Treatment patterns and unmet needs in adults with classic congenital adrenal hyperplasia: A modified Delphi consensus study

BACKGROUND

Classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is a rare autosomal recessive condition characterized by cortisol deficiency and excess androgen production. The current standard of care is glucocorticoid (GC) therapy, and sometimes mineralocorticoids, to replace endogenous cortisol deficiency; however, supraphysiologic GC doses are usually needed to reduce excess androgen production. Monitoring/titrating GC treatment remains a major challenge, and there is no agreement on assessment of treatment adequacy. This study surveyed expert opinions on current treatment practices and unmet needs in adults with classic CAH.

METHODS

A modified two-round Delphi process with adult endocrinologists was conducted via online questionnaire. Survey questions were organized into three categories: practice characteristics/CAH experience, GC management, and unmet needs/complications. Anonymized aggregate data from Round 1 were provided as feedback for Round 2. Responses from both rounds were analyzed using descriptive statistics. Consensus was defined a priori as: full consensus (100%, n=9/9); near consensus (78% to <100%, n=7/9 or 8/9); no consensus (<78%, n<7/9).

RESULTS

The same nine panelists participated in both survey rounds; five (56%) were based in North America and four (44%) in Europe. Most panelists (78%) used hydrocortisone in the majority of patients, but two (22%) preferred prednisone/prednisolone. Panelists agreed (89%) that adequate control is best evaluated using a balance of clinical presentation and androgen/precursor laboratory values; no consensus was reached on optimal timing of collecting samples for androgen testing or laboratory values indicating good control. Despite lack of consensus on many aspects of CAH management, panelists agreed on the importance of many disease- and GC-related complications, and that there is a large unmet need for new treatments. With currently available treatments, panelists reported that 46% of classic CAH patients did not have optimized androgen levels, regardless of GC dose.

CONCLUSIONS

The limited areas of consensus obtained in this study reflect the variability in treatment practices for adults with classic CAH, even among clinicians with expertise in treating this population. However, all panelists agreed on the need for new treatments for classic CAH and the importance of many disease- and GC-related complications, which are difficult to manage with currently available treatments.

Cardiovascular Disease Risk Factors and Metabolic Morbidity in a Longitudinal Study of Congenital Adrenal Hyperplasia

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.

A Phase 2, Multicenter Study of Nevanimibe for the Treatment of Congenital Adrenal Hyperplasia

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.

Androgen excess and diagnostic steroid biomarkers for nonclassic 21-hydroxylase deficiency without cosyntropin stimulation

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.

MON-158 Rates of Illnesses in Patients with Congenital Adrenal Hyperplasia

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.

Individualizing Management of Infertility in Classic Congenital Adrenal Hyperplasia and Testicular Adrenal Rest Tumors

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.

Adrenal morphology and associated comorbidities in congenital adrenal hyperplasia

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.

MON-LB055 A Single Center Experience of Multiple Endocrine Neoplasia Type 1 (MEN1) vs Sporadic Insulinoma: What Can We Learn and Where Are We Going?

Background: Further characterization of insulinomas from MEN1 patients versus sporadic cases may help elucidate pathophysiological differences and improve future diagnostic algorithms. Methods A retrospective analysis of all patients with insulinoma were included (MEN1 between 1971-2019; sporadic between 1997-2019). Demographic, clinical, laboratory results including a supervised fast, imaging and intra-arterial calcium stimulation (CaStim) data were retrieved when available. Categorical and continuous variables were compared using Fisher’s exact test and Mann-Whitney U-test, respectively. Results One hundred and thirteen patients were identified with insulinoma (69 women, median 44 years, range 13-78 years); of these, 27 patients had MEN1 (11 women, median 37 years, range 18-64 years). Patients with MEN1-related insulinomas sustained a significantly longer duration of the fast and had larger surgically resected tumors (29.73±15.32 vs 15.4±10.8 hours, p<0.001; and 3.2±1.3 vs 1.6±0.8 cm, p<0.001, respectively). In MEN1 patients, CT and MRI failed to localize a pancreatic neuroendocrine tumor in 3/15 (20%) and 2/11 (18%) of patients. CaStim localized 5/8 (63%) insulinomas in MEN1 patients versus 66/81 (81%) insulinomas in sporadic patients. Conclusion Insulinomas in MEN1 patients are larger and more difficult to localize. The role of insulinoma-specific imaging, including ⁶⁸Ga-DOTA-exendin-4 PET/CT, may improve localization sensitivity in MEN1 over CaStim. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

SUN-371 Successful Induction of Fertility with Low-Dose Dexamethasone in a Patient with Congenital Adrenal Hyperplasia and Testicular Adrenal Rest Tumor

Background Testicular adrenal rest tumors (TARTs) have been described in men with classic congenital adrenal hyperplasia (CAH) at a prevalence up to 90% and are a common cause of infertility in men with CAH. These tumors are located in the rete testis and because of their central location, can lead to mechanical obstruction, impaired blood flow and functional impairment of seminiferous tubules. TARTs have characteristics of adrenocortical cells and ACTH has been implicated in tumor growth. Previous reports have described restoration of fertility in patients with classic CAH and TARTs with administration of dexamethasone at relatively high doses of 750-1000 mcg daily (1, 2). We describe restoration of fertility in a male with classic CAH and TART with the use of lower dose dexamethasone. Case description A 28-year old male with classic CAH due to 21-hydroxylase deficiency presented to us for a follow-up visit after having been lost to follow-up for over a decade with concerns of impaired fertility. He had known bilateral TARTs, first noted at age 18. He and his wife had discontinued all forms of contraception 6 months prior to seeking care and reported a minimal coital frequency of 2-3 times/ week. His biochemical evaluation showed poor CAH control despite reported compliance with Prednisone 5 mg every morning and Fludrocortisone 50 mcg twice daily{(0800h evaluation prior to medication: 17-hydroxyprogesterone (17-OHP): 13060 ng/dL (reference: 13- 120); androstenedione (A4) 1025 ng/dl (reference: 26- 125), ACTH 866 pg/ml (reference: 5-46), plasma renin activity (PRA) 7.1 ng/ ml/h (reference: 0.6-4.3), FSH 1.7 U/L (reference: 1-11), LH 1.3 U/L (reference: 1-8 U/L) and total testosterone 473 ng/ dL (reference: 240-950). A semen analysis showed azoospermia (sperm count =0). Testicular ultrasonography (U/S) showed marked progression of total TART volume to approximately 16% of his total testicular volume (5.01 cc of 32.30 cc). Patient was switched to dexamethasone (250 mcg at bedtime) to suppress the nocturnal surge of ACTH to help decrease TART size. A follow-up U/S performed 5 months later showed a significant decrease in tumor size bilaterally. His total TART volume decreased by 90% (0.48 cc from a previous volume of 5.01 cc). Repeat semen analysis showed a sperm count of 131. In conjunction, biochemical control of CAH showed improvement with 0800h evaluation prior to medication: 17-OHP 66 ng/dL, A4 16 ng/ dL, ACTH 13.5 pg/ml, PRA 11 ng/ ml/h, FSH 5.4 U/L, LH 1 U/L and T 287 ng/dL. The patient’s wife was confirmed to be pregnant nine months after the initiation of dexamethasone and delivered a healthy full-term baby girl. Conclusion This case demonstrates that use of a long-acting glucocorticoid such as dexamethasone at doses as low as 250 mcg daily can decrease TART size and reverse male infertility. Acknowledgements This research was supported by the Intramural Research Program of the NIH.

SUN-360 Multi-Steroid Panels to Replace Dynamic Testing for the Diagnosis of Nonclassic 21-Hydroxylase Deficiency

Background: The diagnosis of nonclassic 21-hydroxylase deficiency (N21OHD) is considered in children with precocious pubarche, in the differential diagnosis of polycystic ovary syndrome, and in first-degree relatives of patients with 21OHD. Currently, the diagnosis of N21OHD requires cosyntropin (ACTH)-stimulated serum 17α-hydroxyprogesterone (17OHP4) measurements; in addition, 17OHP4 also derives from the ovaries, and basal 17OHP4 is often inconclusive. Objectives: To determine if a panel of steroid biomarkers can diagnose N21OHD in a single blood draw, circumventing the need for dynamic testing. Methods: Patients undergoing evaluation for N21OHD with ACTH stimulation at two tertiary referral centers were included in this study. The diagnosis of N21OHD was based on stimulated serum 17OHP4 concentrations of >1,000 ng/dl (30 nmol/L). Baseline serum samples were used for the quantitation of 22 steroids (18 unconjugated and 4 sulfated steroids) by liquid chromatography-tandem mass spectrometry. Mann Whitney U test was used for two-group steroids comparison. Logistic regression modeling with lasso penalty, combined with clinical knowledge (relevant due to high correlation between biomarkers) were implemented for the selection of a small set of steroids that best discriminate patients with N21OHD from controls. Results: A total of 72 patients (63 females, 9 males) who underwent ACTH stimulation testing, median age 28 (range 6-70 years) were included in this study. Of these, 24 patients (4 males) were diagnosed with N21OHD; the other 48 patients (5 males) in whom N21OHD was excluded served as controls. Age and sex distribution were similar between the two groups (p = 0.9 and 0.5, respectively). Steroids displaying the largest differences between the two groups included: 11-ketotestosterone, 11-ketoandrostenedione (11KA4), 21-deoxycortisol (21dF), 17OHP4 and 16α-hydroxyprogesterone (all higher in N21OHD), plus 11-deoxycorticosterone (DOC) and corticosterone (lower in N21OHD), p <0.0001 for all. Notably, testosterone, androstenedione and all four sulfated steroids were similar between N21OHD patients and controls, including when data analysis was restricted to females. Logistic regression modeling showed that a three-steroid panel incorporating 21dF, 11KA4 and DOC was highly accurate in diagnosing N21OHD in baseline serum samples (AUC, 0.98) and superior to basal 17OHP4. Other combinations of adrenal-derived steroids also provided better discrimination than basal 17OHP4 (AUC >0.97 vs. 0.93). Conclusion: A limited number of adrenal-specific steroids measured in a single baseline blood draw can diagnose N21OHD with high accuracy. Such steroid panels might circumvent the need of dynamic testing in most patients to diagnose or exclude N21OHD.

Longitudinal Assessment of Illnesses, Stress Dosing, and Illness Sequelae in Patients With Congenital Adrenal Hyperplasia

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.

Tumor-induced osteomalacia in association with PTEN-negative Cowden syndrome

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic condition in which phosphaturic mesenchymal tumors (PMTs) secrete high levels of fibroblast growth factor 23 (FGF23) into the circulation. This results in renal phosphate wasting, hypophosphatemia, muscle weakness, bone pain, and pathological fractures. Recent studies suggest that fibronectin-fibroblast growth factor receptor 1 (FN1-FGFR1) translocations may be a driver of tumorigenesis. We present a patient with TIO who also exhibited clinical findings suggestive of Cowden syndrome (CS), a rare autosomal dominant disorder characterized by numerous benign hamartomas, as well as an increased risk for multiple malignancies, such as thyroid cancer. While CS is a clinical diagnosis, most, but not all, harbor a mutation in the tumor suppressor gene PTEN. Genetic testing revealed a somatic FN1-FGFR1 translocation in the FGF23-producing tumor causing TIO; however, a germline PTEN mutation was not identified. To our knowledge, this is the first reported case of concurrent TIO and CS.

Congenital adrenal hyperplasia

Congenital adrenal hyperplasia is a group of autosomal recessive disorders encompassing enzyme deficiencies in the adrenal steroidogenesis pathway that lead to impaired cortisol biosynthesis. Depending on the type and severity of steroid block, patients can have various alterations in glucocorticoid, mineralocorticoid, and sex steroid production that require hormone replacement therapy. Presentations vary from neonatal salt wasting and atypical genitalia, to adult presentation of hirsutism and irregular menses. Screening of neonates with elevated 17-hydroxyprogesterone concentrations for classic (severe) 21-hydroxylase deficiency, the most common type of congenital adrenal hyperplasia, is in place in many countries, however cosyntropin stimulation testing might be needed to confirm the diagnosis or establish non-classic (milder) subtypes. Challenges in the treatment of congenital adrenal hyperplasia include avoidance of glucocorticoid overtreatment and control of sex hormone imbalances. Long-term complications include abnormal growth and development, adverse effects on bone and the cardiovascular system, and infertility. Novel treatments aim to reduce glucocorticoid exposure, improve excess hormone control, and mimic physiological hormone patterns.

Octreotide Is Ineffective in Treating Tumor-Induced Osteomalacia: Results of a Short-Term Therapy

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome in which unregulated hypersecretion of fibroblast growth factor 23 (FGF23) by phosphaturic mesenchymal tumors (PMT) causes renal phosphate wasting, hypophosphatemia, and osteomalacia. The resulting mineral homeostasis abnormalities and skeletal manifestations can be reversed with surgical resection of the tumor. Unfortunately, PMTs are often difficult to locate, and medical treatment with oral phosphate and vitamin D analogues is either insufficient to manage the disease or not tolerated. Octreotide has been proposed as a potential treatment for TIO due to the presence of somatostatin receptors (SSTR) on PMTs; however, the role of somatostatin signaling in PMTs and the efficacy of treatment of TIOs with somatostatin analogues is not clear. In an effort to evaluate the efficacy of octreotide therapy in TIO, five subjects with TIO were treated with octreotide for 3 days. Blood intact FGF23, phosphate, and 1,25(OH)₂ D₃ , and tubular reabsorption of phosphate (TRP) were measured at frequent time points during treatment. Octreotide's effects were assessed by comparing group means of the biochemical parameters at each time-point to mean baseline values. There were no significant changes in blood phosphate, FGF23, 1,25(OH)₂ D₃ , or TRP during octreotide treatment, consistent with a lack of efficacy of octreotide in treating TIO. © 2017 American Society for Bone and Mineral Research.

68Ga-DOTATATE for Tumor Localization in Tumor-Induced Osteomalacia

CONTEXT

Phosphaturic mesenchymal tumors (PMTs) are small, typically difficult to localize, and express somatostatin receptors. Recent work suggests imaging studies using ⁶⁸Gallium (⁶⁸Ga)-conjugated somatostatin peptide analogues, such as 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)TATE, which enables somatostatin receptor imaging with positron emission tomography (PET), may be useful at identifying these tumors.

OBJECTIVE

Our objective was to evaluate the use of ⁶⁸Ga-DOTATATE PET/computed tomography (CT) for tumor localization in tumor-induced osteomalacia (TIO).

DESIGN

This was a single-center prospective study of patients with TIO.

SETTING

The study was conducted at the National Institutes of Health Clinical Center between February 2014 and February 2015.

SUBJECTS

Eleven subjects (six females, five males) with TIO were included.

INTERVENTION

Subjects underwent ⁶⁸Ga-DOTATATE PET/CT in addition to ¹¹¹In-pentetreotide single-photon emission CT (Octreoscan- SPECT/CT) and fluorodeoxyglucose-PET/CT (¹⁸F FDG-PET/CT) scan.

MAIN OUTCOME MEASURES

Localization of PMTs on the previously described imaging modalities were determined.

RESULTS

The tumor was successfully localized in 6/11 (54.5%) subjects (one was metastatic). The tumor was identified by ⁶⁸Ga-DOTATATE in all six cases. Both Octreoscan-SPECT/CT and ¹⁸F FDG-PET each identified the tumor in 4/6. In no cases was ⁶⁸Ga-DOTATATE the only imaging study to identify the tumor.

CONCLUSIONS

In this first prospective study comparing ⁶⁸Ga-DOTATATE PET/CT to Octreoscan-SPECT/CT and ¹⁸F FDG-PET in TIO localization, ⁶⁸Ga-DOTATATE PET/CT demonstrated the greatest sensitivity and specificity, suggesting that it may be the best single study for localization of PMTs in TIO.

Stability and degradation of fibroblast growth factor 23 (FGF23): the effect of time and temperature and assay type

There is growing need for a reliable assay for measuring fibroblast growth factor 23 (FGF23), a regulator of phosphorus and vitamin D. In this work, we analyze and compare the performance of three available assays, including the effect of temperature and time. This knowledge will allow for better understanding of FGF23 in the future.

INTRODUCTION

Intact and C-terminal FGF23 (iFGF23 and cFGF23) concentrations are important in the diagnosis of hypo- and hyperphosphatemic diseases. The effects of temperature, storage, and specimen handling on FGF23 levels are not well known. We investigated the effects of various factors on plasma and serum measurement of FGF23 using three different assays.

METHODS

Serum and plasma FGF23 were measured using three commercially available ELISA assays-two measuring iFGF23 and one measuring cFGF23. Samples from subjects with known FGF23 disorders were stored at 4, 22, and 37 °C and analyzed at different intervals up to 48 hours (h). A subset of samples underwent repeated freeze-thaw cycles, and samples frozen at -80 °C for up to 60 months were reanalyzed. The effect of adding a furin convertase inhibitor on FGF23 degradation was investigated using samples stored at 37 °C for 48 h. Intact FGF23 levels were measured from plasma samples of four different groups to test the correlation of the two assays.

RESULTS

Plasma FGF23 levels were stable when stored at 4 and 22 °C for 48 h. Both plasma and serum FGF23 levels demonstrated relative stability after five freeze-thaw cycles. Long-term storage at -80 °C for 40 months induced some variability in FGF23 levels. The addition of a furin inhibitor did not affect FGF23 degradation. Intact FGF23 levels showed good correlation only at the upper limit of the assay range when comparing the two assays.

CONCLUSIONS

Sample type, handling, and choice of assay are factors that affect FGF23 levels and should be considered when measuring this hormone.

A patient with MEN1 typical features and MEN2-like features

Multiple endocrine neoplasia (MEN) type 1 (MEN1) and 2 (MEN2) rarely co-exist in one case. Here we report a patient with features of both syndromes. The patient presented with typical MEN1 features plus pheochromocytoma and thickened corneal nerves. She had a germline 1132delG frameshift mutation in MEN1, no mutation in CDKN1B (p27) and no RET mutation, but had both RET polymorphisms Gly691Ser and Arg982Cys. This is the first case report of a combination of typical clinical findings of MEN1 harboring a germline MEN1 mutation and the MEN2-like phenotype with negative full RET gene analysis of pathogenic variants. Possible explanations include a previously unrecognized phenotype-genotype association or the influence of potential phenotypic modifying RET variants. Furthermore, the combination observed in this patient may point to a single molecular pathway, and supports the possibility of as yet unrecognized connections between the molecular pathways for MEN1/menin protein and MEN2/RET protein.

Accelerated atherosclerosis and elevated lipoprotein (a) after liver transplantation

Cumulative evidence suggests that lipoprotein(a) [Lp(a)] exerts an independent effect on the initiation and progression of atherosclerotic cardiovascular disease. The genetically mediated expression of apolipoprotein(a), which is the key structural and functional component of Lp(a), occurs in hepatocytes with subsequent extracellular Lp(a) assembly at the hepatic cell surface. Here, we describe a case of elevated Lp(a) concentrations identified after (and likely acquired by) orthotopic liver transplantation that contributed to accelerated atherosclerotic cardiovascular disease despite intensive therapeutic interventions. This case study represents an important example to include Lp(a) screening in routine lipid panel testing for all liver transplant donors and recipients; to reduce unanticipated and debilitating cardiovascular morbidity and mortality.

Cortical bone mineral density in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency

BACKGROUND

Prior studies reveal that bone mineral density (BMD) in congenital adrenal hyperplasia (CAH) is mostly in the osteopaenic range and is associated with lifetime glucocorticoid dose. The forearm, a measure of cortical bone density, has not been evaluated.

OBJECTIVE

We aimed to evaluate BMD at various sites, including the forearm, and the factors associated with low BMD in CAH patients.

METHODS

Eighty CAH adults (47 classic, 33 nonclassic) underwent dual-energy-x-ray absorptiometry and laboratory and clinical evaluation. BMD Z-scores at the AP spine, total hip, femoral neck, forearm and whole body were examined in relation to phenotype, body mass index, current glucocorticoid dose, average 5-year glucocorticoid dose, vitamin D, 17-hydroxyprogesterone, androstenedione, testosterone, dehydroepiandrosterone and dehydroepiandrosterone sulphate (DHEAS).

RESULTS

Reduced BMD (T-score <-1 at hip, spine, or forearm) was present in 52% and was more common in classic than nonclassic patients (P = 0·005), with the greatest difference observed at the forearm (P = 0·01). Patients with classic compared to nonclassic CAH, had higher 17-hydroxyprogesterone (P = 0·005), lower DHEAS (P = 0·0002) and higher non-traumatic fracture rate (P = 0·0005). In a multivariate analysis after adjusting for age, gender, height standard deviation, phenotype and cumulative glucocorticoid exposure, higher DHEAS was independently associated with higher BMD at the spine, radius and whole body.

CONCLUSION

Classic CAH patients have lower BMD than nonclassic patients, with the most affected area being the forearm. This first study of forearm BMD in CAH patients suggests that low DHEAS may be associated with weak cortical bone independent of glucocorticoid exposure.

Takotsubo cardiomyopathy associated with thyrotoxicosis: a case report and review of the literature

BACKGROUND

Takotsubo or stress-induced cardiomyopathy is a form of reversible cardiomyopathy commonly associated with emotional or physical stress. Thyrotoxicosis has been identified as a rare cause of Takotsubo cardiomyopathy, with only 12 cases reported in the literature. Here, we report a case of thyroid storm presenting with Takotsubo cardiomyopathy in the setting of Graves' disease.

PATIENT FINDINGS

A 71-year-old woman presented with abdominal pain, vomiting, confusion, and history of weight loss. She was initially diagnosed and treated for diabetic ketoacidosis at another hospital and was transferred to our hospital one day after initial presentation because of concern for acute coronary syndrome. A diagnosis of Takotsubo cardiomyopathy was made on the basis of cardiac catheterization. At that time, she was diagnosed and treated for thyroid storm. Follow-up 7 weeks later revealed improvement of her cardiac function and near-normalization of thyroid hormone levels.

SUMMARY

In this patient, who presented with symptoms of heart failure, acute coronary syndrome was initially considered, but the diagnosis of Takotsubo cardiomyopathy associated with thyroid storm was ultimately made based on cardiac catheterization and laboratory investigation.

CONCLUSIONS

Thyrotoxicosis is associated with adverse disturbances in the cardiovascular system. Takotsubo cardiomyopathy could be a presenting manifestation of thyroid storm, perhaps related to excess catecholamine levels or sensitivity.

Tumor localization and biochemical response to cure in tumor-induced osteomalacia

Tumor-induced osteomalacia (TIO) is a rare disorder of phosphate wasting due to fibroblast growth factor-23 (FGF23)-secreting tumors that are often difficult to locate. We present a systematic approach to tumor localization and postoperative biochemical changes in 31 subjects with TIO. All had failed either initial localization, or relocalization (in case of recurrence or metastases) at outside institutions. Functional imaging with ¹¹¹Indium-octreotide with single photon emission computed tomography (octreo-SPECT or SPECT/CT), and ¹⁸fluorodeoxyglucose positron emission tomography/CT (FDG-PET/CT) were performed, followed by anatomic imaging (CT, MRI). Selective venous sampling (VS) was performed when multiple suspicious lesions were identified or high surgical risk was a concern. Tumors were localized in 20 of 31 subjects (64.5%). Nineteen of 20 subjects underwent octreo-SPECT imaging, and 16 of 20 FDG-PET/CT imaging. Eighteen of 19 (95%) were positive on octreo-SPECT, and 14 of 16 (88%) on FDG-PET/CT. Twelve of 20 subjects underwent VS; 10 of 12 (83%) were positive. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were as follows: sensitivity = 0.95, specificity = 0.64, PPV = 0.82, and NPV = 0.88 for octreo-SPECT; sensitivity = 0.88, specificity = 0.36, PPV = 0.62, and NPV = 0.50 for FDG-PET/CT. Fifteen subjects had their tumor resected at our institution, and were disease-free at last follow-up. Serum phosphorus returned to normal in all subjects within 1 to 5 days. In 10 subjects who were followed for at least 7 days postoperatively, intact FGF23 (iFGF23) decreased to near undetectable within hours and returned to the normal range within 5 days. C-terminal FGF23 (cFGF23) decreased immediately but remained elevated, yielding a markedly elevated cFGF23/iFGF23 ratio. Serum 1,25-dihydroxyvitamin D₃ (1,25D) rose and exceeded the normal range. In this systematic approach to tumor localization in TIO, octreo-SPECT was more sensitive and specific, but in many cases FDG-PET/CT was complementary. VS can discriminate between multiple suspicious lesions and increase certainty prior to surgery. Sustained elevations in cFGF23 and 1,25D were observed, suggesting novel regulation of FGF23 processing and 1,25D generation.

Development and treatment of tertiary hyperparathyroidism in patients with pseudohypoparathyroidism type 1B

CONTEXT

Pseudohypoparathyroidism type 1B (PHP1B) patients have PTH resistance at the renal proximal tubule and develop hypocalcemia and secondary hyperparathyroidism. Hyperparathyroid bone disease also develops in some patients. PHP1B patients are at theoretical risk of developing tertiary hyperparathyroidism.

SETTING

Patients were studied in a clinical research center.

PATIENTS

Five female PHP1B patients presented with hypercalcemia and elevated PTH.

INTERVENTION

Patients either underwent parathyroidectomy (n = 4) or received cinacalcet (n = 1).

MAIN OUTCOME MEASURES

Serum calcium and PTH were serially measured before and after intervention.

RESULTS

Five PHP1B patients developed concomitantly elevated serum calcium and PTH levels (range, 235-864 ng/liter) requiring termination of calcium and vitamin D therapy (time after diagnosis, 21-42 yr; median, 34 yr), consistent with tertiary hyperparathyroidism. Four patients underwent parathyroidectomy with removal of one (n = 2) or two (n = 2) enlarged parathyroid glands. Calcium and vitamin D therapy was reinstituted postoperatively, and at 93-month median follow-up, PTH levels ranged between 56 and 182 (normal, <87) ng/liter. One patient was treated with cinacalcet, resulting in resolution of hypercalcemia.

CONCLUSIONS

PHP1B patients are at risk of developing tertiary hyperparathyroidism and/or hyperparathyroid bone disease and should therefore be treated with sufficient doses of calcium and vitamin D to achieve serum calcium and PTH levels within or as close to the normal range as possible. Surgery is the treatment of choice in this setting. Cinacalcet may be a useful alternative in those who do not undergo surgery.

Vitamin D deficiency and its relation to bone mineral density and liver fibrosis in HIV-HCV coinfection

BACKGROUND

Fractures and cirrhosis are major causes of morbidity and mortality among HIV-HCV-coinfected individuals. It is not known whether vitamin D deficiency is associated with these outcomes.

METHODS

Between 2005 and 2007, 116 HIV-HCV-coinfected individuals underwent dual-energy X-ray absorptiometry within 1 year of a liver biopsy. 25-Hydroxyvitamin D (25OHD) and parathyroid hormone were measured from archived samples. Low bone mineral density (BMD) was defined as BMD≥2 standard deviations lower than age-, sex- and race-matched controls (Z-score ≤-2.0) at the total hip, femoral neck or lumbar spine. Histological fibrosis staging was assessed according to the METAVIR system (0 [no fibrosis] to 4 [cirrhosis]).

RESULTS

The cohort was 87% African-American and 63% male. The median age (IQR) was 49.9 years (46.5-53.3). A total of 89% had a CD4(+) T-cell count >200 cells/mm(3) and 64% were receiving HAART. The median 25OHD was 19 ng/ml (IQR 11.0-26.0). Hypovitaminosis D (25OHD≤15 ng/ml) was present in 41% and secondary hyperparathyroidism, defined by parathyroid hormone >65 pg/ml, was present in 24%. In total, 27% had low BMD (Z-score ≤-2) at the spine, femoral neck or total hip, and 39% had significant hepatic fibrosis (METAVIR≥2). In multivariate analysis, vitamin D deficiency was not associated with significant fibrosis or with BMD at any site.

CONCLUSIONS

Vitamin D deficiency was highly prevalent in this mostly African-American HIV-HCV-coinfected population, but was not related to BMD or liver disease severity. These data suggest that efforts to increase vitamin D levels in this population may not improve bone or liver outcomes.

Controlled HIV viral replication, not liver disease severity associated with low bone mineral density in HIV/HCV co-infection

BACKGROUND & AIMS

To evaluate the prevalence and risk factors for low bone mineral density (BMD) in persons co-infected with HIV and Hepatitis C.

METHODS

HIV/HCV co-infected study participants (n=179) were recruited into a prospective cohort and underwent dual-energy X-ray absorptiometry (DXA) within 1 year of a liver biopsy. Fibrosis staging was evaluated according to the METAVIR system. Osteoporosis was defined as a T-score ≤-2.5. Z-scores at the total hip, femoral neck, and lumbar spine were used as the primary outcome variables to assess the association between degree of liver disease, HIV-related variables, and BMD.

RESULTS

The population was 65% male, 85% Black with mean age 50.3 years. The prevalence of osteoporosis either at the total hip, femoral neck, or lumbar spine was 28%, with 5% having osteoporosis of the total hip, 6% at the femoral neck, 25% at the spine. The mean Z-scores (standard deviation) were -0.42 (1.01) at the total hip, -0.16 (1.05) at the femoral neck, and -0.82 (1.55) at the lumbar spine. In multivariable models, controlled HIV replication (HIV RNA <400 copies/ml vs. ≥400 copies/ml) was associated with lower Z-scores (mean ± standard error) at the total hip (-0.44 ± 0.17, p = 0.01), femoral neck (-0.59 ± 0.18, p = 0.001), and the spine (-0.98 ± 0.27, p = 0.0005). There was no association between degree of liver fibrosis and Z-score.

CONCLUSIONS

Osteoporosis was very common in this population of predominately African-American HIV/HCV co-infected patients, particularly at the spine. Lower BMD was associated with controlled HIV replication, but not liver disease severity.

Prevalence of low bone mineral density in a low-income inner-city population

Bone mineral density (BMD) is an important factor linked to bone health. Little is known of the prevalence of low BMD and its associated risk factors in an urban underserved population. Between 2001 and 2004, we recruited 338 subjects who completed drug use and medical history questionnaires, underwent hormonal measurements, and underwent whole-body dual-energy X-ray absorptiometry (DXA) for evaluation of BMD and body composition. Of these, 132 subjects had site-specific DXA (lumbar spine and hip) performed. Osteoporosis was defined as a T-score of -2.5 or less for men 50 years of age and older and postmenopausal women and a Z-score of -2.0 or less in men younger than 50 years of age and premenopausal women at either the lumbar spine, total hip, or femoral neck, according to National Osteoporosis Foundation (NOF) guidelines. The cohort consisted of mostly African-American, middle-aged people with a high prevalence of illicit drug use, 50% HIV(+), and 39% hepatitis C(+). Osteoporosis was identified in 22% of subjects (24 men, 5 women), with the majority of cases (90%) attributable to osteoporosis at the lumbar spine. Osteoporosis was more common in men than in women. Lower whole-body BMD among women was associated with multiple risk factors, but only with lower lean mass among men. Osteoporosis was highly prevalent in men, mainly at the spine. The risk factors for bone loss in this population need to be further clarified. Screening men for osteoporosis starting at age 50 might be warranted in this population given the multiple risk factors and the unexpectedly high prevalence of low BMD.

Decreased Persistence to Cholinesterase Inhibitor Therapy with Concomitant Use of Drugs That Can Impair Cognition

STUDY OBJECTIVES

To assess persistence with cholinesterase inhibitor therapy 6 months after the start of treatment, and to determine whether the likelihood of persistence is associated with the coprescription of drugs that can impair cognition.

DESIGN

Retrospective cohort study.

SETTING

Community (home residence) or long-term care facility.

PATIENTS

A total of 1183 patients enrolled in the Rhode Island Medicaid program, aged 45 years or older, who were dispensed a cholinesterase inhibitor from January 1, 2000-June 30, 2002.

MEASUREMENTS AND MAIN RESULTS

Patients were considered persistent with treatment if they filled at least five prescriptions for a 1-month supply of the same cholinesterase inhibitor, without an extended gap in days between refills. We compared rates of persistence among patients receiving and those not receiving drugs that can impair cognition. Covariates assessed were patient age, sex, race, and care setting. Approximately one in four patients discontinued cholinesterase inhibitor therapy within 6 months. Patients aged 85 years or older were more persistent than younger patients (77% vs 71%, p<0.05). Caucasian patients were more likely to be persistent than non-Caucasian patients (74% vs 52%, p<0.001). Patients living in the community were less likely to persist than those residing in long-term care facilities (58% vs 76%, p<0.001). After adjusting for race and care setting, patients who were prescribed drugs that can impair cognition were more likely not to have persisted with cholinesterase inhibitor therapy at 6 months than those who did not receive such drugs (odds ratio 1.56, 95% confidence interval 1.13-2.16).

CONCLUSION

A substantial percentage of patients who began receiving cholinesterase inhibitor therapy had discontinued the therapy within 6 months. Many patients also received prescriptions for agents that can impair cognition. Our findings indicated a modest but statistically significant increase in likelihood of treatment discontinuation among patients who also received prescriptions for drugs that can impair cognition. Iatrogenic causes of dementia are important to recognize and address so that therapies for enhancing cognition can be fully effective.