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Hawcutt DB, Francis B, Carr DF, Jorgensen AL, Yin P, Wallin N, O'Hara N, Zhang EJ, Bloch KM, Ganguli A, Thompson B, McEvoy L, Peak M, Crawford AA, Walker BR, Blair JC, Couriel J, Smyth RL, Pirmohamed M. Susceptibility to corticosteroid-induced adrenal suppression: a genome-wide association study. Lancet Respir Med 2018; 6:442-450. [PMID: 29551627 PMCID: PMC5971210 DOI: 10.1016/s2213-2600(18)30058-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 01/24/2018] [Accepted: 01/25/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND A serious adverse effect of corticosteroid therapy is adrenal suppression. Our aim was to identify genetic variants affecting susceptibility to corticosteroid-induced adrenal suppression. METHODS We enrolled children with asthma who used inhaled corticosteroids as part of their treatment from 25 sites across the UK (discovery cohort), as part of the Pharmacogenetics of Adrenal Suppression with Inhaled Steroids (PASS) study. We included two validation cohorts, one comprising children with asthma (PASS study) and the other consisting of adults with chronic obstructive pulmonary disorder (COPD) who were recruited from two UK centres for the Pharmacogenomics of Adrenal Suppression in COPD (PASIC) study. Participants underwent a low-dose short synacthen test. Adrenal suppression was defined as peak cortisol less than 350 nmol/L (in children) and less than 500 nmol/L (in adults). A case-control genome-wide association study was done with the control subset augmented by Wellcome Trust Case Control Consortium 2 (WTCCC2) participants. Single nucleotide polymorphisms (SNPs) that fulfilled criteria to be advanced to replication were tested by a random-effects inverse variance meta-analysis. This report presents the primary analysis. The PASS study is registered in the European Genome-phenome Archive (EGA). The PASS study is complete whereas the PASIC study is ongoing. FINDINGS Between November, 2008, and September, 2011, 499 children were enrolled to the discovery cohort. Between October, 2011, and December, 2012, 81 children were enrolled to the paediatric validation cohort, and from February, 2010, to June, 2015, 78 adults were enrolled to the adult validation cohort. Adrenal suppression was present in 35 (7%) children in the discovery cohort and six (7%) children and 17 (22%) adults in the validation cohorts. In the discovery cohort, 40 SNPs were found to be associated with adrenal suppression (genome-wide significance p<1 × 10-6), including an intronic SNP within the PDGFD gene locus (rs591118; odds ratio [OR] 7·32, 95% CI 3·15-16·99; p=5·8 × 10-8). This finding for rs591118 was validated successfully in both the paediatric asthma (OR 3·86, 95% CI 1·19-12·50; p=0·02) and adult COPD (2·41, 1·10-5·28; p=0·03) cohorts. The proportions of patients with adrenal suppression by rs591118 genotype were six (3%) of 214 patients with the GG genotype, 15 (6%) of 244 with the AG genotype, and 22 (25%) of 87 with the AA genotype. Meta-analysis of the paediatric cohorts (discovery and validation) and all three cohorts showed genome-wide significance of rs591118 (respectively, OR 5·89, 95% CI 2·97-11·68; p=4·3 × 10-9; and 4·05, 2·00-8·21; p=3·5 × 10-10). INTERPRETATION Our findings suggest that genetic variation in the PDGFD gene locus increases the risk of adrenal suppression in children and adults who use corticosteroids to treat asthma and COPD, respectively. FUNDING Department of Health Chair in Pharmacogenetics.
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Affiliation(s)
- Daniel B Hawcutt
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK; Wolfson Centre for Personalised Medicine, Medical Research Council (MRC) Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Ben Francis
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Daniel F Carr
- Wolfson Centre for Personalised Medicine, Medical Research Council (MRC) Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | - Peng Yin
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Naomi Wallin
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Natalie O'Hara
- Wolfson Centre for Personalised Medicine, Medical Research Council (MRC) Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Eunice J Zhang
- Wolfson Centre for Personalised Medicine, Medical Research Council (MRC) Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Katarzyna M Bloch
- Wolfson Centre for Personalised Medicine, Medical Research Council (MRC) Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Amitava Ganguli
- Wolfson Centre for Personalised Medicine, Medical Research Council (MRC) Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Ben Thompson
- Wolfson Centre for Personalised Medicine, Medical Research Council (MRC) Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Laurence McEvoy
- Wolfson Centre for Personalised Medicine, Medical Research Council (MRC) Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Matthew Peak
- National Institute for Health Research (NIHR) Alder Hey Clinical Research Facility, Alder Hey Children's Hospital, Liverpool, UK
| | - Andrew A Crawford
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; MRC Integrated Epidemiology Unit at the University of Bristol, Bristol, UK
| | - Brian R Walker
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne C Blair
- Department of Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Jonathan Couriel
- Department of Respiratory Medicine, Alder Hey Children's Hospital, Liverpool, UK
| | - Rosalind L Smyth
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Medical Research Council (MRC) Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.
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Hawcutt DB, Jorgensen AL, Wallin N, Thompson B, Peak M, Lacy D, Newland P, Didi M, Couriel J, Blair J, Pirmohamed M, Smyth RL. Adrenal responses to a low-dose short synacthen test in children with asthma. Clin Endocrinol (Oxf) 2015; 82:648-56. [PMID: 25378183 DOI: 10.1111/cen.12655] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [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: 08/19/2014] [Revised: 09/12/2014] [Accepted: 10/30/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Corticosteroids are known to cause adrenal suppression. The aim of this study was to assess clinical factors affecting responses to a low dose short synacthen test (LDSST) in asthmatic children using corticosteroids. DESIGN Patients were recruited from secondary care paediatric asthma populations within the UK. PATIENTS Asthmatic children (5-18 years), receiving corticosteroids, underwent a LDSST (n = 525). MEASUREMENTS Demographics and corticosteroid doses were tested for association with baseline and peak (stimulated) cortisol concentrations. RESULTS Baseline cortisol was significantly associated with age (log baseline increased 0·04 nm per year of age, P < 0·0001), but not with gender or corticosteroid dose. Peak cortisol was significantly associated with total corticosteroid cumulative dose (decreased 0·73 nm per 200 mcg/day, P < 0·001) but not with age, gender inhaled/intranasal corticosteroid cumulative dose or number of courses of rescue corticosteroids. Biochemically impaired response (peak cortisol ≤500 nm) occurred in 37·0% (161/435) overall, including children using GINA low (200-500 mcg/day beclomethasone-CFC equivalent 32%, n = 60), medium (501-1000 mcg/day (33%, n = 57) and high (>1000 mcg/day 40%, n = 13) doses of inhaled corticosteroid (ICS) similarly, and 36·6% of those using fluticasone ICS ≥500 mcg/day (71/194). Impaired response was more frequent in patients on regular oral corticosteroids (66%, n = 27, P < 0·001). CONCLUSION Children with asthma can develop biochemical adrenal suppression at similar frequencies for all ICS preparations and doses. The clinical consequence of biochemical suppression needs further study.
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Affiliation(s)
- Daniel B Hawcutt
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK; Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Blair J, Lancaster G, Titman A, Peak M, Newlands P, Collingwood C, Chesters C, Moorcroft T, Wallin N, Hawcutt D, Gardner C, Didi M, Lacy D, Couriel J. Early morning salivary cortisol and cortisone, and adrenal responses to a simplified low-dose short Synacthen test in children with asthma. Clin Endocrinol (Oxf) 2014; 80:376-83. [PMID: 23895277 DOI: 10.1111/cen.12302] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [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: 05/05/2013] [Revised: 05/29/2013] [Accepted: 07/15/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine serum cortisol responses to a simplified low-dose short Synacthen test (LDSST) in children treated with inhaled corticosteroids (ICS) for asthma and to compare these to early morning salivary cortisol (EMSC) and cortisone (EMSCn) levels. DESIGN Early morning salivary cortisol and EMSCn samples were collected for three consecutive days. On day three, Synacthen 500 ng/1·73 m(2) was administered intravenously. Samples were collected at 0, 15, 25, 35 min. RESULTS A total of 269 subjects (160 M: 109 F), median (range) age 10·0 (5·1-15·2) years were studied. Peak cortisol in the LDSST was <500 nmol/l in 101 subjects (37·5%) and <350 nmol/l in 12 subjects (4·5%). Basal cortisol correlated with peak cortisol: r = 0·55, (95% CI: 0·46, 0·63, P < 0·0001). Time at which peak cortisol concentration was achieved was significantly related to the value of peak cortisol (P < 0·0001), with higher cortisol peaks occurring later in the test and lower cortisol peaks occurring earlier. EMSC and EMSCn had no predictive value for the identification of patients with a peak cortisol <500 nmol/l. EMSCn was superior to EMSC in identifying patients with a peak cortisol <350 nmol/l: a minimum EMSCn cut-off value of 12·5 nmol/l gave a negative predictive value of 99·2% and positive predictive value of 30·1%. CONCLUSION Our data illustrate that basal measures of cortisol are likely to be of value in screening populations for patients at greatest risk of adrenal crisis. EMSCn shows promise as a screening tool for the identification of patients with severe adrenal insufficiency.
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Affiliation(s)
- Joanne Blair
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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