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Dubinski I, Bechtold-Dalla Pozza S, Bidlingmaier M, Hawley J, Keevil B, Kunz S, Nowotny HF, Reisch N, Schiergens K, Tschaidse L, Schmidt H. Diurnal 11-ketotestosterone and 17-hydroxyprogesterone saliva profiles in paediatric classical congenital adrenal hyperplasia. J Pediatr Endocrinol Metab 2024; 37:419-424. [PMID: 38557593 DOI: 10.1515/jpem-2024-0027] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES The most suitable biochemical markers for therapy adjustment in patients with congenital adrenal hyperplasia are controversial. 11-Oxygenated androgens are a promising new approach. The objective of this study was to investigate the diurnal rhythm of 11-ketotestosterone in children and adolescents in saliva and to correlate it with salivary 17-hydroxyprogesterone. METHODS Fifty-one samples of steroid day-profiles from 17 patients were additionally analysed for 11-ketotestosterone, retrospectively. All patients were treated in our university outpatient clinic for paediatric endocrinology between 2020 and 2022. Steroid day-profiles of 17 patients could be examined. The cohort showed a balanced sex ratio. The median age was 13 years. The measurements for 17-hydroxyprogesterone were carried out during routine care by immunoassay. The measurements of 11-ketotestosterone were performed from frozen saliva samples using an implemented in-house protocol for liquid chromatography-tandem mass spectrometry (LC-MS/MS). The most important outcome were the absolute values for 11-ketotestosterone, their diurnal rhythmicity and the correlation with 17-hydroxyprogesterone. RESULTS Both steroids show a circadian diurnal rhythm. 17-hydroxyprogesterone and 11-ketotestosterone correlate significantly. 11-Ketotestosterone showed a positive correlation with BMI at all times of the day. CONCLUSIONS 11-Ketotestosterone shows circadian rhythmicity in our cohort and correlates with 17-hydroxyprogesterone. These findings serve as an important basis for prospective research into 11-oxygenated androgens as therapeutic markers in paediatrics. However, 11-ketotestosterone appears to be very dependent on BMI.
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Affiliation(s)
- Ilja Dubinski
- Department of Paediatrics, Division of Paediatric Endocrinology, 74939 Dr. von Hauner Children's Hospital, University Hospital, LMU Munich , Munich, Germany
| | - Susanne Bechtold-Dalla Pozza
- Department of Paediatrics, Division of Paediatric Endocrinology, 74939 Dr. von Hauner Children's Hospital, University Hospital, LMU Munich , Munich, Germany
| | - Martin Bidlingmaier
- Department of Medicine IV, 74939 University Hospital, LMU Munich , Munich, Germany
| | - James Hawley
- Department of Clinical Biochemistry, 5293 Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre , Manchester, UK
| | - Brian Keevil
- Department of Clinical Biochemistry, 5293 Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre , Manchester, UK
| | - Sonja Kunz
- Department of Medicine IV, 74939 University Hospital, LMU Munich , Munich, Germany
| | | | - Nicole Reisch
- Department of Medicine IV, 74939 University Hospital, LMU Munich , Munich, Germany
| | - Katharina Schiergens
- Department of Paediatrics, Division of Paediatric Endocrinology, 74939 Dr. von Hauner Children's Hospital, University Hospital, LMU Munich , Munich, Germany
| | - Lea Tschaidse
- Department of Medicine IV, 74939 University Hospital, LMU Munich , Munich, Germany
| | - Heinrich Schmidt
- Department of Paediatrics, Division of Paediatric Endocrinology, 74939 Dr. von Hauner Children's Hospital, University Hospital, LMU Munich , Munich, Germany
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Tschaidse L, Wimmer S, Nowotny HF, Auer MK, Lottspeich C, Dubinski I, Schiergens KA, Schmidt H, Quinkler M, Reisch N. Frequency of stress dosing and adrenal crisis in paediatric and adult patients with congenital adrenal hyperplasia: a prospective study. Eur J Endocrinol 2024; 190:275-283. [PMID: 38584334 DOI: 10.1093/ejendo/lvae023] [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: 10/12/2023] [Revised: 01/03/2024] [Accepted: 02/06/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE Patients with congenital adrenal hyperplasia (CAH) require life-long glucocorticoid replacement, including stress dosing (SD). This study prospectively assessed adrenal crisis (AC) incidence, frequency, and details of SD and disease knowledge in adult and paediatric patients and their parents. DESIGN Prospective, observational study. METHODS Data on AC and SD were collected via a patient diary. In case of AC, medical records were reviewed and patient interviews conducted. Adherence to sick day rules of the German Society of Endocrinology (DGE) and disease knowledge using the German version of the CAH knowledge assessment questionnaire (CAHKAQ) were assessed. RESULTS In 187 adult patients, the AC incidence was 8.4 per 100 patient years (py) and 5.1 in 100 py in 38 children. In adults, 195.4 SD episodes per 100 py were recorded, in children 169.7 per 100 py. In children 72.3% and in adults 34.8%, SD was performed according to the recommendations. Children scored higher on the CAHKAQ than adults (18.0 [1.0] vs 16.0 [4.0]; P = .001). In adults, there was a positive correlation of the frequency of SD and the incidence of AC (r = .235, P = .011) and CAHKAQ score (r = .233, P = .014), and between the incidence of AC and CAHKAQ (r = .193, P = .026). CONCLUSION The AC incidence and frequency of SD in children and adults with CAH are high. In contrast to the paediatric cohort, the majority of SD in adults was not in accordance with the DGE recommendations, underlining the need for structured and repeated education of patients with particular focus on transition.
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Affiliation(s)
- Lea Tschaidse
- Department of Medicine IV, LMU University Hospital, LMU Munich, 80336 Munich, Germany
| | - Sophie Wimmer
- Department of Medicine IV, LMU University Hospital, LMU Munich, 80336 Munich, Germany
| | - Hanna F Nowotny
- Department of Medicine IV, LMU University Hospital, LMU Munich, 80336 Munich, Germany
| | - Matthias K Auer
- Department of Medicine IV, LMU University Hospital, LMU Munich, 80336 Munich, Germany
| | - Christian Lottspeich
- Department of Medicine IV, LMU University Hospital, LMU Munich, 80336 Munich, Germany
| | - Ilja Dubinski
- Department of Paediatrics, Division of Paediatric Endocrinology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Katharina A Schiergens
- Department of Paediatrics, Division of Paediatric Endocrinology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Heinrich Schmidt
- Department of Paediatrics, Division of Paediatric Endocrinology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, 80336 Munich, Germany
| | | | - Nicole Reisch
- Department of Medicine IV, LMU University Hospital, LMU Munich, 80336 Munich, Germany
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Alam A, Agrawal NK, Singh SK. Congenital adrenal hyperplasia complicated by gonadotropin-dependent precocious puberty. BMJ Case Rep 2024; 17:e257579. [PMID: 38442976 DOI: 10.1136/bcr-2023-257579] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
Precocious puberty, characterised by the early appearance of secondary sexual characteristics, poses challenges in diagnosis and management. Here, we describe a case of precocious puberty diagnosed in a boy in middle childhood, who presented with progressive phallus enlargement, pubic hair development and increased aggressive behaviour. Hormonal evaluation confirmed the diagnosis of congenital adrenal hyperplasia (CAH), complicated by gonadotropin-dependent precocious puberty. The case highlights the importance of assessment of testicular volume in a patient presenting with precocious puberty. Symmetrical testicular enlargement in a patient with CAH suggests premature activation of the hypothalamic-pituitary-gonadal axis. The patient received glucocorticoid therapy to suppress androgen production related to CAH and gonadotropin-releasing hormone analogue therapy to control premature activation of the hypothalamic-pituitary-gonadal axis. Follow-up visits showed regression of secondary sexual characteristics and improved growth velocity.
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Affiliation(s)
- Ahmad Alam
- Rajiv Gandhi Centre for Diabetes and Endocrinology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Neeraj Kumar Agrawal
- Endocrinology and Metabolism, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Surya K Singh
- Endocrinology and Metabolism, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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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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Waselewski AC, Klumpner TT, Kountanis JA, Sandberg ES, Shumer DE. Dexamethasone for postoperative nausea and vomiting prophylaxis in cesarean delivery and a delayed diagnosis of neonatal congenital adrenal hyperplasia. Int J Obstet Anesth 2024; 57:103969. [PMID: 38195332 DOI: 10.1016/j.ijoa.2023.103969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 07/03/2023] [Revised: 09/19/2023] [Accepted: 12/07/2023] [Indexed: 01/11/2024]
Abstract
The case of a false-negative newborn screen for congenital adrenal hyperplasia in a 37 weeks' gestation 46,XX neonate, thought to be due to maternal administration of dexamethasone intra-operatively prior to umbilical cord clamping, for postoperative nausea and vomiting prophylaxis after neuraxial anesthesia, is described.
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Affiliation(s)
- A C Waselewski
- University of Michigan, Department of Pediatric Endocrinology, Ann Arbor, Michigan, USA.
| | - T T Klumpner
- University of Michigan, Department of Anesthesiology, Ann Arbor, Michigan, USA
| | - J A Kountanis
- University of Michigan, Department of Anesthesiology, Ann Arbor, Michigan, USA
| | - E S Sandberg
- University of Michigan, Department of Pediatric Endocrinology, Ann Arbor, Michigan, USA
| | - D E Shumer
- University of Michigan, Department of Pediatric Endocrinology, Ann Arbor, Michigan, USA
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Тюльпаков МА, Нагаева ЕВ, Калинченко НЮ, Безлепкина ОБ. [A promising approach for therapy control in congenital adrenal hyperplasia. Problems of Endocrinology]. Probl Endokrinol (Mosk) 2024; 69:102-108. [PMID: 38311999 PMCID: PMC10848187 DOI: 10.14341/probl13328] [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] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/23/2023] [Accepted: 08/31/2023] [Indexed: 02/06/2024]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders requiring lifelong glucocorticoid replacement (GC) therapy. Lack of GC therapy leads to precocious puberty in boys, heterosexual development in girls, accelerated bone maturation and short final height in both sexes. In adolescence, the lack of GC therapy is the cause of menstrual disorders in girls and the development of TART in boys, as a result reducing the reproductive potential in both sexes. On the other hand, an overdose of GC leads to drug-induced Itsenko-Cushing's syndrome. In order to select adequate doses of GC in childhood and adolescence, multiple determinations of 17-hydroxyprogesterone, androstenedione, and testosterone in blood plasma, and thus multiple venous blood sampling are required. The blood sampling requires specially trained medical staff and can effect on the results due to stress reaction especially in young patients. Hence, the development and implementation of a non-invasive method for determining the steroid profile is extremely important in monitoring GC therapy in children. In addition, the currently used immunofluorescence assay cannot determine other adrenal steroids, has a high variation due to the «cross-reaction» of steroids that are similar in structure, which inflates the results. Unlike immunofluorescence assay, liquid chromatography and tandem mass spectrometry is more preferable method, since it is more specific and accurate. In this literature review, saliva presented as an alternative substrate and the non-invasive method for determining the steroid profile. This method can solve the above disadvantages, simplify and make more accurate the selection of GC therapy in patients with CAH, which is especially important in childhood.
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Affiliation(s)
- М. А. Тюльпаков
- Национальный медицинский исследовательский центр эндокринологии
| | - Е. В. Нагаева
- Национальный медицинский исследовательский центр эндокринологии
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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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8
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Zhang Y, Yuan Y. Genetic diagnosis and clinical analysis of 17α-hydroxylase/17, 20-lyase deficiency combined with type 2 diabetes mellitus: A case report. Medicine (Baltimore) 2023; 102:e36727. [PMID: 38206738 PMCID: PMC10754554 DOI: 10.1097/md.0000000000036727] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/29/2023] [Indexed: 01/13/2024] Open
Abstract
RATIONALE 17α-Hydroxylase/17, 20-lyase deficiency (17OHD) is a recessively inherited autosomal disease caused by CYP17A1 gene mutations. It is characterized by failure to synthesize cortisol, adrenal androgens and gonadal steroids. However, it is rare in clinic combining with type 2 diabetes mellitus (T2DM). PATIENT CONCERNS A 21-year-old woman was transferred to an endocrinology clinic because of paroxysmal paralysis. In addition, she presented with hypertension, primary amenorrhea and lack of pubertal development. Blood evaluation revealed hypokalemia, and a low cortisol level with an increased adrenocorticotropic hormone concentration. The renin activity and testosterone and estrogen levels were suppressed, and the gonadotropin levels were high. CT scan showed bilateral adrenal hyperplasia. Besides, this patient had hyperglycemia, hyperinsulinism and negative diabetes type 1 related antibodies. A homozygous mutation c. 985 to 987delinsAA in exon 6 was found in the patient which caused the missense mutation (p.Y329fs). DIAGNOSES 17α-hydroxylase/17, 20-lyase deficiency combined with T2DM was considered. INTERVENTIONS The patient received dexamethasone, estradiol valerate, metformin, amlodipine besylate and D3 calcium carbonate tablets. The doses of dexamethasone was changed according to her blood potassium levels. OUTCOMES After treatment, the blood pressure, blood potassium and blood glucose returned to normal range. Besides, she had restored her menstrual cycle. LESSONS For patients with hypertension, hypokalemia and lack of pubertal development, the possibility of 17OHD should be considered. The subsequent treatment would be challenging in patients with combined 17OHD and T2DM, considering the potential contribution of glucocorticoids to diabetic balance and osteoporosis.
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Affiliation(s)
- Yumin Zhang
- Department of Geriatric Endocrinology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu Province, China
- Department of Endocrinology, Zhongda Hospital, Southeast University, Nanjing, Jiangsu Province, China
| | - Yuexing Yuan
- Department of Endocrinology, Zhongda Hospital, Southeast University, Nanjing, Jiangsu Province, China
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Leszczyńska D, Tuszyńska-Meissner A, Ciebiera M, Włodarczyk M, Zgliczyński W. Giant uterine fibroid and adrenal tumor in a patient who ceased congenital adrenal hyperplasia treatment. Pol Arch Intern Med 2023; 133:16587. [PMID: 37874249 DOI: 10.20452/pamw.16587] [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] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
- Dorota Leszczyńska
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | | | - Michał Ciebiera
- Warsaw Institute of Women’s Health, Warsaw, Poland
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Marta Włodarczyk
- Department of Biochemistry and Pharmacogenomics, Faculty of Pharmacy, Medical University of Warsaw, Warsaw, Poland
- Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Wojciech Zgliczyński
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
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Lawrence NR, Bacila I, Dawson J, Mahdi S, Alvi S, Cheetham TD, Crowne E, Das U, Dattani MT, Davies JH, Gevers E, Krone RE, Patel L, Randell T, Ryan FJ, Keevil B, Ahmed SF, Krone NP. Quality of Life in Children and Young People With Congenital Adrenal Hyperplasia-UK Nationwide Multicenter Assessment. J Clin Endocrinol Metab 2023; 109:e336-e346. [PMID: 37439248 DOI: 10.1210/clinem/dgad405] [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: 03/16/2023] [Revised: 06/26/2023] [Accepted: 07/11/2023] [Indexed: 07/14/2023]
Abstract
CONTEXT Quality of life (QoL) has been inconsistently reported in children and young people (CYP) with congenital adrenal hyperplasia (CAH). OBJECTIVE Assess QoL in CYP with CAH in the UK alongside biometric and androgen profiles. DESIGN To define the evidence base for health care delivery, we conducted a cross-sectional study in CYP with CAH in the UK. Questionnaire results were compared with normative data and between groups, and modelled for association with sex, height, weight, body mass index, or steroid biomarkers of CAH control. SETTING Tertiary care in 14 UK centers. PATIENTS Results from 104 patients, 55% female, mean age 12.7 years (SD 3.0), paired responses from parents. INTERVENTIONS Strengths and Difficulties questionnaire (SDQ) and pediatric QoL questionnaire. MAIN OUTCOME MEASURE Total QoL scores as assessed by SDQ and a pediatric QoL questionnaire in comparison to normative data. RESULTS Total scores were worse in parents than normative data, but similar in patients. Patient QoL was rated better in social functioning but worse in emotional, school, and peer domains by patients, and worse in total scores and domains of peer problems, and psychosocial, emotional, and school functioning by parents. Parents consistently scored QoL of their children lower than their child. Larger height-SD score and lower weight-SD score were associated with better QoL. Girls with lower steroid biomarkers had worse SDQ scores. CONCLUSIONS In CYP with CAH, reduced height, increased weight, and hormonal biomarkers consistent with overtreatment were associated with worse QoL; addressing these problems should be prioritized in clinical management.Clinical Trials Registration Number: SCH/15/088.
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Affiliation(s)
| | - Irina Bacila
- Department of Oncology & Metabolism, University of Sheffield, Sheffield S10 2RX, UK
| | - Jeremy Dawson
- Department of Oncology & Metabolism, University of Sheffield, Sheffield S10 2RX, UK
| | - Sundus Mahdi
- Department of Oncology & Metabolism, University of Sheffield, Sheffield S10 2RX, UK
| | - Sabah Alvi
- Department of Paediatric Endocrinology and Diabetes, Leeds Children's Hospital, Leeds LS2 3AX, UK
| | - Timothy D Cheetham
- Department of Paediatric Endocrinology, Great North Children's Hospital, University of Newcastle, Newcastle NE1 4LP, UK
| | - Elizabeth Crowne
- Department of Paediatric Endocrinology & Diabetes, Bristol Royal Hospital for Children, University Hospitals Bristol Foundation Trust, Bristol BS2 8BJ, UK
| | - Urmi Das
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool L14 5AB, UK
| | - Mehul Tulsidas Dattani
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital, London WC1N 1LE, UK
| | - Justin H Davies
- Department of Paediatric Endocrinology, University Hospital Southampton, Southampton SO16 6YD, UK
- Department of Human Development & Health, University of Southampton, Southampton SO17 1BJ, UK
| | - Evelien Gevers
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University London, London and Barts Health NHS Trust-The Royal London Hospital, London E1 1BB, UK
| | - Ruth E Krone
- Department of Paediatric Endocrinology, Birmingham Women's & Children's Hospital, Birmingham B4 6NH, UK
| | - Leena Patel
- Paediatric Endocrine Service, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK
| | - Tabitha Randell
- Department of Paediatric Diabetes and Endocrinology, Nottingham Children's Hospital, Nottingham NG7 2UH, UK
| | - Fiona J Ryan
- Department of Paediatric Endocrinology and Diabetes, Oxford Children's Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Brian Keevil
- Department of Biochemistry, Manchester University NHS Foundation Trust, Manchester M13 9PL, UK
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow G12 8QQ, UK
| | - Nils P Krone
- Department of Oncology & Metabolism, University of Sheffield, Sheffield S10 2RX, UK
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11
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Ahmad J, Ahmad A, Hadid L. Restoration of reproductive capacity in a male patient with congenital adrenal hyperplasia and bilateral testicular adrenal rest tumors (TARTs) after six months of glucocorticoid intensification: A case report. Medicine (Baltimore) 2023; 102:e36061. [PMID: 38065885 PMCID: PMC10713158 DOI: 10.1097/md.0000000000036061] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/20/2023] [Indexed: 12/18/2023] Open
Abstract
RATIONALE Congenital adrenal hyperplasia (CAH) is considered one of the most common inherited disorders. In about more than 95% of all CAH cases, the deficient enzyme is 21-hydroxylase. Infertility is an important complication of this disease, and although this topic has been studied more frequently in females, cases, and literature reviews of the causes of infertility in male patients are constantly increasing. PATIENT CONCERNS A 28 old male with congenital adrenal hyperplasia (we assume to be a nonclassical type) presented to our institution with infertility and suspected bilateral testicular masses after 4 years of stopping dexamethasone. DIAGNOSIS Testicular adrenal rest tumors. INTERVENTIONS Dexamethasone was reapplied in a supraphysiologic dose (1.5 mg before bedtime) with periodic monitoring of the patient. OUTCOMES Treatment with supraphysiologic dose of dexamethasone led to regression of these tumors and significant improvement in sperm count, resulting in being capable of having a child. LESSONS There are many suspected causes of reduced male fertility in male CAH patients and the presence of testicular adrenal rest tumors is the main cause of infertility in this population. These benign tumors are believed to arise from ectopic adrenal cells in the testes, that grow under adrenocorticotropic hormone stimulation in poorly controlled patients. Annual scrotal ultrasound is recommended in all males with CAH for detection and treatment of these tumors as early as possible before they cause permanent damage to the seminiferous tubules and irreversible infertility.
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Affiliation(s)
- Jihan Ahmad
- Department of Endocrinology, Al-Assad University Hospital, Damascus University, Damascus, Syria
| | - Adnan Ahmad
- Department of Urology, Al-Assad University Hospital, Damascus University, Damascus, Syria
| | - Lama Hadid
- Department of Endocrinology, Al-Assad University Hospital, Damascus University, Damascus, Syria
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12
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Dubinski I, Bechtold-Dalla Pozza S, Debor B, Nowotny HF, Reisch N, Tschaidse L, Schmidt H. Continuous Glucose Monitoring in Children and Adolescents with Congenital Adrenal Hyperplasia. J Clin Res Pediatr Endocrinol 2023; 15:380-389. [PMID: 37218136 PMCID: PMC10683536 DOI: 10.4274/jcrpe.galenos.2023.2023-3-5] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/15/2023] [Indexed: 05/24/2023] Open
Abstract
Objective Patients with congenital adrenal hyperplasia (CAH) require lifelong therapy with glucocorticoids to suppress androgen excess and substitute for deficient cortisol. An important aspect of care is the prevention of metabolic sequelae. In infants, potentially lethal nocturnal hypoglycaemia has been described. In adolescence, visceral obesity, hypertension, hyperinsulinism and insulin resistance are reported. To date, systematic studies of glucose profiles in this age group with CAH are lacking. Methods This was a monocentric, prospective, observational study to determine the glucose profiles under different treatment regimens in a cohort of young patients with CAH. The continuous glucose monitoring device used was the latest generation FreeStyle Libre 3® sensor in blinded mode. Therapeutic and auxological data were obtained. Results The cohort consisted of 10 children/adolescents with a mean age of 11 years. Three patients exhibited morning fasting hyperglycaemia. Overall, 6 out of 10 patients had unacceptably few total values in the desired range of 70-120 mg/dL. Tissue glucose values above 140-180 mg/dL were found in 5 of 10 patients. The mean value for glycosylated haemoglobin for the cohort was of 5.8%. All pubertal adolescents with reverse circadian regimens had significantly higher glucose levels at night. Two adolescents showed asymptomatic nocturnal hypoglycaemia. Conclusion Most of the patients exhibited abnormalities in glucose metabolism. Two-thirds had elevated total 24h glucose values outside the age-appropriate reference values. Thus, this aspect may need to be addressed early in life by adjusting the doses, treatment regimen or dietary measures. Consequently, reverse circadian therapy regimens should be critically indicated and closely monitored due to the potential metabolic risk.
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Affiliation(s)
- Ilja Dubinski
- Dr. von Hauner Children’s Hospital; Ludwig Maximilian University, Department of Paediatrics, Division of Paediatric Endocrinology, Munich, Germany
| | - Susanne Bechtold-Dalla Pozza
- Dr. von Hauner Children’s Hospital; Ludwig Maximilian University, Department of Paediatrics, Division of Paediatric Endocrinology, Munich, Germany
| | - Belana Debor
- Dr. von Hauner Children’s Hospital; Ludwig Maximilian University, Department of Paediatrics, Division of Paediatric Endocrinology, Munich, Germany
| | | | - Nicole Reisch
- Ludwig Maximilian University, Department of Medicine IV, Munich, Germany
| | - Lea Tschaidse
- Ludwig Maximilian University, Department of Medicine IV, Munich, Germany
| | - Heinrich Schmidt
- Dr. von Hauner Children’s Hospital; Ludwig Maximilian University, Department of Paediatrics, Division of Paediatric Endocrinology, Munich, Germany
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13
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Nowotny HF, Marchant Seiter T, Ju J, Gottschlich A, Schneider H, Zopp S, Vogel F, Tschaidse L, Auer MK, Lottspeich C, Kobold S, Rothenfusser S, Beuschlein F, Reincke M, Braun L, Reisch N. Major immunophenotypic abnormalities in patients with primary adrenal insufficiency of different etiology. Front Immunol 2023; 14:1275828. [PMID: 38045693 PMCID: PMC10690587 DOI: 10.3389/fimmu.2023.1275828] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/27/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction Patients with primary adrenal insufficiency (PAI) suffer from increased risk of infection, adrenal crises and have a higher mortality rate. Such dismal outcomes have been inferred to immune cell dysregulation because of unphysiological cortisol replacement. As the immune landscape of patients with different types of PAI has not been systematically explored, we set out to immunophenotype PAI patients with different causes of glucocorticoid (GC) deficiency. Methods This cross-sectional single center study includes 28 patients with congenital adrenal hyperplasia (CAH), 27 after bilateral adrenalectomy due to Cushing's syndrome (BADx), 21 with Addison's disease (AD) and 52 healthy controls. All patients with PAI were on a stable GC replacement regimen with a median dose of 25 mg hydrocortisone per day. Peripheral blood mononuclear cells were isolated from heparinized blood samples. Immune cell subsets were analyzed using multicolor flow cytometry after four-hour stimulation with phorbol myristate acetate and ionomycin. Natural killer (NK-) cell cytotoxicity and clock gene expression were investigated. Results The percentage of T helper cell subsets was downregulated in AD patients (Th1 p = 0.0024, Th2 p = 0.0157, Th17 p < 0.0001) compared to controls. Cytotoxic T cell subsets were reduced in AD (Tc1 p = 0.0075, Tc2 p = 0.0154) and CAH patients (Tc1 p = 0.0055, Tc2 p = 0.0012) compared to controls. NKCC was reduced in all subsets of PAI patients, with smallest changes in CAH. Degranulation marker CD107a expression was upregulated in BADx and AD, not in CAH patients compared to controls (BADx p < 0.0001; AD p = 0.0002). In contrast to NK cell activating receptors, NK cell inhibiting receptor CD94 was upregulated in BADx and AD, but not in CAH patients (p < 0.0001). Although modulation in clock gene expression could be confirmed in our patient subgroups, major interindividual-intergroup dissimilarities were not detected. Discussion In patients with different etiologies of PAI, distinct differences in T and NK cell-phenotypes became apparent despite the use of same GC preparation and dose. Our results highlight unsuspected differences in immune cell composition and function in PAI patients of different causes and suggest disease-specific alterations that might necessitate disease-specific treatment.
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Affiliation(s)
- Hanna F. Nowotny
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Jing Ju
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Adrian Gottschlich
- Division of Clinical Pharmacology, University Hospital, LMU Munich, Munich, Germany
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
| | - Holger Schneider
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Stephanie Zopp
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Frederick Vogel
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lea Tschaidse
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Matthias K. Auer
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Sebastian Kobold
- Division of Clinical Pharmacology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- Einheit für Klinische Pharmakologie (EKLiP), Helmholtz Munich, Research Center for Environmental Health (HMGU), Neuherberg, Germany
| | - Simon Rothenfusser
- Division of Clinical Pharmacology, University Hospital, LMU Munich, Munich, Germany
- Einheit für Klinische Pharmakologie (EKLiP), Helmholtz Munich, Research Center for Environmental Health (HMGU), Neuherberg, Germany
| | - Felix Beuschlein
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich (USZ) und Universität Zürich (UZH), Zurich, Switzerland
| | - Martin Reincke
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Leah Braun
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Nicole Reisch
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
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14
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Galderisi A, Kariyawasam D, Stoupa A, Quoc AN, Pinto G, Viaud M, Brabant S, Beltrand J, Polak M, Samara-Boustani D. Glucose pattern in children with classical congenital adrenal hyperplasia: evidence from continuous glucose monitoring. Eur J Endocrinol 2023; 189:K19-K24. [PMID: 37952170 DOI: 10.1093/ejendo/lvad147] [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: 07/27/2023] [Revised: 10/01/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND While the risk for hypoglycemia during acute illness is well described in children with classical congenital adrenal hyperplasia (CAH), there is little evidence for the prevalence of asymptomatic hypoglycemia and the daily glucose patterns in CAH. Herein, we explored the daytime glucose profile of children with classical CAH. METHODS We conducted an observational study in 11 children (6 female; age 3.1 years [1.4, 5.1]; body mass index 17.3 kg/m2 [15.6, 17.9]) with a genetic diagnosis of classical CAH receiving hydrocortisone and fludrocortisone replacement therapy. Participants underwent 2 14-day continuous glucose monitoring (CGM) sessions and an inpatient 24 h series cortisol and adrenocorticotropic hormone (ACTH) measures. Data were analyzed for 3 daytime lags (7 Am-4 Pm, 4 Pm-10pm, 10 Pm-7 Am) corresponding to the hydrocortisone dosing period with cortisol and ACTH measured before the hydrocortisone dose. RESULTS Eleven participants completed at least 1 CGM session, and 7 out of 11 underwent both the CGM session and the cortisol/ACTH serial measures. In the whole cohort, the percentage of time of sensor glucose values <70 mg/dL was higher during the 10 Pm-7 Am and the 7 Am-4 Pm time slots than in the late afternoon period (17% [7, 54] and 15% [6.8, 24] vs 2% [1.1, 16.7] during the periods 7 Am-4 Pm and 4 Pm-10 Pm, respectively [P = .006 and P = .003]). Nighttime hypoglycemia was mostly spent below the 65 mg/dL (10.9% [4.1, 34]). The glycemic pattern paralleled the nadir of daily cortisol at 7 Am (10.3±4.4 μg/dL). A greater percentage of time in hypoglycemia was associated with lower cortisol concentration at 7 Am and 10 Pm (P < .001 and P = .005). CONCLUSIONS Continuous glucose monitoring demonstrated a disrupted daily glucose pattern in children with CAH, paralleled by a lower cortisol concentration. CLINICALTRIALS.GOV REGISTRATION NCT04322435.
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Affiliation(s)
- Alfonso Galderisi
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
- Department of Pediatrics, Pediatric Endocrinology, Yale University, New Haven, CT, United States
| | - Dulanjalee Kariyawasam
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
- Faculty of Medicine, Université Paris Cité, Paris, France
- Cochin Institute, INSERM U1016, Paris, France
- IMAGINE Institute Affiliate, INSERM U1163, Paris, France
| | - Athanasia Stoupa
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
- Faculty of Medicine, Université Paris Cité, Paris, France
- Cochin Institute, INSERM U1016, Paris, France
- IMAGINE Institute Affiliate, INSERM U1163, Paris, France
| | - Adrien Nguyen Quoc
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
- Faculty of Medicine, Université Paris Cité, Paris, France
| | - Graziella Pinto
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
| | - Magali Viaud
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
| | - Severine Brabant
- Department of Functional Explorations, Necker-Enfants Malades University Hospital, AP-HP Centre, Paris, France
| | - Jacques Beltrand
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
- Faculty of Medicine, Université Paris Cité, Paris, France
- Cochin Institute, INSERM U1016, Paris, France
- IMAGINE Institute Affiliate, INSERM U1163, Paris, France
| | - Michel Polak
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
- Faculty of Medicine, Université Paris Cité, Paris, France
- Cochin Institute, INSERM U1016, Paris, France
- IMAGINE Institute Affiliate, INSERM U1163, Paris, France
| | - Dinane Samara-Boustani
- Department of Paediatric Endocrinology, Diabetology, and Gynaecology, Necker-Enfants Malades University Hospital, Centre de Référence des Maladies endocriniennes Rares de la Croissance et du Développement (filière FIRENDO), AP-HP Centre, Paris, France
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15
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Yogi A, Kashimada K. Current and future perspectives on clinical management of classic 21-hydroxylase deficiency. Endocr J 2023; 70:945-957. [PMID: 37380491 DOI: 10.1507/endocrj.ej23-0075] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023] Open
Abstract
Optimizing the glucocorticoid dosage has been a major concern in classic 21OHD (21-hydroxylase deficiency) treatment, as it is essential to adjust it meticulously to the needs of the individual patient. Insufficient glucocorticoid treatment will cause adrenal insufficiency, including life-threatening adrenal crisis, while excess of androgen could cause precocious pubertal growth in children, virilization in female patients, and infertility in male and female adult patients. Meanwhile, overtreatment with glucocorticoids causes iatrogenic Cushing's syndrome which could result in growth impairment, obesity, osteoporosis, and hypertension. The dilemma of 21OHD treatment is that glucocorticoid supplementation therapy at physiological dosage does not sufficiently suppress ACTH, consequently leading to adrenal androgen excess. Accordingly, the window for the appropriate glucocorticoid treatment would have to be substantially narrower than that of other types of adrenal insufficiency without androgen excess, such as adrenal hypoplasia. For the appropriate management of classic 21OHD, the physician has to be well versed in the physiology of the adrenal cortex, growth, and reproductive function. Comprehensive understanding of patients' requirements according to their life stage and sex is essential. Furthermore, female patients with 46,XX need to be cared for as differences in sex development (DSD) with careful psychological management. In this review, we aimed to comprehensively summarize the current status of classic 21OHD treatment, including the initial treatment during the neonatal period, management of adrenal insufficiency, maintenance therapy of each life stage, and the importance of clinical management as DSD for 46,XX female patients. The recently developed agents, Chronocort, and Crinecerfont, are also discussed.
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Affiliation(s)
- Analia Yogi
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
| | - Kenichi Kashimada
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
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Newfield RS, Sarafoglou K, Fechner PY, Nokoff NJ, Auchus RJ, Vogiatzi MG, Jeha GS, Giri N, Roberts E, Sturgeon J, Chan JL, Farber RH. Crinecerfont, a CRF1 Receptor Antagonist, Lowers Adrenal Androgens in Adolescents With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2023; 108:2871-2878. [PMID: 37216921 PMCID: PMC10583973 DOI: 10.1210/clinem/dgad270] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/02/2023] [Accepted: 05/09/2023] [Indexed: 05/24/2023]
Abstract
CONTEXT Crinecerfont, a corticotropin-releasing factor type 1 receptor antagonist, has been shown to reduce elevated adrenal androgens and precursors in adults with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21OHD), a rare autosomal recessive disorder characterized by cortisol deficiency and androgen excess due to elevated adrenocorticotropin. OBJECTIVE To evaluate the safety, tolerability, and efficacy of crinecerfont in adolescents with 21OHD CAH. METHODS This was an open-label, phase 2 study (NCT04045145) at 4 centers in the United States. Participants were males and females, 14 to 17 years of age, with classic 21OHD CAH. Crinecerfont was administered orally (50 mg twice daily) for 14 consecutive days with morning and evening meals. The main outcomes were change from baseline to day 14 in circulating concentrations of ACTH, 17-hydroxyprogesterone (17OHP), androstenedione, and testosterone. RESULTS 8 participants (3 males, 5 females) were enrolled; median age was 15 years and 88% were Caucasian/White. After 14 days of crinecerfont, median percent reductions from baseline to day 14 were as follows: ACTH, -57%; 17OHP, -69%; and androstenedione, -58%. In female participants, 60% (3/5) had ≥50% reduction from baseline in testosterone. CONCLUSION Adolescents with classic 21OHD CAH had substantial reductions in adrenal androgens and androgen precursors after 14 days of oral crinecerfont administration. These results are consistent with a study of crinecerfont in adults with classic 21OHD CAH.
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Affiliation(s)
- Ron S Newfield
- Pediatric Endocrinology, University of California San Diego and Rady Children’s Hospital, San Diego, CA 92123, USA
| | - Kyriakie Sarafoglou
- Department of Pediatrics, Division of Endocrinology, University of Minnesota Medical School, Minneapolis, MN 55454, USA
| | - Patricia Y Fechner
- Departments of Pediatrics, Division of Pediatric Endocrinology, University of Washington School of Medicine, Seattle Children’s, Seattle, WA 98105, USA
| | - Natalie J Nokoff
- Department of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - 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
| | - Maria G Vogiatzi
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - George S Jeha
- Neurocrine Biosciences, Inc., San Diego, CA 92130, USA
| | - Nagdeep Giri
- Neurocrine Biosciences, Inc., San Diego, CA 92130, USA
| | - Eiry Roberts
- Neurocrine Biosciences, Inc., San Diego, CA 92130, USA
| | | | - Jean L Chan
- Neurocrine Biosciences, Inc., San Diego, CA 92130, USA
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17
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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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Tian Y, Hou L, Xiang S, Tian X, Xu J. Congenital adrenal hyperplasia disorder due to 17 α-hydroxylase deficiency: a case report. Gynecol Endocrinol 2023; 39:2250001. [PMID: 37683689 DOI: 10.1080/09513590.2023.2250001] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/06/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder with a related enzyme deficiency involved in the adrenal corticosteroid synthesis pathway due to genetic mutations. 17α-hydroxylase deficiency(17α-OHD) is a rare form of CAH. Herein, we reported clinical data on diagnosis and treatment regimens for a 17α-hydroxylase-deficient patient. A 24-year-old female patient was admitted to the hospital with limb numbness for 7 days and sudden limb weakness. Full laboratory and radio-imaging investigations showed hypokalemia and abdominal occupation. Abnormal rhythm of cortisol(Cor) and adrenocorticotrophic hormone (ACTH)was observed. The diagnosis was confirmed by molecular mutation detection, which showed a homozygous mutation of c.987del in the 17-hydroxylase/17,20-lyase deficiency (17OHD) lease-related CYP17A1 from both biological parents. The patient was treated with prednisone acetate and estradiol valerate. After one year of treatment with predisoone acetate and estradiol valerate, the patient had normal menstruation, increased blood potassium, estradiol and 24h-UFC, and decreased ACTH level. There is no significant change in large adrenal hyperplasia lesions although sexual characteristics and menstrual cycles have recovered. Through this case and literature review, it can be concluded that CAH with 17α-OHD can be diagnosed according to the genetic detection.
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Affiliation(s)
- Yunling Tian
- Department of Endocrinology and Metabolic, The First Hospital of Lanzhou University, Lanzhou, Gansu, P.R.China
| | - Lijie Hou
- Department of Endocrinology and Metabolic, The First Hospital of Lanzhou University, Lanzhou, Gansu, P.R.China
| | - Shulan Xiang
- Department of General Family Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu, P.R.China
| | - Xuguang Tian
- Lintao Country People's Hospital, Lintao, Dingxi, Gansu, P.R.China
| | - Jinhui Xu
- Department of Respiratory medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu, P.R.China
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Harasymiw LA, Grosse SD, Cullen KR, Bitsko RH, Perou R, Sarafoglou K. Depressive and anxiety disorders and antidepressant prescriptions among insured children and young adults with congenital adrenal hyperplasia in the United States. Front Endocrinol (Lausanne) 2023; 14:1129584. [PMID: 37664854 PMCID: PMC10470620 DOI: 10.3389/fendo.2023.1129584] [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: 12/22/2022] [Accepted: 07/25/2023] [Indexed: 09/05/2023] Open
Abstract
Background Dysfunction in the hypothalamic-pituitary-adrenal axis has been associated with depressive and anxiety disorders. Little is known about the risk for these disorders among individuals with congenital adrenal hyperplasia (CAH), a form of primary adrenal insufficiency. Objective We investigated the prevalence of depressive and anxiety disorders and antidepressant prescriptions in two large healthcare databases of insured children, adolescents, and young adults with CAH in the United States. Methods We conducted a retrospective cohort study using administrative data from October 2015 through December 2019 for individuals aged 4-25 years enrolled in employer-sponsored or Medicaid health plans. Results Adjusting for age, the prevalence of depressive disorders [adjusted prevalence ratio (aPR) = 1.7, 95% confidence interval (CI): 1.4-2.0, p<0.001], anxiety disorders [aPR = 1.7, 95% CI: 1.4-1.9, p<0.001], and filled antidepressant prescriptions [aPR = 1.7, 95% CI: 1.4-2.0, p<0.001] was higher among privately insured youth with CAH as compared to their non-CAH peers. Prevalence estimates were also higher among publicly insured youth with CAH for depressive disorders [aPR = 2.3, 95% CI: 1.9-2.9, p<0.001], anxiety disorders [aPR = 2.0, 95% CI: 1.6-2.5, p<0.001], and filled antidepressant prescriptions [aPR = 2.5, 95% CI: 1.9-3.1, p<0.001] as compared to their non-CAH peers. Conclusions The elevated prevalence of depressive and anxiety disorders and antidepressant prescriptions among youth with CAH suggests that screening for symptoms of depression and anxiety among this population might be warranted.
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Affiliation(s)
- Lauren A. Harasymiw
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Scott D. Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Kathryn R. Cullen
- Department of Psychiatry and Behavioral Science, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Rebecca H. Bitsko
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Ruth Perou
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Kyriakie Sarafoglou
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN, United States
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, United States
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Shafaay EA, Aldriweesh MA, Aljahdali GL, Babiker A, Alomar AO, Alharbi KM, Aldalaan H, Alenazi A, Alangari AS, Alsagheir A, Adriaansen BPH, Claahsen – van der Grinten HL, Al Alwan I. The clinical characteristics and quality of life of 248 pediatric and adult patients with Congenital Adrenal Hyperplasia. Front Endocrinol (Lausanne) 2023; 14:1122435. [PMID: 37347111 PMCID: PMC10280019 DOI: 10.3389/fendo.2023.1122435] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/16/2023] [Indexed: 06/23/2023] Open
Abstract
Background Congenital Adrenal Hyperplasia (CAH) is a chronic disease that requires lifelong treatment. Patients may face stigmatization, which may affect their quality of life (QoL). Therefore, we assessed the clinical characteristics and QoL of patients with CAH in the Middle East. Methods This case-control study included patients with CAH aged >5 years from two tertiary centers (2020-2021). The patients were matched to a healthy control group and were then divided into pediatric and adult groups. Data were collected from their electronic medical records. Additionally, the EQ-5D-5L QoL questionnaire was completed by both the patients and control group to assess five domains (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). Results The study included 248 patients with CAH (females: 58.8%), with a family history of the condition (57.3%) and/or parental consanguinity (68.1%). The most frequently reported gene defect was CYP21A2, while the most commonly reported symptoms/signs were ambiguous genitalia and obesity. Almost all female patients had received corrective surgery. The questionnaire response rate was 86.3% (n=214/248). The CAH patient group's mean total QoL score was 85.2 compared with 99.8 in the control. Further, CAH patients had lower QoL scores in all domains compared to those in the control group (p ≤ 0.0001-0.0023). The pain/discomfort and anxiety/depression domains were affected significantly more than the other domains were, with 47.7% and 44.4% participants, respectively, p<0.0001. Additionally, obesity was found to be a predictor of reduced mobility following a logistic regression analysis (p ≤ 0.04, OR (0.18-0.98)). Conclusion Patients with CAH reported lower QoL overall, particularly in the pain/discomfort and anxiety/depression domains. Based on this, we recommend the early involvement of psychologists in a multidisciplinary team approach, pre-marital screening, and the implementation of awareness programs for people diagnosed with CAH in communities with high consanguineous mating.
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Affiliation(s)
- Edi A. Shafaay
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mohammed A. Aldriweesh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ghadeer L. Aljahdali
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Amir Babiker
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pediatrics, King Abdullah Specialized Children’s Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulrahman O. Alomar
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Khulood M. Alharbi
- Department of Pediatrics, College of Medicine, Taibah University, Madinah, Saudi Arabia
| | - Haneen Aldalaan
- Department of Pediatrics, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ahmed Alenazi
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Department of Pediatrics, Prince Mohammed Bin Abdulziz Medical City, Aljouf, Saudi Arabia
| | - Abdulaziz S. Alangari
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Epidemiology and Biostatistics, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Afaf Alsagheir
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Bas P. H. Adriaansen
- Department of Pediatrics, Radboud Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Ibrahim Al Alwan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pediatrics, King Abdullah Specialized Children’s Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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Carrière C, Nguyen LS, Courtillot C, Tejedor I, Chakhtoura Z, Bellanné-Chantelot C, Tardy V, Leban M, Touraine P, Bachelot A. Fertility and pregnancy outcomes in women with nonclassic 21-hydroxylase deficiency. Clin Endocrinol (Oxf) 2023; 98:315-322. [PMID: 36325983 DOI: 10.1111/cen.14842] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/19/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Overall fertility and pregnancy outcomes in patients with nonclassic congenital adrenal hyperplasia (NCCAH) have been poorly studied. It has been suggested that hydrocortisone (HC) may decrease the time to conceive (TTC) and the rate of miscarriage in these patients. OBJECTIVES To describe fertility and pregnancy outcomes in a large cohort of NCCAH women. The secondary objective was to identify factors that could impact reproductive outcomes, with a particular focus on HC dose and genetic status. DESIGN Retrospective study in a referral center for congenital adrenal hyperplasia. PATIENTS AND MEASUREMENTS: One hundred seventy-three female patients with NCCAH confirmed by genetic testing, followed in our center between 2010 and 2019. RESULTS Among the 173 patients, 95 women had a parental project, 86 of whom presented 176 pregnancies, 56% under glucocorticoid (GC) treatment and 44% without, and 76 women obtained 128 live births. Two-thirds of the patients regularized their cycle under GC treatment, with significant decrease of androgens and progesterone levels. This treatment was associated with a shortening of TTC (coef β = -.196, information coefficient [IC] = [-10.7; -0.91], p = .021). Androgen levels and TTC were positively correlated to the rate of miscarriage (OR = 4.8, IC = [1.15; 20.34], p = .021 for testosterone, OR = 1.4, IC = [1.05; 1.81], p = .02 for androstenedione, and OR = 1.03, IC = [1.01; 1.06], p = .015 for TTC). There was no difference in terms of obstetric outcomes between patients with or without GC treatment. CYP21A2 genotype had no impact on pregnancy outcome or TTC. CONCLUSIONS Infertility is relative in patients with NCCAH. HC seems beneficial for fertility and pregnancy outcomes, especially for patients with menstrual disorders and high preconceptional androgen levels.
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Affiliation(s)
- Camille Carrière
- Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
| | - Lee S Nguyen
- Clinical Investigations Center, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
- Research and Innovation Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Carine Courtillot
- Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
| | - Isabelle Tejedor
- Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
| | - Zeina Chakhtoura
- Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
| | - Christine Bellanné-Chantelot
- Department of Medical Genetics, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université Médecine, Paris, France
| | - Véronique Tardy
- Department of Molecular Endocrinology and Rare Diseases, Center for Biology and Eastern Pathology, Civil Hospitals of Lyon, Bron, France
| | - Monique Leban
- Department of Hormonal Biochemistry, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université Médecine, Paris, France
| | - Anne Bachelot
- Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université Médecine, Paris, France
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Bello R, Lazar L, Phillip M, de Vries L. Compromised Adult Height in Females with Non-Classical Congenital Adrenal Hyperplasia Diagnosed in Childhood. Horm Res Paediatr 2023; 96:465-472. [PMID: 36806217 DOI: 10.1159/000529772] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 02/08/2023] [Indexed: 02/22/2023] Open
Abstract
INTRODUCTION Data on adult height (AHt) in individuals with non-classical congenital adrenal hyperplasia (NCCAH) are inconsistent. METHODS We conducted a retrospective study of 109 females diagnosed with NCCAH at age <18 years who reached AHt. We studied AHt compared to target height (THt) and the correlation of AHt with clinical parameters. RESULTS The mean age at diagnosis was 9.7 ± 4.4 years; the mean follow-up was 10.9 ± 6.3 years. Hydrocortisone treatment (11.0 ± 5.0 mg/m2) was initiated at age 9.7 ± 4.0 years. Bone age was more advanced in girls who presented with central precocious puberty or early puberty (CPP/EP) (n = 43) than with timely puberty. AHt-standard deviation score (SDS) was lower than Ht-SDS at diagnosis (-0.8 ± 1.0 vs. +0.2 ± 1.3; p < 0.001) and -0.3 SDS shorter than THt (p < 0.001). Height, weight, and body mass index-SDS at last visits were similar between patients treated with glucocorticoids (n = 92) and those never treated (n = 17). AHt was comparable between patients with timely puberty and with CPP/EP, with no difference between those treated or not by GnRH analogue. AHt was similar between patients who were fully pubertal (Tanner 5), pre-pubertal (Tanner 1), and pubertal (Tanner 2-4) at diagnosis (158.0 ± 7.6, 158.1 ± 6.1, and 157.5 ± 6.5, respectively; p = 0.9). AHt-SDS was correlated with THt (R = 0.67, p < 0.001) and Ht-SDS at diagnosis (R = 0.7, p < 0.001) but not with age at diagnosis (R = -0.05, p = 0.6), the extent of bone age advancement (R = -0.04, p = 0.72), glucocorticoid treatment duration (R = -0.11, p = 0.34), or dose (R = -0.04, p = 0.70). CONCLUSION AHt of females diagnosed with NCCAH in childhood was lower than their THt. Glucocorticoid treatment duration and dose, pubertal status at diagnosis, and having CPP or EP were not correlated with AHt.
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Affiliation(s)
- Rachel Bello
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Liora Lazar
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liat de Vries
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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23
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Tsai MJM, Tsai WY, Lee CT, Liu SY, Chien YH, Tung YC. Adult height of children with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Formos Med Assoc 2023; 122:106-112. [PMID: 36155706 DOI: 10.1016/j.jfma.2022.09.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/11/2022] [Accepted: 09/05/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND/PURPOSES Congenital adrenal hyperplasia attributable to 21-hydroxylase deficiency (21-OHD) is a disorder of adrenal steroidogenesis. Achievement of optimal growth by such patients is challenging. We evaluated the adult height of Taiwanese children with 21-OHD and the effect of a gonadotropin-releasing hormone analogue (GnRHa) in patients with central precocious puberty (CPP) complicating 21-OHD. METHODS Among 116 patients with 21-OHD in Taiwan, 90 who had attained adult height were subjected to an analysis of height outcomes. Nine with progressive CPP were treated with GnRHa and the effects of this therapy on adult height were further analyzed. RESULTS In the pre-screening era, the percentage of boys with 21-OHD was lower than expected. Although neonatal screening can prevent mortality caused by adrenal crisis, some cases may be missed. The pooled mean adult height of the 78 patients treated with conventional therapy were -1.1 SD and -0.5 SD adjusting for the genetic potential. The disease features affecting height outcomes are the genetic height potential and in boys the simple virilizing type. Nine patients with CPP were treated with GnRHa in addition to conventional therapy; the mean adult height increased from the predicted -4.1 SD to -1.0 SD after 6.0 ± 2.5 years of treatment. CONCLUSION Patients with 21-OHD had poorer mean adult height. A high caregiver's index of suspicion is required for the early diagnosis of patients with 21-OHD missed on neonatal screening. Adjuvant therapy with GnRHa can improve the adult height of patients with CPP complicating 21-OHD.
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Affiliation(s)
- Meng-Ju Melody Tsai
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wen-Yu Tsai
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cheng-Ting Lee
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shih-Yao Liu
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yin-Hsiu Chien
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Ching Tung
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan.
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Abstract
Congenital adrenal hyperplasia is a group of autosomal recessive disorders leading to multiple complex hormonal imbalances caused by various enzyme deficiencies in the adrenal steroidogenic pathway. The most common type of congenital adrenal hyperplasia is due to steroid 21-hydroxylase (21-OHase, henceforth 21OH) deficiency. The rare, classic (severe) form caused by 21OH deficiency is characterised by life-threatening adrenal crises and is the most common cause of atypical genitalia in neonates with 46,XX karyotype. After the introduction of life-saving hormone replacement therapy in the 1950s and neonatal screening programmes in many countries, nowadays neonatal survival rates in patients with congenital adrenal hyperplasia are high. However, disease-related mortality is increased and therapeutic management remains challenging, with multiple long-term complications related to treatment and disease affecting growth and development, metabolic and cardiovascular health, and fertility. Non-classic (mild) forms of congenital adrenal hyperplasia caused by 21OH deficiency are more common than the classic ones; they are detected clinically and primarily identified in female patients with hirsutism or impaired fertility. Novel treatment approaches are emerging with the aim of mimicking physiological circadian cortisol rhythm or to reduce adrenal hyperandrogenism independent of the suppressive effect of glucocorticoids.
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Affiliation(s)
- Matthias K Auer
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany.
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25
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Raftopoulou C, Abawi O, Sommer G, Binou M, Paltoglou G, Flück CE, van den Akker ELT, Charmandari E. Leukocyte Telomere Length in Children With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2023; 108:443-452. [PMID: 36181470 DOI: 10.1210/clinem/dgac560] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/21/2022] [Indexed: 01/20/2023]
Abstract
CONTEXT Exposure to chronic stress and hypercortisolism is associated with decreased leukocyte telomere length (LTL), a marker for biological aging and cardiovascular disease. Children with congenital adrenal hyperplasia (CAH) are treated with glucocorticoids. OBJECTIVE To investigate LTL in children with CAH. METHODS In this prospective observational cohort study, conducted at 4 academic pediatric endocrinology outpatient clinics, children with genetically confirmed CAH were assessed at 2 follow-up visits (mean 4.1 ± 0.7 months apart). At each visit, LTL was determined by quantitative real-time PCR. All subjects underwent detailed clinical and endocrinologic evaluation and were classified as undertreated, optimally treated, or overtreated, accordingly. The influence of clinical factors on LTL was investigated using linear mixed models adjusted for age, sex, and BMI-z. RESULTS We studied 76 patients, of whom 31 (41%) were girls, 63 (83%) had classic CAH, 67 (88%) received hydrocortisone, and 8 (11%) prednisolone. Median age at first visit was 12.0 years (IQR, 6.3-15.1), and median BMI-z was 0.51 (IQR, -0.12 to 1.43). LTL was shorter in patients with classic vs nonclassic CAH (-0.29, P = 0.012), in overtreated than in optimally treated patients (-0.07, P = 0.002), and patients receiving prednisolone compared with hydrocortisone (-0.34, P < 0.001). LTL was not associated with undertreatment or daily hydrocortisone-equivalent dose (P > 0.05). CONCLUSION LTL is shorter in patients with classic than nonclassic CAH, and in those who are overtreated with hydrocortisone or treated with long-acting glucocorticoids. These findings may be attributed to chronic exposure to supraphysiologic glucocorticoid concentrations and indicate that LTL may be used as a biomarker for monitoring glucocorticoid treatment.
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Affiliation(s)
- Christina Raftopoulou
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, 'Aghia Sophia' Children's Hospital, Athens 11527, Greece
- Division of Endocrinology and Metabolism, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens 11527, Greece
| | - Ozair Abawi
- Division of Endocrinology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam 3000 CA, The Netherlands
| | - Grit Sommer
- Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Bern and Department of BioMedical Research, University Hospital Inselspital, University of Bern, Bern 3010, Switzerland
| | - Maria Binou
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, 'Aghia Sophia' Children's Hospital, Athens 11527, Greece
- Division of Endocrinology and Metabolism, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens 11527, Greece
| | - George Paltoglou
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, 'Aghia Sophia' Children's Hospital, Athens 11527, Greece
- Division of Endocrinology and Metabolism, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens 11527, Greece
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Bern and Department of BioMedical Research, University Hospital Inselspital, University of Bern, Bern 3010, Switzerland
| | - Erica L T van den Akker
- Division of Endocrinology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam 3000 CA, The Netherlands
| | - E Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, 'Aghia Sophia' Children's Hospital, Athens 11527, Greece
- Division of Endocrinology and Metabolism, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens 11527, Greece
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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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Liu SC, Suresh M, Jaber M, Mercado Munoz Y, Sarafoglou K. Case Report: Anastrozole as a monotherapy for pre-pubertal children with non-classic congenital adrenal hyperplasia. Front Endocrinol (Lausanne) 2023; 14:1101843. [PMID: 36936152 PMCID: PMC10018749 DOI: 10.3389/fendo.2023.1101843] [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: 11/18/2022] [Accepted: 02/17/2023] [Indexed: 03/06/2023] Open
Abstract
Most children with non-classic congenital adrenal hyperplasia (NC-CAH) due to 21-hydroxylase deficiency are asymptomatic and do not require cortisol replacement therapy unless they develop symptoms of hyperandrogenemia. The current practice is to treat symptomatic children with hydrocortisone aimed at suppressing excess adrenal androgen production irrespective of the child's level of endogenous cortisol production. Once on hydrocortisone therapy, even children with normal cortisol production require stress dosing. Some children with NC-CAH may present with premature adrenarche, growth acceleration, and advanced bone age, but with no signs of genital virilization and normal endogenous cortisol production. In these cases, an alternative therapy to hydrocortisone treatment that does not impact the hypothalamic-pituitary-adrenal axis, but targets increased estrogen production and its effects on bone maturation, could be considered. Aromatase inhibitors (AIs), which block the aromatization of androgen to estrogen, have been used off-label in men with short stature to delay bone maturation and as an adjunct therapy in children with classic CAH. The use of AI as a monotherapy for children with NC-CAH has never been reported. We present three pre-pubertal female children with a diagnosis of NC-CAH treated with anastrozole monotherapy after presenting with advanced bone age, early adrenarche, no signs of genital virilization, and normal peak cortisol in response to ACTH stimulation testing. Bone age z-scores normalized, and all three reached or exceeded their target heights. Monotherapy with anastrozole can be an effective alternative in slowing down bone maturation and improving height outcomes in children with NC-CAH and normal adrenal cortisol production.
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Affiliation(s)
- Sandy C. Liu
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Malavika Suresh
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Mutaz Jaber
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, United States
| | - Yesica Mercado Munoz
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Kyriakie Sarafoglou
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN, United States
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, United States
- *Correspondence: Kyriakie Sarafoglou,
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Itonaga T, Hasegawa Y. Monitoring treatment in pediatric patients with 21-hydroxylase deficiency. Front Endocrinol (Lausanne) 2023; 14:1102741. [PMID: 36843618 PMCID: PMC9945343 DOI: 10.3389/fendo.2023.1102741] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
21-hydroxylase deficiency (21-OHD) is the most common form of congenital adrenal hyperplasia. In most developed countries, newborn screening enables diagnosis of 21-OHD in asymptomatic patients during the neonatal period. In addition, recent advances in genetic testing have facilitated diagnosing 21-OHD, particularly in patients with equivocal clinical information. On the other hand, many challenges related to treatment remain. The goals of glucocorticoid therapy for childhood 21-OHD are to maintain growth and maturation as in healthy children by compensating for cortisol deficiency and suppressing excess adrenal androgen production. It is not easy to calibrate the glucocorticoid dosage accurately for patients with 21-OHD. Auxological data, such as height, body weight, and bone age, are considered the gold standard for monitoring of 21-OHD, particularly in prepuberty. However, these data require months to a year to evaluate. Theoretically, biochemical monitoring using steroid metabolites allows a much shorter monitoring period (hours to days). However, there are many unsolved problems in the clinical setting. For example, many steroid metabolites are affected by the circadian rhythm and timing of medication. There is still a paucity of evidence for the utility of biochemical monitoring. In the present review, we have attempted to clarify the knowns and unknowns about treatment parameters in 21-OHD during childhood.
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Affiliation(s)
- Tomoyo Itonaga
- Department of Pediatrics, Oita University Faculty of Medicine, Oita, Japan
- *Correspondence: Tomoyo Itonaga,
| | - Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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Waaijers S, Utari A, van der Doelen RHA, Faradz SMH, Hensen-Lodewijk R, Olthaar AJ, Geutjes PJ, Sweep FC, Claahsen-van der Grinten HL, van Herwaarden AE. Measuring steroids in hair opens up possibilities to identify congenital adrenal hyperplasia in developing countries. Clin Endocrinol (Oxf) 2023; 98:41-48. [PMID: 35514026 PMCID: PMC10084416 DOI: 10.1111/cen.14754] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/16/2022] [Accepted: 04/25/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Patients with congenital adrenal hyperplasia (CAH) in developing countries have limited access to appropriate laboratory facilities for diagnosis and follow-up. The aim of this study is to evaluate steroid measurement in hair as a diagnostic tool to identify and monitor CAH in these patients. DESIGN A method was developed to measure steroids in hair, the stability of steroids in hair was assessed, and the concentration range in healthy volunteers was determined. Hair samples of patients, before and after starting therapy, were transported at ambient temperature to The Netherlands for analysis. PATIENTS Twenty-two Indonesian CAH patients and 84 healthy volunteers participated. MEASUREMENTS Cortisol, 17-hydroxyprogesterone (17OHP), androstenedione, and testosterone in hair were measured by liquid chromatography with tandem mass spectrometry. RESULTS Steroids in hair could be measured and remained stable (<4.9% deviation) for at least 3 weeks at 4°C and 30°C. In each of the untreated patients, hair concentrations of 17OHP (9.43-1135 pmol/g), androstenedione (36.1-432 pmol/g), and testosterone (2.85-69.2 pmol/g) were all above the upper limit of the corresponding range in healthy volunteers; 5.5 pmol/g, 13 pmol/g, and 1.8 pmol/g, respectively. After starting glucocorticoid treatment, the steroid concentrations in the hair of CAH patients decreased significantly for androstenedione (73%) and testosterone (59%) after 6 months. CONCLUSIONS CAH could be confirmed in Indonesian patients based on the concentration of 17OHP, androstenedione, and testosterone in hair, and a treatment effect was observed. These findings open up opportunities to diagnose and/or monitor CAH in developing countries with a simple noninvasive technique.
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Affiliation(s)
- Selma Waaijers
- Department of Laboratory Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Agustini Utari
- Division of Human Genetics, Center for Biomedical Research (CEBIOR), Faculty of Medicine Diponegoro University, Semarang, Indonesia
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine Diponegoro University, Semarang, Indonesia
| | - Rick H A van der Doelen
- Department of Laboratory Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Sultana M H Faradz
- Division of Human Genetics, Center for Biomedical Research (CEBIOR), Faculty of Medicine Diponegoro University, Semarang, Indonesia
| | - Renate Hensen-Lodewijk
- Department of Laboratory Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Andre J Olthaar
- Department of Laboratory Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Paul J Geutjes
- Department of Laboratory Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Fred C Sweep
- Department of Laboratory Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Hedi L Claahsen-van der Grinten
- Department of Pediatrics, Radboud University Medical Center, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
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de Castro M, Martins CS, Antonini SR. Prenatal Dexamethasone Treatment of Congenital Adrenal Hyperplasia: Are We Any Closer to Considering It Safe? J Clin Endocrinol Metab 2022; 108:e9-e10. [PMID: 36101901 DOI: 10.1210/clinem/dgac524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 08/24/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Margaret de Castro
- Department of Internal Medicine of Ribeirao Preto Medical School, University of São Paulo, 14049-900 Ribeirao Preto, São Paulo, Brazil
| | - Clarissa Silva Martins
- Department of Internal Medicine of Ribeirao Preto Medical School, University of São Paulo, 14049-900 Ribeirao Preto, São Paulo, Brazil
- Faculty of Medicine, Federal University of Mato Grosso do Sul, 79070-900, Campo Grande, Mato Grosso do Sul, Brazil
| | - Sonir R Antonini
- Department of Pediatrics of Ribeirao Preto Medical School, University of São Paulo, 14049-900 Ribeirao Preto, São Paulo, Brazil
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Lawrence N, Bacila I, Dawson J, Bryce J, Ali SR, van den Akker ELT, Bachega TASS, Baronio F, Birkebæk NH, Bonfig W, van der Grinten HC, Costa EC, de Vries L, Elsedfy H, Güven A, Hannema S, Iotova V, van der Kamp HJ, Clemente M, Lichiardopol CR, Milenkovic T, Neumann U, Nordenström A, Poyrazoğlu Ş, Probst‐Scheidegger U, De Sanctis L, Tadokoro‐Cuccaro R, Thankamony A, Vieites A, Yavaş Z, Faisal Ahmed S, Krone N. Analysis of therapy monitoring in the International Congenital Adrenal Hyperplasia Registry. Clin Endocrinol (Oxf) 2022; 97:551-561. [PMID: 35781728 PMCID: PMC9796837 DOI: 10.1111/cen.14796] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Congenital adrenal hyperplasia (CAH) requires exogenous steroid replacement. Treatment is commonly monitored by measuring 17-OH progesterone (17OHP) and androstenedione (D4). DESIGN Retrospective cohort study using real-world data to evaluate 17OHP and D4 in relation to hydrocortisone (HC) dose in CAH patients treated in 14 countries. PATIENTS Pseudonymized data from children with 21-hydroxylase deficiency (21OHD) recorded in the International CAH Registry. MEASUREMENTS Assessments between January 2000 and October 2020 in patients prescribed HC were reviewed to summarise biomarkers 17OHP and D4 and HC dose. Longitudinal assessment of measures was carried out using linear mixed-effects models (LMEM). RESULTS Cohort of 345 patients, 52.2% female, median age 4.3 years (interquartile range: 3.1-9.2) were taking a median 11.3 mg/m2 /day (8.6-14.4) of HC. Median 17OHP was 35.7 nmol/l (3.0-104.0). Median D4 under 12 years was 0 nmol/L (0-2.0) and above 12 years was 10.5 nmol/L (3.9-21.0). There were significant differences in biomarker values between centres (p < 0.05). Correlation between D4 and 17OHP was good in multiple regression with age (p < 0.001, R2 = 0.29). In longitudinal assessment, 17OHP levels did not change with age, whereas D4 levels increased with age (p < 0.001, R2 = 0.08). Neither biomarker varied directly with dose or weight (p > 0.05). Multivariate LMEM showed HC dose decreasing by 1.0 mg/m2 /day for every 1 point increase in weight standard deviation score. DISCUSSION Registry data show large variability in 17OHP and D4 between centres. 17OHP correlates with D4 well when accounting for age. Prescribed HC dose per body surface area decreased with weight gain.
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Affiliation(s)
- Neil Lawrence
- Department of Oncology and MetabolismUniversity of SheffieldSheffieldUK
- Sheffield Children's Hospital NHS Foundation TrustSheffieldUK
| | - Irina Bacila
- Department of Oncology and MetabolismUniversity of SheffieldSheffieldUK
| | - Jeremy Dawson
- Institute of Work Psychology, Management SchoolUniversity of SheffieldSheffieldUK
- School of Health and Related Research, University of SheffieldSheffieldUK
| | - Jillian Bryce
- Office for Rare ConditionsRoyal Hospital for Children & Queen Elizabeth University HospitalGlasgowUK
- Office for Rare ConditionsRoyal Hospital for Children & Queen Elizabeth University HospitalGlasgowUK
| | - Salma R. Ali
- Office for Rare ConditionsRoyal Hospital for Children & Queen Elizabeth University HospitalGlasgowUK
- Office for Rare ConditionsRoyal Hospital for Children & Queen Elizabeth University HospitalGlasgowUK
- Developmental Endocrinology Research GroupUniversity of GlasgowGlasgowUK
| | - Erica L. T. van den Akker
- Department of Pediatric Endocrinology, Sophia Children's HospitalErasmus Medical CentreRotterdamthe Netherlands
| | - Tânia A. S. S. Bachega
- Hormones and Molecular Genetics Laboratory LIM 42, Department of Internal MedicineUniversity of Sao PauloSao PauloBrazil
| | - Federico Baronio
- Department of Medical and Surgical Sciences, Pediatric Unit, Endo‐ERN Center for Rare Endocrine DiseasesS. Orsola‐Malpighi University HospitalBolognaItaly
| | | | - Walter Bonfig
- Department of PediatricsTechnical University MunichMunichGermany
- Department of PediatricsKlinikum Wels‐GrieskirchenWelsAustria
| | - Hedi C. van der Grinten
- Department of Pediatric EndocrinologyRadboud University Medical CentreNijmegenthe Netherlands
- Amalia Children's HospitalRadboud University Medical CentreNijmegenthe Netherlands
| | - Eduardo C. Costa
- Pediatric Surgery ServiceHospital de Clínicas de Porto AlegrePorto AlegreBrazil
| | - Liat de Vries
- Institute for Diabetes and EndocrinologySchneider's Children Medical Center of IsraelPetah‐TikvahIsrael
| | - Heba Elsedfy
- Pediatrics DepartmentAin Shams UniversityCairoEgypt
| | - Ayla Güven
- Baskent University Istanbul HospitalPediatric EndocrinologyIstanbulTurkey
| | - Sabine Hannema
- Department of Paediatric Endocrinology, Erasmus MC, Sophia Children's HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
- Department of PaediatricsLeiden University Medical CentreLeidenthe Netherlands
| | - Violeta Iotova
- Department of PaediatricsMedical University of VarnaVarnaBulgaria
| | - Hetty J. van der Kamp
- Pediatric Endocrinology Wilhelmina Children's HospitalUniversity Medical Centre UtrechtUtrechtthe Netherlands
| | - María Clemente
- Paediatric Endocrinology, Hospital Universitario Vall d'HebronCIBER de Enfermedades Raras (CIBERER) ISCIIIBarcelonaSpain
| | | | - Tatjana Milenkovic
- Department of EndocrinologyInstitute for Mother and Child Healthcare of Serbia “Dr Vukan Čupić”BelgradeSerbia
| | - Uta Neumann
- Institute for Experimental Pediatric Endocrinology and Center for Chronically Sick Children, Charite‐UniversitätsmedizinBerlinGermany
| | - Ana Nordenström
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Department of Paediatric Endocrinology, Astrid Lindgren Children HospitalKarolinska University HospitalStockholmSweden
| | - Şukran Poyrazoğlu
- Istanbul Faculty of Medicine, Paediatric Endocrinology UnitIstanbul UniversityIstanbulTurkey
| | | | - Luisa De Sanctis
- Paediatric EndocrinologyRegina Margherita Children's HospitalTorinoItaly
- Department of Public Sciences and PediatricsUniversity of TorinoTorinoItaly
| | - Rieko Tadokoro‐Cuccaro
- Department of PediatricsUniversity of Cambridge, Cambridge, United Kingdom Biomedical CampusCambridgeUK
| | - Ajay Thankamony
- Department of PediatricsUniversity of Cambridge, Cambridge, United Kingdom Biomedical CampusCambridgeUK
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas (CEDIE‐CONICET), Hospital de Niños Ricardo GutiérrezBuenos AiresArgentina
| | - Zehra Yavaş
- Pediatric Endocrinology and DiabetesMarmara UniversityIstanbulTurkey
| | - Syed Faisal Ahmed
- Office for Rare ConditionsRoyal Hospital for Children & Queen Elizabeth University HospitalGlasgowUK
- Office for Rare ConditionsRoyal Hospital for Children & Queen Elizabeth University HospitalGlasgowUK
- Developmental Endocrinology Research GroupUniversity of GlasgowGlasgowUK
| | - Nils Krone
- Department of Oncology and MetabolismUniversity of SheffieldSheffieldUK
- Sheffield Children's Hospital NHS Foundation TrustSheffieldUK
- Department of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität DresdenDresdenGermany
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Ozdemir Dilek S, Turan I, Gurbuz F, Celiloglu C, Yuksel B. The utility of annual growth velocity standard deviation scores and measurements of biochemical parameters in long-term treatment monitoring of children with 21-hydroxylase deficiency. Hormones (Athens) 2022; 21:391-397. [PMID: 35243601 DOI: 10.1007/s42000-022-00354-1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/02/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE This study aimed to investigate the utility of annual growth velocity (GV) standard deviation scores (SDSs) and compatibility and effectiveness of biochemical parameters in long-term treatment monitoring and management of 21-hydroxylase deficiency (21-OHD) in children. METHODS Fifty children with 21-OHD were included in this study, and the biochemical parameters obtained during 402 visits were retrospectively evaluated. The follow-up period was divided between two GV SDS groups (GV SDS < 2 and GV SDS ≥ 2) and compared with auxological, biochemical, and clinical findings. RESULTS Elevation of 17-hydroxyprogesterone (17-OHP) values was observed at 193/402 visits, and both adrenocorticotropic hormone (ACTH) and total testosterone (tT) were observed at 53 of 193 (27.5%) visits. The calculated cut-off value for 17-OHP was > 4.3 ng/ml, with a sensitivity of 85.48% and specificity of 37.59% in the GV SDS ≥ 2 group. In the GV SDS ≥ 2 group, the corrected final height SDS (cFH SDS) was lower, and the delta height was higher than in the GV SDS < 2 group (p = 0.005 and p = 0.008, respectively). Linear regression analysis of the GV SDSs revealed that 17-OHP values and the hydrocortisone dose (mg/m2) were affected (β = 0.037, p = 0.035, and β = - 0.147, p = 0.001, respectively). CONCLUSIONS Annual GV was critical in the final height (FH) of children with 21-OHD. However, we observed inconsistency between the biochemical parameters in the follow-ups, and there were difficulties in evaluating these markers. Therefore, annual GV SDSs and biochemical findings should be used together in patients with 21-OHD at follow-ups.
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Affiliation(s)
- Semine Ozdemir Dilek
- Department of Pediatrics, Division of Pediatric Endocrinology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ihsan Turan
- Department of Pediatrics, Division of Pediatric Endocrinology, Cukurova University Faculty of Medicine, Adana, Turkey.
| | - Fatih Gurbuz
- Department of Pediatrics, Division of Pediatric Endocrinology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Can Celiloglu
- Department of Pediatrics, Division of Pediatric Endocrinology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Bilgin Yuksel
- Department of Pediatrics, Division of Pediatric Endocrinology, Cukurova University Faculty of Medicine, Adana, Turkey.
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张 春, 杨 蕊, 李 蓉, 乔 杰, 王 海, 王 颖. [Successful assisted reproductive technology treatment for a woman with 46XX-17α-hydroxylase deficiency: A case report]. Beijing Da Xue Xue Bao Yi Xue Ban 2022; 54:751-755. [PMID: 35950403 PMCID: PMC9385507 DOI: 10.19723/j.issn.1671-167x.2022.04.027] [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] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Indexed: 06/15/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder, and 17α-hydroxylase deficiency (17α-OHD) is a rare type of CAH. 17α-OHD is caused by CYP17 gene mutation, resulting in partial or complete deficiency of 17α-hydroxylase, which in turn leads to the lack of cortisol and sex hormone production. The disease is manifested by excessive secretion of adrenocorticotropic hormone (ACTH), decreased levels of estradiol (E2) and androgen, elevated levels of proges-terone (P), follicle stimulating hormone (FSH), and luteinizing hormone (LH). Most of the patients are female in gender. According to the chromosome karyotype, 17α-OHD can be divided into 46XX and 46XY, of which 46XX is rarer. The clinical manifestations are hypokalemia and hypertension. Patients with 46XX-karyotype may have irregular menstruation, amenorrhea, and infertility. The severity of symptoms varies according to the degree of 17α-hydroxylase deficiency. Due to its untypical manifestation, the patients with partial 17α-OHD are more likely to be missed or misdiagnosed. Some 17α-OHD patients with 46, XX karyotypes have different degrees of development of internal and external reproductive organ and spontaneous menstrual cycle, so they may have the potential ovulation and fertility opportunities. However, due to the adverse effects of high serum P level on the endometrium, the patients would have infertility problems. To date, four cases from foreign countries have been reported about the infertility treatments among 46XX-17α-OHD patients, and two cases were mentioned in China without describing the process of treatments. Here, one case with partial 46XX-17α-OHD was diagnosed and successfully conceived and delivered after in vitro fertilization-embryo transfer (IVF-ET) in the Center for Reproductive Medicine, Peking University Third Hospital. Controlled ovarian stimulation with ultra-long protocol was initiated after glucocorticoid therapy was given to reduce P level. Ten oocytes were obtained and 6 embryos were cryopreserved. Frozen-thawed embryo transfer under hormonal replacement after gonadotropin releasing hormone agonist (GnRH-a) was carried out in an artificial cycle, and then the patient was successfully pregnant and delivered a healthy boy after 37 weeks of gestation by cesarean section. The treatment of this case suggests that patients with partial 46XX-17α-OHD can obtain oocytes and embryos with good quality. IVF combined with frozen-thawed embryo transfer under artificial cycle is an effective method for patients with partial 46XX-17α-OHD with infertility.
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Affiliation(s)
- 春梅 张
- 北京大学第三医院妇产科,生殖医学中心,北京 100191Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
| | - 蕊 杨
- 北京大学第三医院妇产科,生殖医学中心,北京 100191Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
| | - 蓉 李
- 北京大学第三医院妇产科,生殖医学中心,北京 100191Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
| | - 杰 乔
- 北京大学第三医院妇产科,生殖医学中心,北京 100191Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
| | - 海宁 王
- 北京大学第三医院内分泌科,北京 100191Department of Endocrinology, Peking University Third Hospital, Beijing 100191, China
| | - 颖 王
- 北京大学第三医院妇产科,生殖医学中心,北京 100191Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China
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Costa S, Sampaio L, Berta Sousa A, Xing C, Agarwal AK, Garg A. Face-sparing Congenital Generalized Lipodystrophy Type 1 Associated With Nonclassical Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2022; 107:2433-2438. [PMID: 35857714 PMCID: PMC9387702 DOI: 10.1210/clinem/dgac406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 03/17/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Congenital generalized lipodystrophy, type 1 (CGL1), due to biallelic pathogenic variants in AGPAT2, is characterized by the near total loss of body fat from the face, trunk, and extremities. Patients develop premature diabetes, hypertriglyceridemia, hepatic steatosis, and polycystic ovary syndrome. However, sparing of the facial fat and precocious pubertal development has not been previously reported in CGL1. CASE DESCRIPTION We report a 21-year-old woman of European descent with CGL1 who had sparing of the facial fat and premature thelarche at birth with premature pubarche and menstrual bleeding at age 3 years. Her serum 17-OH progesterone level rose to 1000 ng/dL (30.26 nmol/L) after cosyntropin stimulation test, suggestive of nonclassical congenital adrenal hyperplasia (NCAH) due to 21-hydroxylase deficiency. Hydrocortisone replacement therapy from age 3.5 to 10 years resulted in cessation of menstruation and growth of pubic hair, and a reduction of breast size. Sanger and whole-exome sequencing revealed compound heterozygous variants c.493-1G>C; p.(Leu165_Gln196del), and c.del366_588+534; p.(Leu123Cysfs*55) in AGPAT2 plus c.806G>C; p.(Ser269Thr) and c.844G>T; p.(Val282Leu) in CYP21A2. She developed diabetes at age 13 requiring high-dose insulin and had 7 episodes of acute pancreatitis due to extreme hypertriglyceridemia in the next 5 years. Metreleptin therapy was initiated at age 18 and after 3 years, she had remission of diabetes and hypertriglyceridemia; however, menstrual irregularity and severe hirsutism did not improve. CONCLUSION Concomitant NCAH in this CGL1 patient was associated with precocious pubertal development and sparing of facial fat. Metreleptin therapy drastically improved her hyperglycemia and hyperlipidemia but not menstrual irregularity and hirsutism.
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Affiliation(s)
- Sara Costa
- Paediatric Endocrine Unit, Department of Pediatrics, Hospital de Santa Maria/CHULN, 1649-035 Lisbon, Portugal
| | - Lurdes Sampaio
- Paediatric Endocrine Unit, Department of Pediatrics, Hospital de Santa Maria/CHULN, 1649-035 Lisbon, Portugal
| | - Ana Berta Sousa
- Genetics Service, Department of Pediatrics, Hospital de Santa Maria/CHULN, 1649-035 Lisbon, Portugal
| | - Chao Xing
- Eugene McDermott Center for Human Growth and Development, Department of Bioinformatics, and Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, Texas 75390-8591, USA
| | - Anil K Agarwal
- Division of Nutrition and Metabolic Diseases, Department of Internal Medicine and the Center for Human Nutrition, UT Southwestern Medical Center, Dallas, Texas 75390-8537, USA
| | - Abhimanyu Garg
- Correspondence: Abhimanyu Garg, MD, Division of Nutrition and Metabolic Diseases, Department of Internal Medicine and the Center for Human Nutrition, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8537, USA.
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Kaur J, Singla M, Bhansali A, Bhadada S, Walia R. Anthropometric and Pubertal Outcomes in Girls With Classical Congenital Adrenal Hyperplasia. Indian Pediatr 2022; 59:535-538. [PMID: 35596648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To evaluate the anthropometric and pubertal outcomes, over a spectrum of treatment regimens and compliance. METHODS We reviewed records of the patients with classical CAH seen at the endocrinology clinic of a tertiary care center between 1995 and 2016. RESULTS 25 females were included in the study, the majority (80%) with simple virilizing variant. All patients had genital ambiguity since birth, yet 40% (10/25) presented much later with menstrual complaints. All patients received hydrocortisone, but some switched to dexa-methasone (n=7) or prednisolone (n=4). 7/9 (77.9%) girls who achieved target height, were on hydrocortisone. Menarche occurred with corticosteroid treatment in 60% (15/25) patients at a median (IQR) age of 16 (12-22) years. CONCLUSION Hydrocortisone seems to have a beneficial effect on linear growth. Once target height is achieved, dexamethasone may be considered as an alternative.
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Affiliation(s)
- Japleen Kaur
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh
| | - Mandeep Singla
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh
| | - Sanjay Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh
| | - Rama Walia
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. Correspondence to: Dr Rama Walia, Associate Professor, Endocrinology Office, Nehru Hospital Extension, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160 012.
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Adriaansen BPH, Kamphuis JS, Schröder MAM, Olthaar AJ, Bock C, Brandt A, Stikkelbroeck NMML, Lentjes EGWM, Span PN, Sweep FCGJ, Claahsen‐van der Grinten HL, van Herwaarden AE. Diurnal salivary androstenedione and 17-hydroxyprogesterone levels in healthy volunteers for monitoring treatment efficacy of patients with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2022; 97:36-42. [PMID: 35150157 PMCID: PMC9542109 DOI: 10.1111/cen.14690] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/13/2021] [Accepted: 12/19/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Treatment of congenital adrenal hyperplasia (CAH) patients with glucocorticoids is often challenging since there is a delicate balance between over- and undertreatment. Treatment can be monitored noninvasively by measuring salivary androstenedione (A4) and 17-hydroxyprogesterone (17-OHP). Optimal treatment monitoring requires the establishment of reference values in saliva. DESIGN A descriptive study. PATIENTS For this study saliva of 255 healthy paediatric and adult volunteers with an age range of 4-75 years old was used. MEASUREMENTS We developed a sensitive liquid chromatography-tandem mass spectrometry method, assessed salivary A4 and 17-OHP stability, and measured A4 and 17-OHP concentrations in saliva collected in the morning, afternoon, and evening. RESULTS We quantified A4 and 17-OHP concentrations in the morning, afternoon, and evening and demonstrated that there is a significant rhythm with the highest levels in the morning and decreasing levels over the day. A4 and 17-OHP concentrations display an age-dependent pattern. These steroids remain stable in saliva at ambient temperature for up to 5 days. CONCLUSIONS Good stability of the steroids in saliva enables saliva collection by the patient at home. Since salivary A4 and 17-OHP display a diurnal rhythm and age-dependent pattern, we established reference values for both children and adults at three time points during the day. These reference values support treatment monitoring of children and adults with CAH.
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Affiliation(s)
- Bas P. H. Adriaansen
- Department of Laboratory Medicine, Radboud Institute of Health SciencesRadboud University Medical CentreNijmegenThe Netherlands
- Department of Paediatric Endocrinology, Amalia Children's HospitalRadboud University Medical CentreNijmegenThe Netherlands
| | - Johannes S. Kamphuis
- Department of Clinical Chemistry and HaematologyGelre HospitalsApeldoornThe Netherlands
| | - Mariska A. M. Schröder
- Department of Paediatric Endocrinology, Amalia Children's HospitalRadboud University Medical CentreNijmegenThe Netherlands
- Department of Laboratory Medicine, Radboud Institute of Molecular Life SciencesRadboud University Medical CentreNijmegenThe Netherlands
| | - André J. Olthaar
- Department of Laboratory Medicine, Radboud Institute of Health SciencesRadboud University Medical CentreNijmegenThe Netherlands
| | - Carina Bock
- Department of Laboratory Medicine, Radboud Institute of Health SciencesRadboud University Medical CentreNijmegenThe Netherlands
| | - André Brandt
- Department of Laboratory Medicine, Radboud Institute of Health SciencesRadboud University Medical CentreNijmegenThe Netherlands
| | | | - Eef G. W. M. Lentjes
- Central Diagnostic LaboratoryUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - Paul N. Span
- Department of Radiation OncologyRadboud University Medical CentreNijmegenThe Netherlands
| | - Fred C. G. J. Sweep
- Department of Laboratory Medicine, Radboud Institute of Health SciencesRadboud University Medical CentreNijmegenThe Netherlands
| | | | - Antonius E. van Herwaarden
- Department of Laboratory Medicine, Radboud Institute of Health SciencesRadboud University Medical CentreNijmegenThe Netherlands
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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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Abstract
Patients with classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency (21OHD) need life-long medical treatment to replace the lacking glucocorticoids and potentially lacking mineralocorticoids and to lower elevated adrenal androgens. Long-term complications are common, including gonadal dysfunction, infertility, and cardiovascular and metabolic co-morbidity with reduced quality of life. These complications can be attributed to the exposure of supraphysiological dosages of glucocorticoids and the longstanding exposure to elevated adrenal androgens. Development of novel therapies is necessary to address the chronic glucocorticoid overexposure, lack of circadian rhythm in glucocorticoid replacement, and inefficient glucocorticoid delivery with concomitant periods of hyperandrogenism. In this review we aim to give an overview about the current treatment regimens and its limitations and describe novel therapies especially evaluated for 21OHD patients.
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Affiliation(s)
- Mariska A M Schröder
- Department of Pediatrics, Amalia Childrens Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
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Abstract
PURPOSE OF REVIEW Although the basic treatment of congenital adrenal hyperplasia (CAH) is well established, there are active clinical research projects to more closely mimic the normal diurnal rhythm of cortisol secretion and to reduce total glucocorticoid doses to minimize adverse metabolic effects. RECENT FINDINGS We review clinical studies on CAH treatment published in the last 18 months or currently underway according to ClinicalTrials.gov listings. These can be grouped into several broad themes: alternative dosing forms of hydrocortisone with altered pharmacokinetics or easier dose titration; corticotropin-releasing hormone receptor antagonists that reduce corticotropin (ACTH) secretion and thereby reduce adrenal androgen secretion; androgen biosynthesis inhibitors; a first clinical trial of a gene therapy vector. SUMMARY Alternative dosing forms of hydrocortisone are, or will shortly be, marketed, but cost may be a barrier to utilization, at least in the US market. Trials of corticotropin releasing hormone receptor antagonists and androgen biosynthesis inhibitors are currently underway. The author believes that trials of gene therapy for CAH are premature.
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Affiliation(s)
- Perrin C White
- UT Southwestern Medical Center, Professor of Pediatrics, Dallas, Texas, USA
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Karlsson L, Wallensteen L, Nordenström A, Krmar RT, Lajic S. Ambulatory Blood Pressure Monitoring in Children and Adults Prenatally Exposed to Dexamethasone Treatment. J Clin Endocrinol Metab 2022; 107:e2481-e2487. [PMID: 35148399 PMCID: PMC9113802 DOI: 10.1210/clinem/dgac081] [Citation(s) in RCA: 2] [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: 09/05/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The clinical use of dexamethasone (DEX) prenatally to reduce virilization of external genitalia in female fetuses with congenital adrenal hyperplasia (CAH) is efficient but still controversial. It remains challenging to prevent the excessive exposure of DEX in unborn healthy babies during the first trimester of pregnancy. OBJECTIVE Since endogenous glucocorticoids contribute to the maintenance of blood pressure (BP) and since events during fetal life may program the fetus and affect future metabolic health, the aim of this study was to analyze ambulatory BP measurements in CAH-unaffected children and adults that were prenatally exposed to DEX treatment. METHODS Ambulatory BP measurements were analyzed in 33 (16 female) DEX-treated participants aged 5.1 to 26.3 years (19 participants aged ≤ 18 years) and in 54 (28 female) age- and sex-matched apparently healthy controls aged 5.5 to 25.3 years (27 participants aged ≤ 18 years) with ambulatory normotension. RESULTS Participants' age, height, weight, and body mass index were similar between the DEX-treated group and the control group. Heart rate, 24-hour BP, pulse pressure, and nighttime dipping did not statistically significantly differ between DEX-treated participants and controls. CONCLUSION Our study suggests that prenatal DEX treatment in CAH-unaffected children and adults does not appear to adversely affect ambulatory BP later in life. Our observations need to be confirmed in larger studies.
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Affiliation(s)
- Leif Karlsson
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Lena Wallensteen
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Rafael T Krmar
- Department of Physiology and Pharmacology, Biomedicum 5B, Karolinska Institutet, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
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Ali SR, Bryce J, Krone NP, Claahsen-van der Grinten HL, Ahmed SF. Management of Acute Adrenal Insufficiency-Related Adverse Events in Children with Congenital Adrenal Hyperplasia: Results of an International Survey of Specialist Centres. Horm Res Paediatr 2022; 95:363-373. [PMID: 35569445 DOI: 10.1159/000525075] [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: 11/09/2021] [Accepted: 04/20/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION There is wide variation in reported rates of acute adrenal insufficiency (AI)-related adverse events (sick day episodes and adrenal crises) between centres. This study aimed to evaluate the level of consensus on criteria considered essential for defining and managing these events in children with Congenital Adrenal Hyperplasia. METHODS Active users of the International Congenital Adrenal Hyperplasia and International Disorders of Sex Development (I-CAH/I-DSD) Registries (n = 66), non-active users of I-CAH/I-DSD (n = 35), and the EuRRECa e-Reporting Registry (n = 10) were approached to complete an online survey. RESULTS Fifty-six centres from 27 countries responded to the survey; the response rates for the three groups were 42 (65%), 11 (31%), and 3 (30%), respectively. Steroid management plans, one to one patient education, and contact details of health care staff were provided by over 90% of centres in high-income countries. All 56 centres advised glucocorticoid stress dosing in the event of fever. Less common indications for sick day dosing included vaccination and mild afebrile intercurrent illness, recommended by 17 (30%) and 9 (16%) centres, respectively. The most frequently reported stress dosing regimens were tripling the total daily dose of hydrocortisone and administering 3 times daily and doubling or tripling the largest daily hydrocortisone dose depending on the nature of the trigger and administering 3 times daily, recommended by 24 (43%) and 21 (38%) centres, respectively. Vomiting was the most common indication for intramuscular hydrocortisone injection, reported by 34 (61%) centres. Over 50% of respondents indicated that essential clinical criteria for adrenal crisis should include fatigue and nausea or vomiting and over 60% indicated that hypotension, hyponatraemia, hyperkalaemia, and clinical improvement following parenteral glucocorticoids were essential criteria. In the event of an adrenal crisis, 47 (84%) reported that the majority of patients were admitted to hospital. For the management of an adrenal crisis, a bolus parenteral injection of hydrocortisone was the most frequently administered medication, reported by 50 (89%) centres. CONCLUSION Although there is variation in the definition and management of AI-related adverse events in children amongst centres, there is also a good level of consensus on specific aspects that can lead to greater benchmarking of care.
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Affiliation(s)
- Salma Rashid Ali
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, UK,
- Office for Rare Conditions, University of Glasgow, Glasgow, UK,
| | - Jillian Bryce
- Office for Rare Conditions, University of Glasgow, Glasgow, UK
| | - Nils P Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Hedi L Claahsen-van der Grinten
- Department of Paediatric Endocrinology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, UK
- Office for Rare Conditions, University of Glasgow, Glasgow, UK
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
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Ekbom K, Strandqvist A, Lajic S, Hirschberg A, Falhammar H, Nordenström A. The impact of adherence and therapy regimens on quality of life in patients with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2022; 96:666-679. [PMID: 34994970 PMCID: PMC9303581 DOI: 10.1111/cen.14676] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 10/07/2021] [Revised: 12/15/2021] [Accepted: 12/24/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Varying outcomes regarding the quality of life (QoL) have been reported in patients with congenital adrenal hyperplasia (CAH). To assess the impact of adherence rate to medical therapy regimens on QoL in patients with CAH. PATIENTS Adolescents and adults aged 15-72 years with CAH due to 21-hydroxylase deficiency at Karolinska University Hospital, Stockholm, Sweden. MEASUREMENTS QoL was assessed using the Addison QoL (n = 72) and RAND 36 questionnaires (n = 75). Adherence to therapy regimens was measured using the Adherence Starts with Knowledge questionnaire (ASK-12). Associations between QoL, type of glucocorticoid therapy prescribed and ASK-12 results were examined. Results were compared to reference RAND 36 data obtained from a representative sample from the general Swedish population. RESULTS A good adherence rate to therapy regimens and a younger age were key factors for a better QoL in study participants with CAH. Younger patients on hydrocortisone and with good adherence had higher RAND 36 scores than older patients on prednisolone independently adherence. Participants with classic CAH (both the salt-wasting and simple virilizing form) reported higher QoL than those with nonclassic CAH. Patients with CAH, especially nonclassic, more frequently reported an impaired QoL than the general population, especially regarding limitations related to body pain, vitality and mental health. CONCLUSION A poor adherence rate to therapy regimens, rather than type of glucocorticoid was associated with impaired QoL in adolescents and adults with CAH.
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Affiliation(s)
- Kerstin Ekbom
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Department of Paediatric Endocrinology, Astrid Lindgren Children's HospitalKarolinska University HospitalStockholmSweden
| | - Anna Strandqvist
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Division of Psychology, Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
| | - Svetlana Lajic
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Department of Paediatric Endocrinology, Astrid Lindgren Children's HospitalKarolinska University HospitalStockholmSweden
| | - Angelica Hirschberg
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Department of Gynecology and Reproductive MedicineKarolinska University HospitalStockholmSweden
| | - Henrik Falhammar
- Department of EndocrinologyKarolinska University HospitalStockholmSweden
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Anna Nordenström
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Department of Paediatric Endocrinology, Astrid Lindgren Children's HospitalKarolinska University HospitalStockholmSweden
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Sun B, Lu L, Gao Y, Yu B, Chen S, Tong A, Wu X, Mao J, Wang X, Zhao Z, Zhang W, Nie M. High prevalence of hypertension and target organ damage in patients with 11β-hydroxylase deficiency. Clin Endocrinol (Oxf) 2022; 96:657-665. [PMID: 35067946 DOI: 10.1111/cen.14677] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 12/07/2021] [Accepted: 12/16/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Prevalence of hypertension and hypertension-mediated organ damage (HMOD) had not been well studied in patients with 11β-hydroxylase deficiency (11β-OHD). OBJECTIVE The study was to assess the prevalence and risk factors of hypertension and HMOD in patients with 11β-OHD. DESIGN Retrospective cohort analysis in a single medical centre. PATIENTS Twenty-eight patients with 11β-OHD were recruited between January 2003 and June 2021, and their diagnosis had been confirmed by Sanger sequencing. MEASUREMENTS Blood pressure and clinical indicators for the assessment of HMOD occurrence were collected from the medical records. Medication adherence of antihypertensive drugs and glucocorticoids were determined by the patients' biochemistry. Logistic regression was used to identify factors associated with HMOD. RESULTS Prevalence of hypertension and HMOD in the cohort was 100% and 50%, respectively. The kidneys (71.43%) are the organ most commonly damaged by high blood pressure, followed by the heart (64.29%), eyes (57.14%) and brain (21.43%). Risk factors of HMOD were hypokalemia (odds ratio [OR]: 9.16; 95% confidence interval [CI]: 1.634-51.43; p = .012), blood pressure ≥ 180/110 mmHg (OR: 22.0, 95% CI: 3.08-157.34; p = .002) and irregular glucocorticoid use (OR: 3.18, 95% CI: 1.13-8.98; p = .021). Blood pressure ≥ 180/110 mmHg was an independent predictor for HMOD. CONCLUSION Hypertension and HMOD are prevalent in patients with 11β-OHD in our study. These findings illustrate the importance of early HMOD evaluation and optimal glucocorticoid medication in 11β-OHD patients.
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Affiliation(s)
- Bang Sun
- NHC Key Laboratory of Endocrinology, Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Lin Lu
- NHC Key Laboratory of Endocrinology, Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yinjie Gao
- NHC Key Laboratory of Endocrinology, Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Bingqing Yu
- NHC Key Laboratory of Endocrinology, Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shi Chen
- NHC Key Laboratory of Endocrinology, Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Anli Tong
- NHC Key Laboratory of Endocrinology, Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xueyan Wu
- NHC Key Laboratory of Endocrinology, Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiangfeng Mao
- NHC Key Laboratory of Endocrinology, Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xi Wang
- NHC Key Laboratory of Endocrinology, Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhiyuan Zhao
- NHC Key Laboratory of Endocrinology, Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Zhang
- NHC Key Laboratory of Endocrinology, Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Min Nie
- NHC Key Laboratory of Endocrinology, Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Neumann U, van der Linde A, Krone RE, Krone NP, Güven A, Güran T, Elsedfy H, Poyrazoglu S, Darendeliler F, Bachega TASS, Balsamo A, Hannema SE, Birkebaek N, Vieites A, Thankamony A, Cools M, Milenkovic T, Bonfig W, Costa EC, Atapattu N, de Vries L, Guaragna-Filho G, Korbonits M, Mohnike K, Bryce J, Ahmed SF, Voet B, Blankenstein O, Claahsen-van der Grinten HL. Treatment of congenital adrenal hyperplasia in children aged 0-3 years: a retrospective multicenter analysis of salt supplementation, glucocorticoid and mineralocorticoid medication, growth and blood pressure. Eur J Endocrinol 2022; 186:587-596. [PMID: 35290211 PMCID: PMC9066592 DOI: 10.1530/eje-21-1085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 03/15/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVES International guidelines recommend additional salt supplementation during infancy in classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. The influence of corticoid medication and growth has not been assessed. AIM To investigate the current use of salt supplementation, fludrocortisone (FC) and hydrocortisone (HC) dosage as well as weight, height, BMI and blood pressure (BP) in CAH children aged 0-3 years. METHODS Retrospective multicentre analysis using data from the I-CAH registry. Salt-treated (ST) and non-salt-treated (NST) children were compared regarding FC and HC dosage, weight, height and BP at 0, 3, 6, 9, 12, 18, 24, 30, and 36 months. RESULTS We analysed 2483 visits of 331 patients born after year 2000 in 13 countries (male, n = 145) with 203 ST patients (61%). NST children had significantly higher FC dosages at 1.5-4.5 months and higher HC dosages until 1.5 months of age. No differences in weight, length and BP between subgroups were observed. Children of the whole cohort showed increased BMI-SDS during the study period and about half of the reported BP readings were >P95. CONCLUSION In children treated with additional salt supplementation, FC and HC dosages are lower during the first months of life but without differences in weight, length and BP until 3 years of age compared to NST children. All children showed an increase in BMI-SDS and a high rate of BP readings >P95 until 3 years, indicating the start of weight gain and negative effects on blood pressure already in very early life.
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Affiliation(s)
- Uta Neumann
- Institute for Experimental Paediatric Endocrinology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Correspondence should be addressed to U Neumann;
| | - Annelieke van der Linde
- Amalia Children’s Hospital, Radboud University Medical Centre, Nijmegen, Netherlands
- Amphia Hospital, Breda, The Netherlands
| | - Ruth E Krone
- Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Nils P Krone
- University of Sheffield, Sheffield Children’s Hospital, Western Bank, Sheffield, UK
| | - Ayla Güven
- University of Health Science Zeynep Kamil Women and Children Hospital, Pediatric Endocrinology, Istanbul, Turkey
| | - Tülay Güran
- Marmara University Istanbul, Istanbul, Turkey
| | - Heba Elsedfy
- Pediatrics Department, Ain Shams University, Cairo, Egypt
| | - Sukran Poyrazoglu
- Pediatric Endocrinology Unit, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Feyza Darendeliler
- Pediatric Endocrinology Unit, Istanbul Faculty of Medicine, Istanbul, Turkey
| | | | | | - Sabine E Hannema
- Leiden University Medical Centre, Leiden, Netherlands
- Erasmus Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Niels Birkebaek
- Department of Pediatrics and Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas Buenos Aires, Buenos Aires, Argentina
| | - Ajay Thankamony
- University of Cambridge and Addenbrooke’s Hospital, Cambridge, UK
| | | | - Tatjana Milenkovic
- Institute for Mother and Child Healthcare of Serbia ‘Dr Vukan Čupić’, Belgrade, Serbia
| | - Walter Bonfig
- Technical University of Munich, Munich, Germany
- Klinikum Wels-Grieskirchen, Wels, Austria
| | | | | | - Liat de Vries
- Institute for Diabetes and Endocrinology, Schneider Children's Medical Center of Israel, Petah-Tikvah, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | | | - Klaus Mohnike
- Otto-von-Guericke Universität Magdeburg, Magdeburg, Germany
| | | | | | | | - Oliver Blankenstein
- Institute for Experimental Paediatric Endocrinology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Schröder MAM, van Herwaarden AE, Span PN, van den Akker ELT, Bocca G, Hannema SE, van der Kamp HJ, de Kort SWK, Mooij CF, Schott DA, Straetemans S, van Tellingen V, van der Velden JA, Sweep FCGJ, Claahsen-van der Grinten HL. Optimizing the Timing of Highest Hydrocortisone Dose in Children and Adolescents With 21-Hydroxylase Deficiency. J Clin Endocrinol Metab 2022; 107:e1661-e1672. [PMID: 34788830 PMCID: PMC8947312 DOI: 10.1210/clinem/dgab826] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 07/23/2021] [Indexed: 11/20/2022]
Abstract
CONTEXT Hydrocortisone treatment of young patients with 21-hydroxylase deficiency (21OHD) is given thrice daily, but there is debate about the optimal timing of the highest hydrocortisone dose, either mimicking the physiological diurnal rhythm (morning), or optimally suppressing androgen activity (evening). OBJECTIVE We aimed to compare 2 standard hydrocortisone timing strategies, either highest dosage in the morning or evening, with respect to hormonal status throughout the day, nocturnal blood pressure (BP), and sleep and activity scores. METHODS This 6-week crossover study included 39 patients (aged 4-19 years) with 21OHD. Patients were treated for 3 weeks with the highest hydrocortisone dose in the morning, followed by 3 weeks with the highest dose in the evening (n = 21), or vice versa (n = 18). Androstenedione (A4) and 17-hydroxyprogesterone (17OHP) levels were quantified in saliva collected at 5 am; 7 am; 3 pm; and 11 pm during the last 2 days of each treatment period. The main outcome measure was comparison of saliva 17OHP and A4 levels between the 2 treatment strategies. RESULTS Administration of the highest dose in the evening resulted in significantly lower 17OHP levels at 5 am, whereas the highest dose in the morning resulted in significantly lower 17OHP and A4 levels in the afternoon. The 2 treatment dose regimens were comparable with respect to averaged daily hormone levels, nocturnal BP, and activity and sleep scores. CONCLUSION No clear benefit for either treatment schedule was established. Given the variation in individual responses, we recommend individually optimizing dose distribution and monitoring disease control at multiple time points.
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Affiliation(s)
- Mariska A M Schröder
- Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, HB Nijmegen, the Netherlands
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Paul N Span
- Radiotherapy & OncoImmunology Laboratory, Department of Radiation Oncology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Erica L T van den Akker
- Department of Pediatrics, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, DR Rotterdam, the Netherlands
| | - Gianni Bocca
- Beatrix Children’s Hospital, Department of Pediatrics, University Medical Center Groningen, RB Groningen, the Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, RC Leiden, the Netherlands
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, MB Amsterdam, the Netherlands
| | - Hetty J van der Kamp
- Wilhelmina Children’s Hospital, Utrecht University Medical Center, EA Utrecht, the Netherlands
| | - Sandra W K de Kort
- Department of Pediatrics, Haga Teaching Hospital/Juliana Children’s Hospital, AA The Hague, the Netherlands
| | - Christiaan F Mooij
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, AZ Amsterdam, the Netherlands
| | - Dina A Schott
- Department of Pediatrics Endocrinology, Zuyderland medical center, PC Heerlen, the Netherlands
| | - Saartje Straetemans
- Department of Pediatric Endocrinology, Maastricht university medical center, HX Maastricht, the Netherlands
| | - Vera van Tellingen
- Department of Pediatrics, Catharina Hospital, EJ Eindhoven, the Netherlands
| | - Janiëlle A van der Velden
- Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, HB Nijmegen, the Netherlands
| | - Hedi L Claahsen-van der Grinten
- Amalia Children’s Hospital, Department of Pediatrics, Radboud University Medical Center, HB Nijmegen, the Netherlands
- Correspondence: Hedi L. Claahsen-van der Grinten, MD, PhD, Amalia Children’s Hospital, Radboud University Medical Center, Department of Pediatrics, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, the Netherlands.
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Nowotny H, Neumann U, Tardy-Guidollet V, Ahmed SF, Baronio F, Battelino T, Bertherat J, Blankenstein O, Bonomi M, Bouvattier C, Brac de la Perrière A, Brucker S, Cappa M, Chanson P, Claahsen-van der Grinten HL, Colao A, Cools M, Davies JH, Dörr HG, Fenske WK, Ghigo E, Giordano R, Gravholt CH, Huebner A, Husebye ES, Igbokwe R, Juul A, Kiefer FW, Léger J, Menassa R, Meyer G, Neocleous V, Phylactou LA, Rohayem J, Russo G, Scaroni C, Touraine P, Unger N, Vojtková J, Yeste D, Lajic S, Reisch N. Prenatal dexamethasone treatment for classic 21-hydroxylase deficiency in Europe. Eur J Endocrinol 2022; 186:K17-K24. [PMID: 35235536 PMCID: PMC9010809 DOI: 10.1530/eje-21-0554] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the current medical practice in Europe regarding prenatal dexamethasone (Pdex) treatment of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. DESIGN AND METHODS A questionnaire was designed and distributed, including 17 questions collecting quantitative and qualitative data. Thirty-six medical centres from 14 European countries responded and 30 out of 36 centres were reference centres of the European Reference Network on Rare Endocrine Conditions, EndoERN. RESULTS Pdex treatment is currently provided by 36% of the surveyed centres. The treatment is initiated by different specialties, that is paediatricians, endocrinologists, gynaecologists or geneticists. Regarding the starting point of Pdex, 23% stated to initiate therapy at 4-5 weeks postconception (wpc), 31% at 6 wpc and 46 % as early as pregnancy is confirmed and before 7 wpc at the latest. A dose of 20 µg/kg/day is used. Dose distribution among the centres varies from once to thrice daily. Prenatal diagnostics for treated cases are conducted in 72% of the responding centres. Cases treated per country and year vary between 0.5 and 8.25. Registries for long-term follow-up are only available at 46% of the centres that are using Pdex treatment. National registries are only available in Sweden and France. CONCLUSIONS This study reveals a high international variability and discrepancy in the use of Pdex treatment across Europe. It highlights the importance of a European cooperation initiative for a joint international prospective trial to establish evidence-based guidelines on prenatal diagnostics, treatment and follow-up of pregnancies at risk for CAH.
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Affiliation(s)
- Hanna Nowotny
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Uta Neumann
- Centre for Chronic Sick Children, Department of Paediatric Endocrinology and Diabetology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Véronique Tardy-Guidollet
- Laboratoire de Biochimie et Biologie Moléculaire, Hospices Civils de Lyon, Centre National de Référence ‘Développement Génital: du fœtus à l’adulte DEV-GEN’ Université Lyon I, Lyon, France
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Federico Baronio
- Paediatric Endocrinology Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, University Children’s Hospital, Ljubljana, Slovenia
| | - Jérôme Bertherat
- Service d’Endocinologie et Maladies Métaboliques, Hôpitaux Universitaires Paris-Centre, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Oliver Blankenstein
- Centre for Chronic Sick Children, Department of Paediatric Endocrinology and Diabetology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marco Bonomi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Department of Endocrine and Metabolic Diseases and Lab of Endocrine and Metabolic Research, IRCSS Istituto Auxologico Italiano, Milan, Italy
| | - Claire Bouvattier
- Service d’Endocrinologie de l’Enfant, GHU Paris-Sud, Hôpital de Bicêtre, Paris, France
- Centre National de Référence ‘Développement Génital: du fœtus à l’adulte DEV-GEN’, Paris, France
| | - Aude Brac de la Perrière
- Fédération d’Endocrinologie, de Diabétologie et des Maladies Métaboliques, Hospices Civils des Lyon, Centre National de Référence ‘Développement Génital: du fœtus à l’adulte DEV-GEN’, Lyon, France
| | - Sara Brucker
- Department of Women’s Health, University Women’s Hospital, University of Tübingen, Tübingen, Germany
| | - Marco Cappa
- Endocrinology Unit, Paediatric University Department, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Université Paris-Saclay, Service d’Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de Hypophyse, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Hedi L Claahsen-van der Grinten
- Department of Paediatric Endocrinology, Amalia Children’s Hospital, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita’ Federico II di Napoli, Naples, Italy
| | - Martine Cools
- Department of Paediatric Endocrinology, Ghent University Hospital, University of Ghent, Ghent, Belgium
| | - Justin H Davies
- Paediatric Endocrinology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Helmut-Günther Dörr
- Paediatric Endocrinology, Department of Paediatrics, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Wiebke K Fenske
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Ezio Ghigo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Turin, Turin, Italy
| | - Roberta Giordano
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Turin, Turin, Italy
| | - Claus H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Angela Huebner
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Eystein Sverre Husebye
- Department of Clinical Science and KG Jebsen Centre for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Rebecca Igbokwe
- West Midlands Regional Genetics Laboratory, Birmingham Women’s Hospital NHS Foundation Trust, Birmingham, UK
| | - Anders Juul
- Department of Growth and Reproduction, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Florian W Kiefer
- Clinical Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Juliane Léger
- Department of Paediatric Endocrinology and Diabetology and Reference Centre for Rare Diseases of Growth and Development, AP-HP Paris Nord Université de Paris, CHU Robert-Debre, Paris, France
| | - Rita Menassa
- Laboratoire de Biochimie et Biologie Moléculaire, Hospices Civils de Lyon, Centre National de Référence ‘Développement Génital: du fœtus à l’adulte DEV-GEN’ Université Lyon I, Lyon, France
| | - Gesine Meyer
- Division of Endocrinology, Department of Internal Medicine 1, Goethe University Frankfurt Faculty 16 Medicine, Frankfurt am Main, Germany
| | - Vassos Neocleous
- Department of Molecular Genetics, Function and Therapy, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
- Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Leonidas A Phylactou
- Department of Molecular Genetics, Function and Therapy, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
- Cyprus School of Molecular Medicine, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Julia Rohayem
- Centre of Reproductive Medicine and Andrology, Clinical and Operative Andrology, University of Münster, Münster, Germany
| | - Gianni Russo
- Department of Paediatrics, Endocrine Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Carla Scaroni
- Dipartimento di Medicina, U.O.C. Endocrinologia, Università di Padova, Padova, Italy
| | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Centre for Rare Endocrine and Gynaecological Disorders, Sorbonne Université, Assistance Publique Hopitaux de Paris, Paris, France
| | - Nicole Unger
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, Essen, Germany
| | - Jarmila Vojtková
- Department of Paediatrics, Jessenius Faculty of Medicine, Comenius University in Bratislava, University Hospital in Martin, Martin, Slovakia
| | - Diego Yeste
- Paediatric Endocrinology Service, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
- CIBERER, ISCIII, Madrid, Spain
| | - Svetlana Lajic
- Department of Women’s and Children’s Health, Karolinska Institutet/Karolinska University Hospital, Paediatric Endocrinology Unit (QB83), Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
- Correspondence should be addressed to N Reisch;
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Cheng T, Liu J, Sun W, Song G, Ma H. Congenital adrenal hyperplasia with homozygous and heterozygous mutations: a rare family case report. BMC Endocr Disord 2022; 22:57. [PMID: 35255871 PMCID: PMC8900299 DOI: 10.1186/s12902-022-00969-w] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 02/23/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH), characterized by defective adrenal steroidogenesis, is transmitted in an autosomal recessive manner. Mutations in the steroid 21-hydroxylase gene CYP21A2 causing steroid 21-hydroxylase deficiency account for most cases of CAH. The c.145l-1452delGGinsC gene mutation is rare, and only one case has been reported, but the form of gene mutation is different from this case, resulting in different clinical phenotype. The most common pathogenic genotype of CAH is a homozygous or compound heterozygous mutation, but CAH patients homozygous for the p.I173N mutation and heterozygous for the c.1451-1452delGGinsC mutation have not been reported previously. We report herein a familial case of CAH, in which both siblings carry the rare homozygous p.I173N mutation and heterozygous c.1451-1452delGGinsC mutation. CASE PRESENTATION The proband showed amenorrhea, infertility, polycystic ovaries, and increased levels of androgen, rather than the typical clinical manifestations of CAH such as an adrenal crisis or masculine vulva, so was misdiagnosed with polycystic ovary syndrome for many years. Following a correct diagnosis of CAH, she was given glucocorticoid treatment, her menstruation became more regular, and she became pregnant and delivered a healthy baby girl. CONCLUSIONS The genotypes may be p.I173N homozygous or p.I173N/c.1451-1452delGGinsC heterozygous, both mutations could be pathogenic. This complex combination of mutations has not been reported or studied before. Through the report and analysis of this genotype, the content of CAH gene bank is enriched and the misdiagnosis rate of CAH is reduced.
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Affiliation(s)
- Tiantian Cheng
- Department of Internal Medicine, School of Clinical Medicine, North China University of Science and Technology, Tangshan, 063210, Hebei, China
- Department of Endocrinology and Metabolic Diseases, Hebei General Hospital, Shijiazhuang, 050051, Hebei, China
| | - Jing Liu
- Department of Endocrinology and Metabolic Diseases, Hebei General Hospital, Shijiazhuang, 050051, Hebei, China
| | - Wenwen Sun
- Department of Internal Medicine, School of Clinical Medicine, North China University of Science and Technology, Tangshan, 063210, Hebei, China
- Department of Endocrinology and Metabolic Diseases, Hebei General Hospital, Shijiazhuang, 050051, Hebei, China
| | - Guangyao Song
- Department of Endocrinology and Metabolic Diseases, Hebei General Hospital, Shijiazhuang, 050051, Hebei, China
- Hebei Key Laboratory of Metabolic Diseases, Hebei General Hospital, Shijiazhuang, 050051, Hebei, China
| | - Huijuan Ma
- Department of Internal Medicine, School of Clinical Medicine, North China University of Science and Technology, Tangshan, 063210, Hebei, China.
- Department of Endocrinology and Metabolic Diseases, Hebei General Hospital, Shijiazhuang, 050051, Hebei, China.
- Hebei Key Laboratory of Metabolic Diseases, Hebei General Hospital, Shijiazhuang, 050051, Hebei, China.
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Delai A, Gomes PM, Foss-Freitas MC, Elias J, Antonini SR, Castro M, Moreira AC, Mermejo LM. Hyperinsulinemic-Euglycemic Clamp Strengthens the Insulin Resistance in Nonclassical Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2022; 107:e1106-e1116. [PMID: 34693966 DOI: 10.1210/clinem/dgab767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 07/15/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Insulin sensitivity evaluation by hyperinsulinemic-euglycemic clamp in nonclassical congenital adrenal hyperplasia (NC-CAH) due to 21-hydroxilase deficiency. DESIGN AND SETTING Cross-sectional study at university hospital outpatient clinics. PATIENTS AND METHODS NC-CAH patients (25 females, 6 males; 24 ± 10 years) subdivided into C/NC (compound heterozygous for 1 classical and 1 nonclassical allele) and NC/NC (2 nonclassical alleles) genotypes were compared to controls. RESULTS At diagnosis, C/NC patients presented higher basal and adrenocorticotropin-stimulated 17-hydroxyprogesterone and androstenedione levels than NC/NC genotype. Patients and controls presented similar weight, body mass index, abdominal circumference, and total fat body mass. NC-CAH patients showed higher waist-to-hip ratio, lower adiponectin and lower high-density lipoprotein cholesterol levels with no changes in fasting plasma glucose, glycated hemoglobin, homeostatic model assessment for insulin resistance, leptin, interleukin 6, tumor necrosis factor alpha, C-reactive protein, and carotid-intima-media thickness. All patients had used glucocorticoid (mean time of 73 months). Among the 22 patients with successful clamp, 13 were still receiving glucocorticoid-3 patients using cortisone acetate, 9 dexamethasone, and 1 prednisone (hydrocortisone equivalent dose of 5.5mg/m²/day), while 9 patients were off glucocorticoid but had previously used (hydrocortisone equivalent dose of 5.9mg/m2/day). The NC-CAH patients presented lower Mffm than controls (31 ± 20 vs 55 ± 23µmol/min-1/kg-1, P = 0.002). The Mffm values were inversely correlated with the duration of glucocorticoid treatment (r = -0.44, P = 0.04). There was association of insulin resistance and glucocorticoid type but not with androgen levels. CONCLUSION Using the gold standard method, the hyperinsulinemic-euglycemic clamp, insulin resistance was present in NC-CAH patients and related to prolonged use and long-acting glucocorticoid treatment. Glucocorticoid replacement and cardiometabolic risks should be monitored regularly in NC-CAH.
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Affiliation(s)
- Ariane Delai
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Patricia M Gomes
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Maria Cristina Foss-Freitas
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Jorge Elias
- Departments of Medical Imaging, Hematology, and Oncology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Sonir R Antonini
- Department of Pediatrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Margaret Castro
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Ayrton C Moreira
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Livia M Mermejo
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
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49
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Auchus RJ, Sarafoglou K, Fechner PY, Vogiatzi MG, Imel EA, Davis SM, Giri N, Sturgeon J, Roberts E, Chan JL, Farber RH. Crinecerfont Lowers Elevated Hormone Markers in Adults With 21-Hydroxylase Deficiency Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2022; 107:801-812. [PMID: 34653252 PMCID: PMC8851935 DOI: 10.1210/clinem/dgab749] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 07/06/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency (21OHD) is characterized by impaired cortisol synthesis and excess androgen production. Corticotropin-releasing factor type 1 receptor (CRF1R) antagonism may decrease adrenal androgen production. OBJECTIVE This work aimed to evaluate the safety, tolerability, and efficacy of crinecerfont (NBI-74788), a selective CRF1R antagonist, in 21OHD. METHODS This open-label, phase 2 study, with sequential cohort design (NCT03525886), took place in 6 centers in the United States. Participants included men and women, aged 18 to 50 years, with 21OHD. Interventions included 4 crinecerfont regimens, each administered orally for 14 consecutive days: 50 or 100 mg once daily at bedtime (cohorts 1 and 2, respectively); 100 mg once daily in the evening (cohort 3); and 100 mg twice daily (cohort 4). Participants could enroll in more than 1 cohort. Main outcomes included changes from baseline to day 14 in adrenocorticotropin (ACTH), 17-hydroxyprogesterone (17OHP), androstenedione, and testosterone. RESULTS Eighteen participants (11 women, 7 men) were enrolled: cohort 1 (n = 8), cohort 2 (n = 7), cohort 3 (n = 8), cohort 4 (n = 8). Mean age was 31 years; 94% were White. Median percent reductions were more than 60% for ACTH (-66%), 17OHP (-64%), and androstenedione (-64%) with crinecerfont 100 mg twice a day. In female participants, 73% (8/11) had a 50% or greater reduction in testosterone levels; male participants had median 26% to 65% decreases in androstenedione/testosterone ratios. CONCLUSION Crinecerfont treatment for 14 days lowered ACTH and afforded clinically meaningful reductions of elevated 17OHP, androstenedione, testosterone (women), or androstenedione/testosterone ratio (men) in adults with 21OHD. Longer-term studies are required to evaluate the effects of crinecerfont on clinical end points of disordered steroidogenesis and glucocorticoid exposure in patients with 21OHD.
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Affiliation(s)
- Richard J Auchus
- Departments of Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kyriakie Sarafoglou
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Patricia Y Fechner
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Maria G Vogiatzi
- Division of Endocrinology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Erik A Imel
- Departments of Medicine and Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shanlee M Davis
- Department of Pediatrics, Section of Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nagdeep Giri
- Neurocrine Biosciences Inc, San Diego, California, USA
| | | | - Eiry Roberts
- Neurocrine Biosciences Inc, San Diego, California, USA
| | - Jean L Chan
- Neurocrine Biosciences Inc, San Diego, California, USA
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Nordenström A, Falhammar H, Lajic S. Current and Novel Treatment Strategies in Children with Congenital Adrenal Hyperplasia. Horm Res Paediatr 2022; 96:560-572. [PMID: 35086098 DOI: 10.1159/000522260] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/19/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The standard treatment for congenital adrenal hyperplasia (CAH) in children is still hydrocortisone. Improved strategies for timing of the dose during the day and the dose per square meter body surface area used in children of different ages and developmental phases have improved the situation and outcome for the patients. Neonatal screening enables an earlier diagnosis and initiation of treatment, prevents from adrenal crisis, and improves growth and development also for children with the less severe forms of CAH. SUMMARY This review describes the current treatment strategies for children with CAH and discusses some potential treatment options that have been developed with the primary aim to decrease the adrenal androgen production. Novel modified release glucocorticoid therapies are also discussed. KEY MESSAGES The long-term effects of the new adjunct therapies are unknown, and some are not suitable for use in children and adolescents. The effects of the new therapies on bone mineral density, gonadal functions, and long-term cognitive development are yet to be assessed. It is not known what levels of adrenal androgens are optimal for normal growth, puberty, and bone health. The basis of using glucocorticoids and mineralocorticoids in the treatment of CAH remains, and in some individuals, it may be beneficial to add therapies to reduce the androgen load during certain life stages.
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Affiliation(s)
- Anna Nordenström
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Department of Endocrinology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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