve further clinical benefits and allow reduction of GC doses while controlling relevant disease biomarkers.
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Affiliation(s)
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | | | | | | | - Michael Huang
- former employee of Spruce Biosciences, Daly City, CA, USA
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24
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Parker RW, Ferré EMN, Myint-Hpu K, Schmitt MM, Colton B, Merke DP, Lionakis MS. Posaconazole-induced Pseudohyperaldosteronism Manifesting with Nephrotic-range Proteinuria. Clin Infect Dis 2021; 71:2768-2770. [PMID: 32060559 DOI: 10.1093/cid/ciaa119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Ruth W Parker
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Elise M N Ferré
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Monica M Schmitt
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Ben Colton
- Pharmacy Department, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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25
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Merke DP, Mallappa A, Arlt W, Brac de la Perriere A, Lindén Hirschberg A, Juul A, Newell-Price J, Perry CG, Prete A, Rees DA, Reisch N, Stikkelbroeck N, Touraine P, Maltby K, Treasure FP, Porter J, Ross RJ. Modified-Release Hydrocortisone in Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2021; 106:e2063-e2077. [PMID: 33527139 PMCID: PMC8063257 DOI: 10.1210/clinem/dgab051] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Indexed: 12/11/2022]
Abstract
CONTEXT Standard glucocorticoid therapy in congenital adrenal hyperplasia (CAH) regularly fails to control androgen excess, causing glucocorticoid overexposure and poor health outcomes. OBJECTIVE We investigated whether modified-release hydrocortisone (MR-HC), which mimics physiologic cortisol secretion, could improve disease control. METHODS A 6-month, randomized, phase 3 study was conducted of MR-HC vs standard glucocorticoid, followed by a single-arm MR-HC extension study. Primary outcomes were change in 24-hour SD score (SDS) of androgen precursor 17-hydroxyprogesterone (17OHP) for phase 3, and efficacy, safety and tolerability of MR-HC for the extension study. RESULTS The phase 3 study recruited 122 adult CAH patients. Although the study failed its primary outcome at 6 months, there was evidence of better biochemical control on MR-HC, with lower 17OHP SDS at 4 (P = .007) and 12 (P = .019) weeks, and between 07:00h to 15:00h (P = .044) at 6 months. The percentage of patients with controlled 09:00h serum 17OHP (< 1200 ng/dL) was 52% at baseline, at 6 months 91% for MR-HC and 71% for standard therapy (P = .002), and 80% for MR-HC at 18 months' extension. The median daily hydrocortisone dose was 25 mg at baseline, at 6 months 31 mg for standard therapy, and 30 mg for MR-HC, and after 18 months 20 mg MR-HC. Three adrenal crises occurred in phase 3, none on MR-HC and 4 in the extension study. MR-HC resulted in patient-reported benefit including menses restoration in 8 patients (1 on standard therapy), and 3 patient and 4 partner pregnancies (none on standard therapy). CONCLUSION MR-HC improved biochemical disease control in adults with reduction in steroid dose over time and patient-reported benefit.
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Affiliation(s)
- Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Aude Brac de la Perriere
- Hospices Civils de Lyon, Fédération d’Endocrinologie, Groupement hospitalier Est, Bron Cedex, France
| | - Angelica Lindén Hirschberg
- Department of Women’s and Children’s Health, Karolinska Institutet and Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Juul
- Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D Aled Rees
- Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Pitie Salpêtriere Hospital, France
- Sorbonne University, Center for Rare Endocrine and Gynecological Disorders, Paris, France
| | | | | | | | - Richard J Ross
- University of Sheffield, Sheffield, UK
- Diurnal Ltd, Cardiff, UK
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26
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Lao Q, Merke DP. Molecular genetic testing of congenital adrenal hyperplasia due to 21-hydroxylase deficiency should include CAH-X chimeras. Eur J Hum Genet 2021; 29:1047-1048. [PMID: 33824469 PMCID: PMC8298381 DOI: 10.1038/s41431-021-00870-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/03/2021] [Accepted: 03/11/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Qizong Lao
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Deborah P Merke
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, MD, USA. .,Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
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27
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Lao Q, Mallappa A, Rueda Faucz F, Joyal E, Veeraraghavan P, Chen W, Merke DP. A TNXB splice donor site variant as a cause of hypermobility type Ehlers-Danlos syndrome in patients with congenital adrenal hyperplasia. Mol Genet Genomic Med 2020; 9:e1556. [PMID: 33332743 PMCID: PMC8077117 DOI: 10.1002/mgg3.1556] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 09/18/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is an autosomal recessive disease of steroidogenesis that affects 1 in 15,000. Approximately, 10% of the CAH population also suffer from CAH-X, a connective tissue dysplasia consistent with hypermobility type Ehlers-Danlos syndrome (EDS). Most patients with CAH-X carry a contiguous gene deletion involving CYP21A2 encoding 21-hydroxylase and TNXB encoding tenascin-X (TNX), but some are of unknown etiology. METHODS We conducted clinical evaluation and medical history review of EDS-related manifestations in subjects from two unrelated CAH families who carry a heterozygous TNXB c.12463+2T>C variant that alters the splice donor site of intron 42. A next generation sequencing (NGS) based EDS panel composed of 45 genes was performed for index patients from each family. TNX expression in patient skin biopsy tissues and dermal fibroblasts was assessed by qRT-PCR and Sanger sequencing. RESULTS All three evaluated CAH patients carrying the TNXB splice site variant had moderate EDS manifestations. An NGS panel excluded involvement of other known EDS-related variants. RNA assay on skin biopsies and dermal fibroblasts did not detect splicing errors in TNX mRNA; however, the removal of intron 42 was less efficient in the allele harboring the splice site variant as evidenced by the existence of a premature TNX RNA form, leading to an allele specific decrease in TNX mRNA. CONCLUSIONS Carrying a TNXB c.12463+2T>C variant at the intron 42 splice donor site causes an allele specific decrease in TNX expression, which can be associated with moderate EDS in CAH patients.
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Affiliation(s)
- Qizong Lao
- National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Fabio Rueda Faucz
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Elizabeth Joyal
- National Institutes of Health Clinical Center, Bethesda, MD, USA
| | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, MD, USA.,The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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28
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Jha S, Turcu AF, Sinaii N, Brookner B, Auchus RJ, Merke DP. 11-Oxygenated Androgens Useful in the Setting of Discrepant Conventional Biomarkers in 21-Hydroxylase Deficiency. J Endocr Soc 2020; 5:bvaa192. [PMID: 33447690 DOI: 10.1210/jendso/bvaa192] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Indexed: 11/19/2022] Open
Abstract
Context Serum 17-hydroxyprogesterone (17OHP) and androstenedione (A4) are the conventional biomarkers used to assess disease control in patients with 21-hydroxylase deficiency (21OHD). However, discrepancy between the two is not uncommon, limiting interpretation. Objective To evaluate 11-oxyandrogens in discriminating good versus poor disease control in 21OHD in the setting of discrepant 17OHP and A4. Methods Retrospective analysis of 2738 laboratory assessments obtained as part of Natural History Study of congenital adrenal hyperplasia (CAH) at the National Institutes Health Clinical Center. Patients with discrepant 17OHP and A4 and available sera were selected. A 15-steroid mass-spectrometry panel was performed in sera from patients with 21OHD and age- and sex-matched controls. Patients were categorized in "good" or "poor" control based on clinical assessment (bone age advancement, signs and symptoms of precocious puberty, menstrual irregularity, hirsutism, or hypogonadotrophic hypogonadism). Results Discrepant 17OHP and A4 was found in 469 (17%) laboratory assessments. Of these, 403 (86%) had elevated 17OHP with A4 in reference range. Of 46 patients with available sera, 30 (65%) were in good control. Median fold elevation relative to controls was higher in patients with poor versus good control for 11-hydroxytestosterone (median [interquartile range], 2.82 [1.25-5.43] vs 0.91 [0.49- 2.07], P = .003), and 11-ketotestosterone (3.57 [2.11-7.41] vs 1.76 [1.24-4.00], P = .047). Fold elevation of 11-hydroxytestosterone between 3.48 (sensitivity 97%, specificity 47%) and 3.88 (sensitivity 100%, specificity 40%) provided the best discrimination between poor vs good control. Conclusion 11-Oxyandrogens, especially 11-hydroxytestosterone, may be useful in the management of CAH when conventional biomarkers are inconclusive.
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Affiliation(s)
- Smita Jha
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, MD, USA.,Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health, Bethesda, MD, USA
| | - Brittany Brookner
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Deborah P Merke
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, MD, USA.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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Dwiggins M, Brookner B, Fowler K, Veeraraghavan P, Gomez-Lobo V, Merke DP. Multidimensional Aspects of Female Sexual Function in Congenital Adrenal Hyperplasia: A Case-Control Study. J Endocr Soc 2020; 4:bvaa131. [PMID: 34485799 DOI: 10.1210/jendso/bvaa131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/28/2020] [Indexed: 11/19/2022] Open
Abstract
Context 46,XX patients with classic congenital adrenal hyperplasia (CAH) are exposed to elevated androgens in utero causing varying levels of virilization. The majority undergo feminizing genitoplasty early in life, with potential impact on sexual function and health-related quality of life (HRQoL). Objective We aimed to determine how sexual and lower urinary tract function, body image, and global HRQoL differs between patients with classic CAH and controls and to characterize how gynecologic anatomy contributes to outcomes. Methods 36 patients with classic CAH and 27 control women who were matched for age, race, and marital status underwent standardized gynecological examination and validated questionnaires. The responses were analyzed in relation to gynecological measurements, genotype, and disease status. Results Compared with controls, patients with CAH were more likely to have sexual dysfunction (P = 0.009), dyspareunia (P = 0.007), and other pelvic pain (P = 0.007); were less likely to be heterosexual (P = 0.013) or ever have been sexually active (P = 0.003); had poorer body image independent of body mass index (P < 0.001); and had worse HRQoL in the areas of general health (P = 0.03) and pain (P = 0.009). The patients with CAH had smaller vaginal calibers and perineal body lengths and larger clitoral indexes when compared with controls (P < 0.001). A larger vaginal caliber in CAH patients was associated with better overall sexual function (P = 0.024), increased sexual satisfaction (P = 0.017), less pain (P < 0.001), and greater number of sexual partners (P = 0.02). Conclusions 46,XX patients with CAH have increased rates of sexual dysfunction, poor body image, and poor HRQoL, which is mitigated by having a larger vaginal caliber. Management aimed at optimizing vaginal caliber might improve sexual function.
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Affiliation(s)
- Maggie Dwiggins
- Medstar Washington Hospital Center and Children's National Medical Center, Washington, District of Columbia.,Norton Children's Medical Group, Louisville, Kentucky
| | | | - Kylie Fowler
- Medstar Washington Hospital Center and Children's National Medical Center, Washington, District of Columbia.,Children's Minnesota, Minneapolis, Minnesota
| | | | - Veronica Gomez-Lobo
- Medstar Washington Hospital Center and Children's National Medical Center, Washington, District of Columbia.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Affiliation(s)
- Deborah P Merke
- From the National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (D.P.M.); and the Division of Metabolism, Endocrinology, and Diabetes and the Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor (R.J.A.)
| | - Richard J Auchus
- From the National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (D.P.M.); and the Division of Metabolism, Endocrinology, and Diabetes and the Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor (R.J.A.)
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El-Maouche D, Merke DP, Vogiatzi MG, Chang AY, Turcu AF, Joyal EG, Lin VH, Weintraub L, Plaunt MR, Mohideen P, Auchus RJ. A Phase 2, Multicenter Study of Nevanimibe for the Treatment of Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2020; 105:5863384. [PMID: 32589738 PMCID: PMC7331874 DOI: 10.1210/clinem/dgaa381] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/22/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with classic congenital adrenal hyperplasia (CAH) often require supraphysiologic glucocorticoid doses to suppress adrenocorticotropic hormone (ACTH) and control androgen excess. Nevanimibe hydrochloride (ATR-101), which selectively inhibits adrenal cortex function, might reduce androgen excess independent of ACTH and thus allow for lower glucocorticoid dosing in CAH. 17-hydroxyprogesterone (17-OHP) and androstenedione are CAH biomarkers used to monitor androgen excess. OBJECTIVE Evaluate the efficacy and safety of nevanimibe in subjects with uncontrolled classic CAH. DESIGN This was a multicenter, single-blind, dose-titration study. CAH subjects with baseline 17-OHP ≥4× the upper limit of normal (ULN) received the lowest dose of nevanimibe for 2 weeks followed by a single-blind 2-week placebo washout. Nevanimibe was gradually titrated up if the primary outcome measure (17-OHP ≤2× ULN) was not met. A total of 5 nevanimibe dose levels were possible (125, 250, 500, 750, 1000 mg twice daily). RESULTS The study enrolled 10 adults: 9 completed the study, and 1 discontinued early due to a related serious adverse event. At baseline, the mean age was 30.3 ± 13.8 years, and the maintenance glucocorticoid dose, expressed as hydrocortisone equivalents, was 24.7 ± 10.4 mg/day. Two subjects met the primary endpoint, and 5 others experienced 17-OHP decreases ranging from 27% to 72% during nevanimibe treatment. The most common side effects were gastrointestinal (30%). There were no dose-related trends in adverse events. CONCLUSIONS Nevanimibe decreased 17-OHP levels within 2 weeks of treatment. Larger studies of longer duration are needed to further evaluate its efficacy as add-on therapy for CAH.
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Affiliation(s)
- Diala El-Maouche
- Division of Endocrinology & Metabolism, George Washington University, Washington, DC
- The National Institutes of Health Clinical Center, Bethesda, Maryland
- Correspondence and Reprint Requests: Richard J. Auchus, Rm 5560A, MSRBII, 1150 W. Medical Center Drive, Ann Arbor, MI 48109, US. E-mail
| | - Deborah P Merke
- The National Institutes of Health Clinical Center, Bethesda, Maryland
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Maria G Vogiatzi
- Division of Endocrinology and Diabetes, Children’s Hospital of Pennsylvania, Philadelphia, Pennsylvania
| | - Alice Y Chang
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
| | - Elizabeth G Joyal
- The National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Vivian H Lin
- Millendo Therapeutics US, Inc, Ann Arbor, Michigan
| | | | | | | | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, Michigan
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Turcu AF, El-Maouche D, Zhao L, Nanba AT, Gaynor A, Veeraraghavan P, Auchus RJ, Merke DP. Androgen excess and diagnostic steroid biomarkers for nonclassic 21-hydroxylase deficiency without cosyntropin stimulation. Eur J Endocrinol 2020; 183:63-71. [PMID: 32487778 PMCID: PMC7458124 DOI: 10.1530/eje-20-0129] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/29/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The clinical presentation of patients with nonclassic 21-hydroxylase deficiency (N21OHD) is similar with that for other disorders of androgen excess. The diagnosis of N21OHD typically requires cosyntropin stimulation. Additionally, the management of such patients is limited by the lack of reliable biomarkers of androgen excess. Herein, we aimed to: (1.) compare the relative contribution of traditional and 11-oxyandrogens in N21OHD patients and (2.) identify steroids that accurately diagnose N21OHD with a single baseline blood draw. DESIGN We prospectively enrolled patients who underwent a cosyntropin stimulation test for suspected N21OHD in two tertiary referral centers between January 2016 and August 2019. METHODS Baseline sera were used to quantify 15 steroids by liquid chromatography-tandem mass spectrometry. Logistic regression modeling was implemented to select steroids that best discriminate N21OHD from controls. RESULTS Of 86 participants (72 females), median age 26, 32 patients (25 females) had N21OHD. Age, sex distribution, and BMI were similar between patients with N21OHD and controls. Both testosterone and androstenedione were similar in patients with N21OHD and controls, while four 11-oxyandrogens were significantly higher in patients with N21OHD (ratios between medians: 1.7 to 2.2, P < 0.01 for all). 17α-Hydroxyprogesterone (6.5-fold), 16α-hydroxyprogesterone (4.1-fold), and 21-deoxycortisol (undetectable in 80% of the controls) were higher, while corticosterone was 3.6-fold lower in patients with N21OHD than in controls (P < 0.001). Together, baseline 17α-hydroxyprogesterone, 21-deoxycortisol, and corticosterone showed perfect discrimination between N21OHD and controls. CONCLUSIONS Adrenal 11-oxyandrogens are disproportionately elevated compared to conventional androgens in N21OHD. Steroid panels can accurately diagnose N21OHD in unstimulated blood tests.
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Affiliation(s)
- Adina F. Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, 40109
| | - Diala El-Maouche
- National Institutes of Health (NIH) Clinical Center, Bethesda, MD, 20892
| | - Lili Zhao
- School of Public Health, University of Michigan, Ann Arbor, MI, 40109
| | - Aya T. Nanba
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, 40109
| | - Alison Gaynor
- National Institutes of Health (NIH) Clinical Center, Bethesda, MD, 20892
| | | | - Richard J. Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, 40109
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, 40109
| | - Deborah P. Merke
- National Institutes of Health (NIH) Clinical Center, Bethesda, MD, 20892
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, 20892
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Jha S, Turcu AF, Sinaii N, Brookner B, Veeraraghavan P, Mallappa A, Auchus RJ, Merke DP. SUN-037 Discordant Serum 17-hydroxyprogesterone and Androstenedione in the Management of Congenital Adrenal Hyperplasia: Are 11-oxygenated Androgens Useful? J Endocr Soc 2020. [PMCID: PMC7207767 DOI: 10.1210/jendso/bvaa046.1756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background 21-hydroxylase-deficiency (21OHD) accounts for more than 95% of CAH cases. Serum 17-hydroxyprogesteron (17OHP) and androstenedione (A4) are traditional biomarkers for monitoring therapy. While generally there is good linear correlation between 17OHP and A4, physicians are likely to encounter scenarios where 17OHP is within “acceptable range” while A4 is elevated and vice versa. Mildly elevated 17OHP is considered acceptable, as normalization of 17OHP is likely to result in overtreatment. 11-ketotestosterone (11KT) is a potent agonist of the androgen receptor with androgenic activity equivalent to testosterone. We hypothesized that patients with high 17OHP would be more likely than those with high A4 to be in good disease control. We speculated that A4 would correlate more strongly with 11-oxygenated C19 steroids (11oxyandrogens) than 17OHP and that patients in poor clinical control would have higher median fold-elevation of 11oxyandrogens, especially 11-KT, compared to controls. Methods We performed retrospective analysis of patients seen at NIH from 2006 to 2019 and identified discordant 17OHP and A4 (17-OHP ≥1200 ng/dL with A4 normal for age/sex or tanner stage and vice-versa). Good or poor clinical control was based on abnormal growth, precocious puberty, irregular menses, hypogonadotrophic hypogonadism and A4/T. Quantitation of 15 steroids in stored peripheral sera was performed by LC-MS/ MS and compared to age- and sex-matched controls. Data between groups were compared using t-tests or non-parametric Wilcoxon rank sum tests. Correlation analyses utilized the Pearson and Spearman’s rho. Results We identified 122 of 789 (15%) discordant laboratory assessments among adults [84 with high 17OHP (69%)] and 347 of 1,949 (18%) among children [319 with high 17OHP (92%)]. Of these, 50 patients with available serum samples were identified (44 with high 17OHP). Twenty-five patients (50%) appeared to have good disease control. There was no difference in the frequency of patients in good or poor control between patients with high 17OHP or those with high A4 (p=0.7). Median fold elevation of 11KT relative to controls was higher in patients in poor control (2.87 fold, IQR 1.87-5.42, range 0.31-10.69) but with wide ranges and substantial overlap compared to those in good control (1.71 fold, IQR 1.06-2.92, range 0.35-16.59, p=0.068). 17OHP correlated with 21-deoxycortisol (rs=0.67, p<.001) while A4 correlated strongly with 11oxyandrogens (rs range 0.42-0.71, p<.003 for all). However, we did not find any substantial difference in the level of 11oxyandrogens between patients with high 17OHP and those with high A4. Conclusion: Discordance between 17OHP and A4 is common in the management of CAH and patients with elevation of either of these biomarkers are equally likely to have poor disease control. Limited evidence suggests a role for 11KT, as a discriminator for disease control.
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Affiliation(s)
- Smita Jha
- National Institutes of Health, Bethesda, MD, USA
| | | | - Ninet Sinaii
- National Institutes of Health, Bethesda, MD, USA
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Merke DP, Mallappa A, Arlt W, de la Perriere AB, Hirschberg AL, Juul A, Newell-Price JDC, Perry CG, Prete A, Rees A, Reisch N, Stikkelbroeck M, Touraine PA, Maltby K, Treasure P, Porter J, Ross RJM. OR25-02 A Phase 3 Study of a Modified-Release Hydrocortisone in the Treatment of Congenital Adrenal Hyperplasia. J Endocr Soc 2020. [PMCID: PMC7209435 DOI: 10.1210/jendso/bvaa046.214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Patients with congenital adrenal hyperplasia (CAH) due to classic 21-hydroxylase deficiency have poor health outcomes related to inadequate glucocorticoid (GC) replacement. We compared disease control of adults with classic CAH treated with a modified release hydrocortisone (MRHC), which replicates physiological diurnal cortisol secretion, versus standard GC therapy. Methods: 6 month, open label, study in 122 patients randomised either to treatment with MRHC (Chronocort®, Diurnal Ltd, Cardiff, UK) twice daily at ~ 0700h & ~2300h, or to remain on their standard GC regimen (hydrocortisone, prednisolone, prednisone, dexamethasone). Patients had 24-hr profiling of serum 17-hydroxyprogesterone (17-OHP) at baseline and for dose titration at 4 and 12 weeks. The primary efficacy endpoint was the change from baseline to 24 weeks in the natural logarithm of the mean of the 24-hr standard deviation score (SDS) profile for 17-OHP. Results: Both groups achieved improved hormonal control at 24 weeks. The mean 24-hour 17-OHP SDS was significantly lower on MRHC compared to standard GC at 4 weeks (p = 0.0074) and 12 weeks (p = 0.019), but not at 24 weeks. In post-hoc analyses at 24 weeks, MRHC treatment showed a greater reduction in 17-OHP SDS compared to standard GC in the morning, 0700-1500h (p = 0.0442) and a greater reduction in log transformed 17-OHP 24 hour AUC (p=0.0251). Defining a morning 17-OHP <1200ng/dl (<36 nmol/L) as good control, for patients not controlled at baseline 85% were well controlled at 24 weeks with MHRC versus 50% on standard GC. For patients controlled at baseline 100% were controlled at 24 weeks on MHRC versus 84% with standard GC (p = 0.0018). The variability of 17-OHP over 24 hours was significantly reduced in the MRHC group compared to standard GC: the ratio of amplitude at 24 weeks divided by amplitude at baseline was for MRHC, 0.361 [95% CI: 0.235, 0.651], and standard GC, 0.917 [0.773, 1.366]; (p = 0.0001).There were no adrenal crises on MRHC and fewer stress doses despite similar incidence of inter-current illness to the standard GC group which had 3 adrenal crises. MRHC was associated with patient reported benefit including restoration of menstruation in 4 patients on MRHC and 1 on standard GC and two partner pregnancies in patients on MRHC and none on standard GC. Discussion: This is the largest randomised controlled trial of GC treatment in CAH and showed that intensification of therapy could improve control of the androgen-precursor, 17-OHP, and that this hormonal control was superior in the morning with MRHC. MRHC reduced the fluctuations in 17-OHP such that in the majority of patients the 17-OHP profile was within the reference range throughout 24 hours, providing consistent and optimal disease control. Conclusion: Diurnal cortisol replacement with a MRHC improves the biochemical control of classic CAH with a twice-daily therapeutic regimen.
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Affiliation(s)
| | | | - Wiebke Arlt
- Univ of Birmingham, Birmingham, United Kingdom
| | | | | | | | | | | | | | - Aled Rees
- Cardiff University, Cardiff, United Kingdom
| | - Nicole Reisch
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
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Jha S, Turcu A, Brookner B, Abel BS, Startzell M, Auchus RJ, Brown RJ, Merke DP. SUN-LB4 Androgenic Profiles of Patients With Severe Insulin Resistance. J Endocr Soc 2020. [PMCID: PMC7209492 DOI: 10.1210/jendso/bvaa046.2298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Patients with severe insulin resistance have ovarian hyperthecosis, high testosterone (T) and minimal adipose tissue. Recent studies have found elevated levels of 11-oxygenated (11-oxy) androgens in women with polycystic ovary syndrome (PCOS) compared to age and sex-matched controls. 11-oxy-androgens are produced by CYP11B1, an enzyme expressed predominantly in the adrenal, with minor ovarian expression. We analyzed 11-oxy-androgens in women with severe insulin resistance. Methods We performed retrospective analysis of women with severe insulin resistance (lipodystrophy or insulin receptor defects) seen at the NIH and identified 19 patients with testosterone ≥ 80 ng/dl (immunoassay) and available serum samples. Quantitation of androgens was performed by LC-MS/ MS and compared to age, sex and BMI-matched controls. Data between groups was compared using non-parametric Mann-Whitney U test. Correlation analyses utilized the Pearson and Spearman’s rho. Results Median patient age was 18yrs (IQR 17-26) with median fasting insulin of 63mcU/ mL (IQR 40-184). Serum insulin correlated strongly with fold elevation of T in patients relative to controls (r= 0.47, P=0.04). Median levels of all androgens except 11-hydroxytestosterone (11OHT) were significantly higher in patients than controls, including 11-ketotestosterone (11KT), a clinically relevant androgen in both congenital adrenal hyperplasia and PCOS [69 ng/dl (IQR 27-82) vs 24 ng/dl (IQR 16-40), P < 0.001]. 11KT/ T was lower in patients (0.30, IQR 0.12-1.15) compared to controls (1.1, IQR 0.41-1.5, P = 0.04). All 11-oxy-androgens correlated with each other (rs range: 0.6-0.8, P < .05) in both groups. There was no difference in the proportionate contribution of 11-oxy-androgens to the total circulating androgenic pool in patients vs. controls. Conclusion: Elevated 11-oxy-androgens in patients with severe insulin resistance suggests that both adrenal and ovarian androgens are upregulated by hyperinsulinemia. Lower 11KT/T in patients compared to controls despite higher 11-oxy-androgens than in controls is consistent with predominant ovarian T excess in patients with severe IR. Correlation between insulin and fold elevation of T relative to controls supports hyperinsulinemia as the cause of high T in states of hyperinsulinism. Acknowledgement: This research was supported by the Intramural Program of NIH Clinical Center and NIDDK.
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Affiliation(s)
- Smita Jha
- National Institutes of Health, Derwood, MD, USA
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Kolli V, Werneck I, Kim S, Mallappa A, Gaynor A, Quezado M, Merke DP. MON-171 Characterization of the Adrenal Gland and Adrenal Rest Tissues in Congenital Adrenal Hyperplasia. J Endocr Soc 2020. [PMCID: PMC7208114 DOI: 10.1210/jendso/bvaa046.1100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Adrenonodular hyperplasia and tumor formation are common long-term complications of congenital adrenal hyperplasia (CAH) driven by chronic ACTH elevation. Clinical studies indicate that the majority of males with classic CAH have testicular adrenal rest tumors (TART). Ovarian adrenal rest tumors (OART) are less commonly observed. Little is known about the pathophysiology of adrenal rest, however both adrenal cortex and Leydig cell markers have been described in TART, suggesting a pluripotent embryological cell origin. Objective: To characterize adrenals and adrenal rest tissues of patients with CAH in comparison with normal tissues. Materials and Methods: Using immunohistochemistry (IHC) and, real-time qRT-PCR we investigated CAH-affected adrenals (n=5), adrenal rest tissues (n=2; 1 testicular, 1 ovarian), controls [normal adrenal (n=2), testis (n=1), and ovary (n=1)]. Tissue sections prepared from paraffin embedded tissue blocks were immunostained with adrenal [melanocortin 2 receptor (MC2R), delta-like homolog 1 (DLK-1), steroidogenic factor 1 (SF-1), steroidogenic acute regulatory protein (StAR) and other cytochrome P450 genes], inflammatory [interleukin 2 receptor (IL-2R), B-lymphocyte antigen (CD20), cluster of differentiation 3 (CD3), tumor necrosis factor alpha (TNFα), interleukin 6 (IL6)], and gonadal markers [progesterone receptor (PR), androgen receptor (AR), insulin-like 3 (INSL3)]. RNA was isolated and gene expression studies were performed. High-throughput RNA sequencing technology was used to analyze the differential transcriptome profiles between the CAH adrenals, adrenal rest and normal tissues. Results: In contrast to the controls, CAH adrenals and adrenal rest tissues showed the following: (i) IHC studies revealed 95% of tissue positive for adrenal zona-reticularis; (ii) significant nodular lymphocytic infiltration with a predominance of B and T lymphocytes and overexpression of lymphocyte markers IL-2R, CD20, CD3, and inflammatory cytokines TNFα and IL6; (iii) increased expression of adrenocortical specific genes MC2R, DLK1. Conclusion: CAH-affected adrenals and adrenal rest tissue have similar predominance of zona reticularis and demonstrate lymphocytic infiltration. Active inflammation may play a role in the abnormal development of adrenal and adrenal rest tissue in CAH patients.
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Affiliation(s)
- Vipula Kolli
- National Institutes of Health, Bethesda, MD, USA
| | | | - SunA Kim
- National Institutes of Health, Bethesda, MD, USA
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Mallappa A, Sinaii N, El-Maouche D, Veeraraghavan P, Joyal E, Hargreaves CJ, Merke DP. MON-158 Rates of Illnesses in Patients with Congenital Adrenal Hyperplasia. J Endocr Soc 2020. [PMCID: PMC7207682 DOI: 10.1210/jendso/bvaa046.1156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is the most common cause of primary adrenal insufficiency during childhood and patients are at risk for life-threatening adrenal crisis. In a recent study from our group, we reported gastrointestinal and upper respiratory tract infections as the two most common precipitating events for adrenal crises and hospitalizations across all ages. We also reported 11 incidents of life-threatening hypoglycemic events in children, sometimes accompanied by seizures. Objective: To evaluate the annual rates of illnesses in patients with CAH. Methods: We retrospectively reviewed longitudinally collected data over 23 years from 156 CAH patients enrolled in our CAH natural history study (www.clinicaltrials.gov #NCT00250159). Incidence of illnesses and occurrence of stress-dose days were computed per person-years. Incidence rate ratio (IRR) with 95% confidence intervals (CI) were calculated for comparisons. Results: A total of 2298 visits (1909 for children and 389 for adults) were available for evaluation among the 156 patients (21-OHD: 97.4%). A total of 1870 illness events (1664 in children) were observed in 143 patients (121 children) and 2710 stress-dose days (2460 in children) were observed in 141 patients (120 children) during the study period. The incidence rate of illnesses was higher in children than adults (1.5 vs. 0.5 illnesses/person-years, IRR = 3.1, 95% CI 2.7 - 3.6; P<.0001) with incidence highest in young patients: 2.5 illnesses/person-years in <3 year olds. Similarly, the stress-dose days were higher in children than adults (2.2 vs. 0.6 days/person-years, IRR = 3.8, 95% CI 3.3 - 4.3; P<.0001). Conclusions: Patients with CAH do not appear to have higher rates of infectious illnesses than expected, but remain at risk for life-threatening adrenal crises. As expected, illness rates are higher during childhood than adulthood. Prevention of adrenal crisis is crucial and is best accomplished through repeated age-specific education of patients and caregivers. Acknowledgement: This research was supported by the Intramural Research Program at the National Institutes of Health (NIH), Bethesda, Maryland.
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Affiliation(s)
| | | | - Diala El-Maouche
- National Institutes of Health Clinical Center, Rockville, MD, USA
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Kolli V, Kim H, Rao H, Lao Q, Gaynor A, Milner JD, Merke DP. Measurement of serum tenascin-X in patients with congenital adrenal hyperplasia at risk for Ehlers-Danlos contiguous gene deletion syndrome CAH-X. BMC Res Notes 2019; 12:711. [PMID: 31666125 PMCID: PMC6820911 DOI: 10.1186/s13104-019-4753-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/18/2019] [Indexed: 11/10/2022] Open
Abstract
Objective Approximately 10% of patients with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency carry a mutation that disrupts CYP21A2 and the flanking TNXB gene resulting in CAH-X, a contiguous gene deletion syndrome. TNXB encodes tenascin-X (TNX), an extracellular matrix glycoprotein that plays an important role in collagen organization. TNXB impairment is associated with Ehlers–Danlos syndrome. Symptoms include joint hypermobility, hernias and cardiac defects. We measured serum TNX using an antibody targeting the amino-terminal of the TNX protein in 161 subjects, including extensively genotyped and phenotyped CAH patients, their relatives, and healthy controls. Results We evaluated the potential of serum TNX as a screening tool for CAH-X. CAH-X patients, especially haploinsufficient patients carrying the TNXA-TNXB chimeric gene CAH-X-CH-1 showed reduced TNX levels compared to controls (P < 0.05). TNX levels were similar in all subjects carrying a TNXB mutation. However, CAH patients who did not harbor a TNXB mutation also had reduced TNX compared to controls (P < 0.001). Thus, measuring serum TNX is not an effective screen for CAH-X amongst patients with CAH. TNXB genotyping is recommended for CAH patients who have symptoms of a connective tissue disorder. Epigenetic factors that influence TNX expression require further study.
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Affiliation(s)
- Vipula Kolli
- National Institutes of Health Clinical Center, 10 Center Drive, Building 10, Room 1-2740, Bethesda, MD, 20892-1932, USA
| | - Hannah Kim
- National Institutes of Health Clinical Center, 10 Center Drive, Building 10, Room 1-2740, Bethesda, MD, 20892-1932, USA
| | - Hamsini Rao
- National Institutes of Health Clinical Center, 10 Center Drive, Building 10, Room 1-2740, Bethesda, MD, 20892-1932, USA
| | - Qizong Lao
- National Institutes of Health Clinical Center, 10 Center Drive, Building 10, Room 1-2740, Bethesda, MD, 20892-1932, USA
| | - Alison Gaynor
- National Institutes of Health Clinical Center, 10 Center Drive, Building 10, Room 1-2740, Bethesda, MD, 20892-1932, USA
| | - Joshua D Milner
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, 20892, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center, 10 Center Drive, Building 10, Room 1-2740, Bethesda, MD, 20892-1932, USA. .,The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, USA.
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Jha S, El-Maouche D, Marko J, Mallappa A, Veeraraghavan P, Merke DP. Individualizing Management of Infertility in Classic Congenital Adrenal Hyperplasia and Testicular Adrenal Rest Tumors. J Endocr Soc 2019; 3:2290-2294. [PMID: 31745525 PMCID: PMC6853670 DOI: 10.1210/js.2019-00227] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 10/11/2019] [Indexed: 12/31/2022] Open
Abstract
Testicular adrenal rest tumors (TARTs) are a common cause of male infertility in patients with classic congenital adrenal hyperplasia (CAH). These tumors are located in the rete testis and can lead to impaired blood flow and functional impairment of seminiferous tubules. We describe restoration of fertility in a man with CAH and bilateral TARTs with use of lower-dose glucocorticoid therapy than previously described. A 28-year-old man with classic salt-wasting CAH presented with impaired fertility. Biochemical evaluation showed poor CAH control despite reported compliance with prednisone 5 mg every morning and fludrocortisone 50 μg twice daily. Semen analysis showed azoospermia. Testicular ultrasonography showed TARTs occupying 16% of total testicular volume. After 5 months of dexamethasone 250 μg at bedtime, total TART volume decreased 90%, biochemical control improved, and semen analysis showed a sperm count of 132 × 106 million per milliliter. The patient’s wife was confirmed to be pregnant 9 months after the initial visit and delivered a healthy full-term baby girl. The patient’s glucocorticoid therapy was changed to prednisone 3 mg twice daily, and 2 years later he continues to show adequate CAH control, stable TART volume, and normal semen analysis, and his wife is pregnant again. Management of CAH in men with TARTs needs to be individualized, and high-dose dexamethasone may not be indicated. The use of a long-acting glucocorticoid at typical recommended dosages can decrease TART size and reverse male infertility. Prednisone given once daily does not adequately control the ACTH-driven complications of CAH.
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Affiliation(s)
- Smita Jha
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland.,Clinical and Investigative Orthopedics Surgery Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Diala El-Maouche
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Jamie Marko
- Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Maryland
| | - Ashwini Mallappa
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Padmasree Veeraraghavan
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Deborah P Merke
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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El-Maouche D, Hannah-Shmouni F, Mallappa A, Hargreaves CJ, Avila NA, Merke DP. Adrenal morphology and associated comorbidities in congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2019; 91:247-255. [PMID: 31001843 PMCID: PMC6635023 DOI: 10.1111/cen.13996] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 03/12/2019] [Accepted: 04/15/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Adrenonodular hyperplasia and tumour formation are potential long-term complications of congenital adrenal hyperplasia (CAH) with little known regarding the clinical implications. Our aim was to describe volumetric adrenal morphology and determine the association between radiological findings and comorbidities in adults with classic CAH. DESIGN This was a cross-sectional study of 88 patients (mean age 29.2 ± 13 years, 47 females) with classic CAH seen in a tertiary referral centre. METHODS CT imaging, performed at study entry or when reaching adulthood, was used to create 3-dimensional volumetric models. Clinical, genetic and hormonal evaluations were collected and correlated with adrenal morphology and tumour formation. RESULTS Over one-third of the cohort was obese. 53% had elevated 17-OH-progesterone or androstenedione; and 60% had adrenal hyperplasia. Tumours included 11 myelolipomas, 8 benign adrenocortical adenomas, 1 pheochromocytoma and 50% of men had testicular adrenal rest tissue. CAH patients with adrenal hyperplasia had significantly higher number of comorbidities than those with morphologically normal adrenals (P = 0.03). Variables that positively correlated with adrenal volume included hypogonadal/oligomenorrhoeic status, hypertension, androstenedione, aldosterone, and triglyceride levels, and in women, low HDL and insulin resistance. Elevated aldosterone was observed in a subset of patients with simple virilizing CAH. CONCLUSIONS Adrenocortical hyperplasia is associated with a number of comorbidities, especially hypogonadism. Aldosterone production associated with adrenal enlargement may play a role in the development of metabolic risk factors. Further studies are needed to assess the long-term impact of the excess adrenal steroid milieu associated with adrenal enlargement to develop improved management strategies for CAH.
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Affiliation(s)
- Diala El-Maouche
- The National Institutes of Health Clinical Center, Bethesda, Maryland, 20892
| | - Fady Hannah-Shmouni
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20892
| | - Ashwini Mallappa
- The National Institutes of Health Clinical Center, Bethesda, Maryland, 20892
| | | | - Nilo A. Avila
- National Heart, Lung and Blood Institute, Bethesda, Maryland, 20892
| | - Deborah P. Merke
- The National Institutes of Health Clinical Center, Bethesda, Maryland, 20892
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20892
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Lao Q, Brookner B, Merke DP. High-Throughput Screening for CYP21A1P-TNXA/TNXB Chimeric Genes Responsible for Ehlers-Danlos Syndrome in Patients with Congenital Adrenal Hyperplasia. J Mol Diagn 2019; 21:924-931. [PMID: 31229653 DOI: 10.1016/j.jmoldx.2019.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/29/2019] [Accepted: 06/06/2019] [Indexed: 11/29/2022] Open
Abstract
Many patients with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency have CAH-X syndrome, a connective tissue dysplasia consistent with hypermobility-type Ehlers-Danlos syndrome due to a contiguous gene deletion involving the adjacent CYP21A2 and TNXB genes. CAH-X syndrome is caused by carrying CYP21A1P-TNXA/TNXB chimeric genes [CAH-X chimera 1 (CH-1) and chimera 2 (CH-2)] on one or more alleles. Genetic analysis is cumbersome due to pseudogene interference. We developed a PCR-based CAH-X high-throughput screening method to assess the copy numbers of TNXB exons 35 and 40; this method is amenable to either real-time quantitative PCR or droplet digital PCR (ddPCR). The assay was validated in a cohort of 278 subjects from 146 unrelated CAH families. Results were confirmed by a validated Sanger sequencing platform. A total of 44 CAH-X-positive calls were made, with 42 (26 CH-1 and 16 CH-2) confirmed. The assay had 100% sensitivity (42 true/42 positives), 99.2% specificity (234 true/236 negatives), and an overall 99.3% accuracy (276/278). Calls made by real-time quantitative PCR and ddPCR were consistent (100%), and ddPCR offered easier data interpretation. The CAH-X prevalence was 15.6% (21/135 probands), higher than the previously estimated 8.5%, and was particularly high (29.2% or 21/72) in those with a 30-Kb deletion. This assay is suitable for high-throughput CAH-X screening, especially in subjects testing positive for CAH in neonatal screening.
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Affiliation(s)
- Qizong Lao
- NIH Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Brittany Brookner
- NIH Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Deborah P Merke
- NIH Clinical Center, National Institutes of Health, Bethesda, Maryland; Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
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Speiser PW, Auchus RJ, Merke DP, Miller WL, White PC. Response to Letter to the Editor: "Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab 2019; 104:1928. [PMID: 30561699 PMCID: PMC6615294 DOI: 10.1210/jc.2018-02629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/12/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, Lake Success, New York
- Zucker Hofstra University School of Medicine, New Hyde Park, New York
- Correspondence and Reprint Requests: Phyllis W. Speiser, MD, Division of Pediatric Endocrinology, Cohen Children’s Medical Center of New York, 1991 Marcus Avenue, Suite M100, Lake Success, New York 11042. E-mail:
| | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Walter L Miller
- University of California, San Francisco, Benioff Children Hospital, San Francisco, California
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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Kolli V, Lao Q, Merke DP. Response to Letter to the Editor: "Characterization of the CYP11A1 Nonsynonymous Variant p.E314K in Children Presenting With Adrenal Insufficiency". J Clin Endocrinol Metab 2019; 104:1415-1416. [PMID: 30500909 PMCID: PMC6607963 DOI: 10.1210/jc.2018-02512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/27/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Vipula Kolli
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Qizong Lao
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Jayakrishnan R, Lao Q, Adams SD, Ward WW, Merke DP. Revisiting the association of HLA alleles and haplotypes with CYP21A2 mutations in a large cohort of patients with congenital adrenal hyperplasia. Gene 2019; 687:30-34. [PMID: 30419250 DOI: 10.1016/j.gene.2018.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/03/2018] [Accepted: 11/08/2018] [Indexed: 11/20/2022]
Abstract
The CYP21A2 gene encoding 21‑hydroxylase is on chromosome 6p21.3 within the human leukocyte antigen (HLA) class III major histocompatibility complex and an association between congenital adrenal hyperplasia (CAH) due to 21‑hydroxylase deficiency and HLA class I and II alleles has been shown in genetically isolated populations. One-third of CAH causing alleles are 30-kb deletions due to homologous recombination events between active and pseudogenes resulting in chimeric genes. The aim of this study was to re-visit the association between the CYP21A2 variants and HLA polymorphisms in a large ethnically diverse cohort of patients with CAH who underwent comprehensive CYP21A2 genotyping, including specification of chimeric gene subtypes (CAH CH-1 through CH-9 of CYP21A1P/CYP21A2 chimeras; CAH-X CH-1 through CH-3 of TNXA/TNXB chimeras) in alleles with 30-kb deletions. The study population included 201 patients (86 males, 115 females, age 3-75 years) with CAH due to 21‑hydroxylase deficiency (159 classic, 42 nonclassic) and 194 parents. Based on the availability of parental genotype, we determined the haplotypes of CYP21A2 mutations and HLA types in 95 probands (190 alleles). Five prevalent haplotype associations were found: p.V281L and B*14-C*08 (P < 0.0001); p.I172N and DQB1*03 (P = 0.035); and of the chimeric genes caused by 30-kb deletions: CH-1 and A*03 (P = 0.033); CH-5 and C*06-DRB1*07 (P < 0.0001); and CAH-X CH-1 and DQB1*03 (P = 0.004). Our findings show that a number of associations between HLA alleles and haplotypes and CYP21A2 mutations, including large 30-kb deletions, exist commonly across ethnicities. These HLA associations may have clinical implications for patients with CAH and may provide insight into the genetics of this highly complex region of the human genome.
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Affiliation(s)
| | - Qizong Lao
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - Sharon D Adams
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - William W Ward
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA; Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
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Kolli V, Kim H, Torky A, Lao Q, Tatsi C, Mallappa A, Merke DP. Characterization of the CYP11A1 Nonsynonymous Variant p.E314K in Children Presenting With Adrenal Insufficiency. J Clin Endocrinol Metab 2019; 104:269-276. [PMID: 30299480 PMCID: PMC6607962 DOI: 10.1210/jc.2018-01661] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 10/03/2018] [Indexed: 12/15/2022]
Abstract
CONTEXT Cholesterol side-chain cleavage enzyme (P450scc), encoded by CYP11A1, catalyzes the first step of steroidogenesis. Complete P450scc deficiency leads to primary adrenal insufficiency (PAI) and 46,XY disordered sexual development. Partial impairment can cause variable adrenal and gonadal dysfunction. OBJECTIVE Our aim was to evaluate the effects of the CYP11A1 variant p.E314K, identified in patients with PAI, specifically on P450scc enzyme stability and function. PATIENTS AND METHODS We studied four boys from two unrelated families presenting with PAI during childhood (3.6 to 9 years old). All patients were compound heterozygous for c.940G>A (p.E314K), a CYP11A1 nonsynonymous variant likely to be pathogenic by some but not all in silico prediction models, and c.835delA (p.I79Yfs*10), a known pathogenic variant. HEK293T cells were transfected with wild type (WT) and p.E314K mutant vectors, and a cycloheximide chase assay was performed to analyze protein stability. Pregnenolone production was assayed from cells expressing WT and p.E314K-F2 fusion proteins. RESULTS Two boys experienced spontaneous puberty but then developed evidence of primary gonadal failure at 14 and 18 years old. Two boys had testicular adrenal rest tumor (TART), detected by ultrasound at ages 8.6 and 16 years. Compared with WT, mutant protein synthesis was reduced (P = 0.0006) with increased protein turnover, and mutant P450scc half-life was decreased by ~50%. p.E314K mutant P450scc retained 60% of WT enzymatic activity (P = 0.007). CONCLUSIONS The CYP11A1 p.E314K variant impairs P450scc stability and is a possible cause of PAI in childhood. Pathogenic CYP11A1 variants potentially affect both adrenal and gonadal function, and male patients may develop TART.
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Affiliation(s)
- Vipula Kolli
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Hannah Kim
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Ahmed Torky
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Qizong Lao
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Christina Tatsi
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Correspondence and Reprint Requests: Deborah P. Merke, MD, National Institutes of Health Clinical Center, Building 10, Room 1-2740, 10 Center Drive, Bethesda, Maryland 20892-1932. E-mail:
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Lao Q, Jardin MD, Jayakrishnan R, Ernst M, Merke DP. Complement component 4 variations may influence psychopathology risk in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Hum Genet 2018; 137:955-960. [PMID: 30465166 DOI: 10.1007/s00439-018-1959-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/13/2018] [Indexed: 11/24/2022]
Abstract
CYP21A2 defects result in congenital adrenal hyperplasia (CAH), an autosomal recessive disorder characterized by impaired adrenal steroidogenesis. CYP21A2 lies within the major histocompatibility complex in an area of the genome highly susceptible to genetic variation. Alterations in the neighboring complement component 4 isotypes C4A and C4B have been associated with psychiatric and autoimmune disease. The purpose of this study was to evaluate C4A and C4B in patients with CAH in relation to CYP21A2 genotype and psychiatric and autoimmune comorbidity. We determined the copy numbers of C4A and C4B in 145 patients with CAH (median age: 15.5 years, IQR: 16.8) and 108 carrier relatives (median age: 41.5 years, IQR: 12.0) and evaluated serum C4 concentrations. Comorbidity was determined by medical record review. Only 30% of subjects had the expected two copies each of the two C4 genes. C4B copy number determined total C4 copy number and serum C4 concentration, negatively correlated with carriership of a 30-kb deletion (P < 10- 5), and positively correlated with carriership of p.V281L (P < 10- 5). High C4A copy number (≥ 3) was associated with increased risk of having an externalizing psychiatric condition (relative risk: 2.67, 95% CI: 1.03-6.89, P = 0.04). No association was found between C4 copy number and autoimmune disease. Mutation-specific C4 structural variations commonly occur in patients with CAH and may have important clinical consequences, including increased risk of psychiatric morbidity. Trial registration NCT00250159 (November 7, 2005).
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Affiliation(s)
- Qizong Lao
- National Institutes of Health Clinical Center, 10 Center Drive, Room 1-2740, Bethesda, MD, 20892-1932, USA
| | - Marcia Des Jardin
- National Institutes of Health Clinical Center, 10 Center Drive, Room 1-2740, Bethesda, MD, 20892-1932, USA
| | - Rahul Jayakrishnan
- National Institutes of Health Clinical Center, 10 Center Drive, Room 1-2740, Bethesda, MD, 20892-1932, USA
| | - Monique Ernst
- National Institute of Mental Health, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center, 10 Center Drive, Room 1-2740, Bethesda, MD, 20892-1932, USA. .,Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA.
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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 505] [Impact Index Per Article: 84.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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Mallappa A, Nella AA, Sinaii N, Rao H, Gounden V, Perritt AF, Kumar P, Ling A, Liu CY, Soldin SJ, Merke DP. Long-term use of continuous subcutaneous hydrocortisone infusion therapy in patients with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2018; 89:399-407. [PMID: 30003563 PMCID: PMC6166869 DOI: 10.1111/cen.13813] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/18/2018] [Accepted: 07/08/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND In a phase 2 short-term (6 months) study of patients with congenital adrenal hyperplasia (CAH), continuous subcutaneous hydrocortisone infusion (CSHI) was found to be a safe, effective and well-tolerated method of replacing cortisol with improved disease and patient-related outcomes. OBJECTIVE To evaluate the safety and efficacy of long-term CSHI. DESIGN Single-centre, open-label, phase 2 extension study. PATIENTS Five adults with classic CAH. MEASUREMENTS Biomarkers of disease control, metabolic indices and health-related quality-of-life (HRQoL) estimates. RESULTS Six of eight patients chose to continue on long-term CSHI therapy. Compared to baseline, eighteen months of CSHI resulted in decreased (P = 0.043) 0700-hour ACTH, 17-hydroxyprogesterone, androstenedione and progesterone; increased whole-body lean mass (P = 0.024); and improved HRQoL, especially symptoms of adrenal insufficiency (P = 0.003). Findings at six and eighteen months did not differ, and improvements achieved in androgen control, lean body mass and HRQoL after 6 months of CSHI were maintained at eighteen months. The hydrocortisone dose appeared to decrease with time [6 vs 18 months: 38.3 ± 8.8 vs 33.6 ± 12.2 mg/day (P = 0.062)], especially in women receiving oral contraceptives. Reduction of testicular adrenal rest and adrenal size observed at 6 months remained stable. In one patient, an adrenal adenoma continually decreased over time. Subjective improvement in hirsutism was reported. CONCLUSIONS Long-term use of CSHI is a safe and well-tolerated treatment option in a select set of adults with classic CAH. Improvements observed short term in disease control and subjective health status continued long term.
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Affiliation(s)
- Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Aikaterini A. Nella
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA 20892
| | - Ninet Sinaii
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Hamsini Rao
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Verena Gounden
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Ashley F. Perritt
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Parag Kumar
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Alexander Ling
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Chia-Ying. Liu
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Steven J. Soldin
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
| | - Deborah P. Merke
- National Institutes of Health Clinical Center, Bethesda MD, USA 20892
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA 20892
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El-Maouche D, Hargreaves CJ, Sinaii N, Mallappa A, Veeraraghavan P, Merke DP. Longitudinal Assessment of Illnesses, Stress Dosing, and Illness Sequelae in Patients With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2018; 103:2336-2345. [PMID: 29584889 PMCID: PMC6276663 DOI: 10.1210/jc.2018-00208] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/19/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with congenital adrenal hyperplasia (CAH) are at risk for life-threatening adrenal crises. Management of illness episodes aims to prevent adrenal crises. OBJECTIVE We evaluated rates of illnesses and associated factors in patients with CAH followed prospectively and receiving repeated glucocorticoid stress dosing education. METHODS Longitudinal analysis of 156 patients with CAH followed at the National Institutes of Health Clinical Center over 23 years was performed. The rates of illnesses and stress-dose days, emergency room (ER) visits, hospitalizations, and adrenal crises were analyzed in relation to phenotype, age, sex, treatment, and hormonal evaluations. RESULTS A total of 2298 visits were evaluated. Patients were followed for 9.3 ± 6.0 years. During childhood, there were more illness episodes and stress dosing than adulthood (P < 0.001); however, more ER visits and hospitalizations occurred during adulthood (P ≤ 0.03). The most robust predictors of stress dosing were young age, low hydrocortisone and high fludrocortisone dose during childhood, and female sex during adulthood. Gastrointestinal and upper respiratory tract infections (URIs) were the two most common precipitating events for adrenal crises and hospitalizations across all ages. Adrenal crisis with probable hypoglycemia occurred in 11 pediatric patients (ages 1.1 to 11.3 years). Undetectable epinephrine was associated with ER visits during childhood (P = 0.03) and illness episodes during adulthood (P = 0.03). CONCLUSIONS Repeated stress-related glucocorticoid dosing teaching is essential, but revised age-appropriate guidelines for the management of infectious illnesses are needed for patients with adrenal insufficiency that aim to reduce adrenal crises and prevent hypoglycemia, particularly in children.
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Affiliation(s)
- Diala El-Maouche
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | | | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health,
Bethesda, Maryland
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human
Development, National Institutes of Health, Bethesda, Maryland
- Correspondence and Reprint Requests: Deborah P. Merke, MD, National Institutes of Health Clinical Center, 10 Center
Drive, Room 1-2740, Bethesda, Maryland 20892. E-mail:
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Abstract
Mutations of the CYP21A2 gene encoding adrenal 21-hydroxylase cause congenital adrenal hyperplasia (CAH). The CYP21A2 gene is partially overlapped by the TNXB gene, which encodes an extracellular matrix protein called Tenascin-X (TNX). Mutations affecting both alleles of TNXB cause a severe, autosomal recessive form of Ehlers-Danlos syndrome (EDS). Rarely, patients with severe, salt-wasting CAH have deletions of CYP21A2 that extend into TNXB, resulting in a "contiguous gene syndrome" consisting of CAH and EDS. Heterozygosity for TNXB mutations causing haploinsufficiency of TNX may be associated with the mild "hypermobility form" of EDS, which principally affects small and large joints. Studies of patients with salt-wasting CAH found that up to 10% had clinical features of EDS, associated joint hypermobility, haploinsufficiency of TNX and heterozygosity for TNXB mutations, now called "CAH-X." These patients have joint hypermobility and a spectrum of other comorbidities associated with their connective tissue disorder, including chronic arthralgia, joint subluxations, hernias, and cardiac defects. Other disorders are beginning to be associated with TNX deficiency, including familial vesicoureteral reflux and neurologic disorders. Further work is needed to delineate the full spectrum of TNX-deficient disorders, with and without associated CAH.
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Affiliation(s)
- Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute of Human Genetics, University of California, San Francisco, California, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
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