Perspectives on the management of adrenal insufficiency

Posted on November 7, 2013 by MaryO

Source

Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7EJ, UK.

Abstract

BACKGROUND:

Conventional glucocorticoid (GC) replacement for patients with adrenal insufficiency (AI) is inadequate. Patients with AI continue to have increased mortality and morbidity and compromised quality of life despite treatment and monitoring.

OBJECTIVES:

i) To review current management of AI and the unmet medical need based on literature and treatment experience and ii) to offer practical advice for managing AI in specific clinical situations.

METHODS:

The review considers the most urgent questions endocrinologists face in managing AI and presents generalised patient cases with suggested strategies for treatment.

RESULTS:

Optimisation and individualisation of GC replacement remain a challenge because available therapies do not mimic physiological cortisol patterns. While increased mortality and morbidity appear related to inadequate GC replacement, there are no objective measures to guide dose selection and optimisation. Physicians must rely on experience to recognise the clinical signs, which are not unique to AI, of inadequate treatment. The increased demand for corticosteroids during periods of stress can result in a life-threatening adrenal crisis (AC) in a patient with AI. Education is paramount for patients and their caregivers to anticipate, recognise and provide proper early treatment to prevent or reduce the occurrence of ACs.

CONCLUSIONS:

This review highlights and offers suggestions to address the challenges endocrinologists encounter in treating patients with AI. New preparations are being developed to better mimic normal physiological cortisol levels with convenient, once-daily dosing which may improve treatment outcomes.

PMID:
24031090
[PubMed – in process] 
PMCID:
PMC3805018
 [Available on 2013/12/1]

From http://www.mdlinx.com/endocrinology/newsl-article.cfm/4829245/ZZ4747461521296427210947/?news_id=2364&newsdt=110713&subspec_id=1509&utm_source=Focus-On&utm_medium=newsletter&utm_content=Top-New-Article&utm_campaign=article-section

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Cushing’s syndrome – A structured short- and long-term management plan for patients in remission

Posted on August 30, 2013 by MaryO

European Journal of Endocrinology, 08/30/2013  Review Article

harvey-bookRagnarsson O et al. – One–hundred years have passed since Harvey Williams Cushing presented the first patient with the syndrome that bears his name.

The focus of the long–term specialized care should be to identify cognitive impairments and psychiatric disorders, evaluate cardiovascular risk, follow pituitary function and to detect possible recurrence of Cushing’s syndrome.

Source

O Ragnarsson, Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden.

Abstract

One-hundred years have passed since Harvey Williams Cushing presented the first patient with the syndrome that bears his name. In patients with Cushing’s syndrome body composition, lipid-, carbohydrate- and protein-metabolism is dramatically affected and psychopathology and cognitive dysfunction is frequently observed.

Untreated patients with Cushing’s syndrome have a grave prognosis with an estimated five-year survival of only 50%. Remission can be achieved by surgery, radiotherapy and sometimes with medical therapy.

Recent data indicate that the adverse metabolic consequences of Cushing’s syndrome are present for years after successful treatment. In addition, recent studies have demonstrated that health related quality of life and cognitive function is impaired in patients with Cushing’s syndrome in long-term remission.

The focus of specialized care should therefore not only be on the diagnostic work-up and the early post-operative management, but also the long-term follow-up.

In this paper we review the long-term consequences in patients with Cushing’s syndrome in remission with focus on the neuropsychological effects and discuss the importance of these findings for long-term management. We also discuss three different phases in the postoperative management of surgically treated patients with Cushing’s syndrome, each phase distinguished by specific challenges; the immediate post-operative phase, the glucocorticoid dose tapering phase and the long-term management. The focus of the long-term specialized care should be to identify cognitive impairments and psychiatric disorders, evaluate cardiovascular risk, follow pituitary function and to detect possible recurrence of Cushing’s syndrome.

PMID:
23985132
[PubMed – as supplied by publisher]

From http://www.ncbi.nlm.nih.gov/pubmed/23985132

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Adrenal Glands

Posted on June 23, 2013 by MaryO

adrenal-glandsAnatomy of the adrenal glands:

Adrenal glands, which are also called suprarenal glands, are small, triangular glands located on top of both kidneys. An adrenal gland is made of two parts: the outer region is called the adrenal cortex and the inner region is called the adrenal medulla.

Function of the adrenal glands:

The adrenal glands work interactively with the hypothalamus and pituitary gland in the following process:

  • the hypothalamus produces corticotropin-releasing hormones, which stimulate the pituitary gland.
  • the pituitary gland, in turn, produces corticotropin hormones, which stimulate the adrenal glands to produce corticosteroid hormones.

Both parts of the adrenal glands — the adrenal cortex and the adrenal medulla — perform very separate functions.

What is the adrenal cortex?

The adrenal cortex, the outer portion of the adrenal gland, secretes hormones that have an effect on the body’s metabolism, on chemicals in the blood, and on certain body characteristics. The adrenal cortex secretes corticosteroids and other hormones directly into the bloodstream. The hormones produced by the adrenal cortex include:

  • corticosteroid hormones
    • hydrocortisone hormone – this hormone, also known as cortisol, controls the body’s use of fats, proteins, and carbohydrates.
    • corticosterone – this hormone, together with hydrocortisone hormones, suppresses inflammatory reactions in the body and also affects the immune system.
  • aldosterone hormone – this hormone inhibits the level of sodium excreted into the urine, maintaining blood volume and blood pressure.
  • androgenic steroids (androgen hormones) – these hormones have minimal effect on the development of male characteristics.

What is the adrenal medulla?

The adrenal medulla, the inner part of the adrenal gland, is not essential to life, but helps a person in coping with physical and emotional stress. The adrenal medulla secretes the following hormones:

  • epinephrine (also called adrenaline) – this hormone increases the heart rate and force of heart contractions, facilitates blood flow to the muscles and brain, causes relaxation of smooth muscles, helps with conversion of glycogen to glucose in the liver, and other activities.
  • norepinephrine (also called noradrenaline) – this hormone has little effect on smooth muscle, metabolic processes, and cardiac output, but has strong vasoconstrictive effects, thus increasing blood pressure.

From: University of Maryland Center for Diabetes and Endocrinology

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MR Brain Spectroscopy Detects Damage In The Hippocampus Of Patients Exposed To Excess Cortisol

Posted on May 8, 2013 by MaryO

New research shows that patients who are “biochemically cured” of Cushing’s syndrome have levels of brain metabolites which are associated with neural damage. This will have implications for treatment of Cushing’s patients, but might also suggest that patients using high levels of glucocorticoid drugs may suffer similar long-term problems. The work was presented yesterday at the European Congress of Endocrinology in Copenhagen.

Cushing’s syndrome is an endocrine disease causing an overproduction of the stress hormone cortisol. Surgery and medical treatment can normalise cortisol levels, however recently it has been shown that “biochemically cured” patients continue to have memory problems. Now for the first time a group of researchers from the Sant Pau Hospital in Barcelona has scanned the brains of patients who had suffered from Cushing’s syndrome and found that they exhibit changed levels of brain metabolites, which are associated with memory and cognitive impairments. This finding may also have clinical implications for otherwise healthy patients who take high levels of glucocorticoid drugs for inflammatory, rheumatoid diseases, allergies and probably everyday chronic stress.

Cortisol (a glucocorticoid hormone), is naturally produced by the adrenal glands in response to stress. Long term exposure to high levels of cortisol is known to be associated with a range of cognitive impairments – this is true for Cushing’s syndrome patients, and probably would be also for those who take glucocorticoid drugs.

Eugenia Resmini and colleagues, working at the Centre for Biomedical Research on Rare Diseases (CIBERER), Sant Pau hospital in Barcelona, used proton magnetic resonance spectroscopy to measure a series of metabolites in the hippocampus of the brains of 18 patients who had been treated for Cushing’s syndrome, and compared these results to 18 healthy control subjects. They found that levels of the metabolite NAA (NAcetyl-aspartate) were significantly lower in the Cushing’s patients, indicating neural dysfunction, whereas Glx (Glutamate +Glutamine) levels were higher, suggesting that glial cells were proliferating as a repair mechanism.

According to Dr Resmini MD, PhD, Endocrinologist at the Centre for Biomedical Research on Rare Diseases (CIBERER), Hospital de Sant Pau, Barcelona, Spain:

“Patients with Cushing’s syndrome are exposed to abnormally high levels of glucocorticoids, which is associated with a wide range of cognitive impairments, as well as loss of brain volume. We studied the hippocampus, which is a critical area for learning and memory and, as it is rich in glucocorticoid receptors, is especially vulnerable to glucocorticoid overexposure. Cushing’s syndrome patients with severe memory impairment are known to have a smaller hippocampus. We have now found abnormal levels of metabolites in the hippocampi of Cushing’s patients with normal hippocampal volumes, indicating that these are early markers of glucocorticoid neurotoxicity, which would precede hippocampal volume reduction.

“Identifying these metabolites as a marker would be a way of allowing earlier diagnosis and treatment of cognitive impairments. This may also allow us to monitor patients taking glucocorticoid drugs, which have potentially damaging side effects. On the other hand, the fact that these markers are still present in Cushing’s patients after being “biochemically cured”, may show that once cognition has been damaged in Cushing’s syndrome, it may not be fully reversible. For this reason an earlier diagnosis of the disease and a rapid normalization of hypercortisolism would avoid the progression of hippocampal damage and of memory problems”.

From Medical News Today

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Abnormal Metabolites Found in Cured Cushing’s Patients

Posted on May 3, 2013 by MaryO

Patients with Cushing’s syndrome have abnormal brain metabolites suggestive of neuronal dysfunction even after they appeared to have been cured, according to a study presented at the annual European Congress of Endocrinology, held from April 27 to May 1 in Copenhagen.

(HealthDay News) — Patients with Cushing’s syndrome have abnormal brain metabolites suggestive of neuronal dysfunction even after they appeared to have been cured, according to a study presented at the annual European Congress of Endocrinology, held from April 27 to May 1 in Copenhagen.

Using proton magnetic resonance spectroscopy, Eugenia Resmini, M.D., Ph.D., from Hospital Sant Pau in Barcelona, Spain, and colleagues measured metabolites in the hippocampi of 18 adults with Cushing’s syndrome who had been biochemically cured and 18 age- and education-matched healthy adults.

The researchers found that the two groups had similar left and right total hippocampal volumes. Patients with Cushing’s syndrome had significantly lower NAcetyl-aspartate in the left and right hippocampus as well as significantly lower NAcetyl-aspartate plus N-Acetyl-aspartyl-glutamate in the right hippocampus. In addition, patients with Cushing’s syndrome had significantly higher glutamate plus glutamine in both hippocampi. The alterations are suggestive of neuronal dysfunction, according to the authors.

“Persistently abnormal metabolites are evidenced in the hippocampi of Cushing’s syndrome patients despite endocrine cure,” Resmini and colleagues conclude. “These functional alterations could be early markers of glucocorticoids neurotoxicity and would precede hippocampal volume reduction.”

Abstract
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From HealthDay

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