Cushing's Syndrome and Hypothalamic-Pituitary Adrenal Axis Suppression Induced by Medroxyprogesterone Acetate

1996 ◽  
Vol 33 (3) ◽  
pp. 187-189 ◽  
Author(s):  
K J Malik ◽  
K Wakelin ◽  
S Dean ◽  
D H Cove ◽  
P J Wood
Keyword(s):  
Cushing’S Syndrome ◽  
Medroxyprogesterone Acetate ◽  
Plasma Cortisol ◽  
Cushing's Syndrome ◽  
Adrenocorticotrophic Hormone ◽  
Adrenal Axis ◽  
Synacthen Test ◽  
Cortisol Responses ◽  
Short Synacthen Test ◽  
Pituitary Adrenal Axis

The referral of a patient with features of Cushing's syndrome but with suppressed plasma cortisol and adrenocorticotrophic hormone concentrations prompted us to study the effect of medroxyprogesterone acetate (MPA) therapy on the adrenal axis. 11 women (aged 54–82 years) who were receiving 200–400 mg/day MPA were studied. Of these, four had subnormal plasma cortisol responses to a short synacthen test, and two more had borderline responses (30 min post-synacthen plasma cortisol results of 411 and 511 nmol/L). We conclude that suppression of the adrenal axis occurs relatively frequently in patients on MPA and that such patients should be checked for evidence of suppression before MPA therapy is withdrawn.

A study of hypothalamic-pituitary-adrenal suppression following curative surgery for Cushing's syndrome due to adrenal adenoma

1987 ◽  
Vol 114 (2) ◽  
pp. 166-170 ◽  
Author(s):  
D. Gordon ◽  
C. G. Semple ◽  
G. H. Beastall ◽  
J. A. Thomson
Keyword(s):  
Cushing’S Syndrome ◽  
Adrenal Adenoma ◽  
Cushing's Syndrome ◽  
Hypothalamic Pituitary Adrenal Axis ◽  
Curative Surgery ◽  
Unilateral Adrenalectomy ◽  
Hypothalamic Pituitary Adrenal ◽  
Adrenal Axis ◽  
Cortisol Responses ◽  
Pituitary Adrenal Axis

Abstract. The hypothalamic-pituitary-adrenal axis was investigated in all six patients requiring glucocorticoid replacement 2.5–11 years after unilateral adrenalectomy for adrenal adenomas causing Cushing's syndrome. The hypothalamic-pituitary-adrenal axis was assessed by insulin induced hypoglycaemia and CRF testing in each patient. Two patients showed normal cortisol and ACTH responses to hypoglycaemia. Two patients showed subnormal cortisol responses to hypoglycaemia in the presence of high or normal basal ACTH concentrations. ACTH concentrations increased with both hypoglycaemia and CRF. Two patients showed subnormal cortisol responses to hypoglycaemia and CRF. One of these patients showed an ACTH rise following hypoglycaemia but not CRF. Defects at either hypothalamic-pituitary or adrenal levels were demonstrated and recovery of the axis appears to commence at the hypothalamic-pituitary level.

Treatment of iatrogenic Cushing’s syndrome: questions of glucocorticoid withdrawal

2007 ◽  
Vol 148 (5) ◽  
pp. 195-202 ◽  
Author(s):  
Péter Igaz ◽  
Károly >Rácz ◽  
Miklós Tóth ◽  
Edit Gláz ◽  
Zsolt Tulassay
Keyword(s):  
Cushing’S Syndrome ◽  
Underlying Disease ◽  
Cushing's Syndrome ◽  
Hypothalamic Pituitary Adrenal Axis ◽  
Hypothalamic Pituitary Adrenal ◽  
Adrenal Axis ◽  
Laboratory Examinations ◽  
High Doses ◽  
Pituitary Adrenal Axis ◽  
Iatrogenic Cushing’S Syndrome

Iatrogenic Cushing’s syndrome is the most common form of hypercortisolism. Glucocorticoids are widely used for the treatment of various diseases, often in high doses that may lead to the development of severe hypercortisolism. Iatrogenic hypercortisolism is unique, as the application of exogenous glucocorticoids leads to the simultaneous presence of symptoms specific for hypercortisolism and the suppression of the endogenous hypothalamic-pituitary-adrenal axis. The principal question of its therapy is related to the problem of glucocorticoid withdrawal. There is considerable interindividual variability in the suppression and recovery of the hypothalamic-pituitary-adrenal axis, therefore, glucocorticoid withdrawal and substitution can only be conducted in a stepwise manner with careful clinical follow-up and regular laboratory examinations regarding endogenous hypothalamic-pituitary-adrenal axis activity. Three major complications which can be associated with glucocorticoid withdrawal are: i. reactivation of the underlying disease, ii. secondary adrenal insufficiency, iii. steroid withdrawal syndrome. Here, the authors summarize the most important aspects of this area based on their clinical experience and the available literature data.

scholarly journals Predictive Accuracy of Delta Cortisol on Recovery of Adrenal Function in Patients With Drug Induced Cushing’s Syndrome With Secondary Adrenal Insufficiency

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A91-A91
Author(s):  
Bo Bo San
Keyword(s):  
Cushing’S Syndrome ◽  
Cushing Syndrome ◽  
Serum Cortisol ◽  
Cushing's Syndrome ◽  
Adrenal Function ◽  
Drug Induced ◽  
Basal Serum ◽  
Synacthen Test ◽  
Short Synacthen Test

Abstract There is a growing concern upon the finding of many drug induced Cushing’s syndrome because of inadvertent use of glucocorticoids (GC) either prescribed or as alternative medicine in Myanmar. These patients are presenting with diversity of clinical problems ranging from hypertension, diabetes to acute adrenal crisis due to hypothalamic-pituitary-adrenal (HPA) axis suppression and secondary adrenal insufficiency (AI). The present study aimed to assess the delta cortisol (the degree of cortisol increments) during the first short Synacthen test (SST) as a factor predictive of adrenal function recovery in patients with drug induced Cushing’ syndrome with secondary AI and to determine the proportion of patients who recovered from AI within six-month follow-up. This was a hospital based prospective analytical study that enrolled a total of 52 patients with drug induced Cushing’s syndrome with secondary AI from January 2018 to June 2019. Secondary AI is defined by morning basal serum cortisol ≤ 400 nmol/L with Synacthen stimulated peak cortisol level ≤ 550 nmol/L and serum ACTH < 60 pg/ml. The follow-up SSTs were performed at three-month and six-month after first SST, and the patients with morning basal serum cortisol > 400 nmol/L (or) Synacthen stimulated peak serum cortisol > 550 nmol/L during follow-up SSTs are defined as recovered adrenal function group. In this study, a total of 52 patients were treated with modified regimen of physiological dose of prednisolone with tapering schedule or stress dose GC based on the basal serum cortisol levels up to six months. Among them, nearly half (n=25 / 48.1%) of the patients with drug induced Cushing’s syndrome with secondary AI achieved normal adrenal function within six-month follow-up. It was found that mean values for delta cortisol were not statistically significant between recovered and non-recovered groups, 118.6 nmol/L (SD 72.3) and 97.2 nmol/L (SD 64.2) respectively. The delta cortisol during the first SST could not predict strongly (AUC - 0.6, 95% CI - 0.44 to 0.76, P = 0.2) the recovery of adrenal function in patients with drug induced Cushing’s syndrome with secondary AI and it was inconsistent with previous studies. The older age of the patients, oral route of administration of drugs causing Cushing’s syndrome and comorbid hypertension were found to be more significant in the non-recovered group. In conclusion, the present study did not support the evidence that the delta cortisol during the first SST could predict adrenal function recovery in patients with drug induced Cushing’ syndrome with secondary AI. Reference: (1) Baek et al., 2016; Recovery of Adrenal Function in Patients with Glucocorticoids Induced Secondary AI. Endocrinol Metab.31, pp. 153–160. (2) Pofi et al., 2018; The Short Synacthen Test Can Be Used to Predict Recovery of HPA Axis Function. J Clin Endocrinol Metab.103(8), pp. 3050–3059.

scholarly journals The Midnight to Morning Urinary Cortisol Increment Is an Accurate, Noninvasive Method for Assessment of the Hypothalamic-Pituitary-Adrenal Axis

1999 ◽  
Vol 84 (9) ◽  
pp. 3093-3098 ◽  
Author(s):  
W. M. Kong ◽  
J. Alaghband-Zadeh ◽  
J. Jones ◽  
G. Carter ◽  
D. O’Shea
Keyword(s):  
Tolerance Test ◽  
Hypothalamic Pituitary Adrenal Axis ◽  
Urinary Cortisol ◽  
Optimal Method ◽  
Hypothalamic Pituitary Adrenal ◽  
Adrenal Axis ◽  
Insulin Tolerance ◽  
Synacthen Test ◽  
Short Synacthen Test ◽  
Pituitary Adrenal Axis

The optimal method for assessing the hypothalamic-pituitary-adrenal axis (HPA) remains controversial. The insulin tolerance test (ITT) is considered the gold standard, but is invasive and potentially dangerous. The short Synacthen test (SST) is the most commonly used alternative, but its concordance with the ITT is poor. Using sleep as a reliable stimulus to ACTH release, we proposed that the increment in urinary cortisol levels between midnight and waking could provide a noninvasive, physiological means for the assessment of the HPA axis. Double voided urine samples were collected at home at midnight and waking in 40 patients with pituitary disease and 40 controls. Cortisol and creatinine levels were measured, and the cortisol/creatinine (Cort/Cr) ratio was calculated. The Cort/Cr increment was defined as the morning Cort/Cr ratio minus the midnight Cort/Cr ratio. The Cort/Cr increment of the patients was compared to the results of their ITT or SST. Using the results from the 40 controls, a normal Cort/Cr increment was defined as greater then 9. The positive predictive value of a Cort/Cr increment for the diagnosis of HPA insufficiency was 95%. These findings suggest that the midnight to morning Cort/Cr increment is a reliable, noninvasive alternative to the ITT/SST for assessment of the HPA.

scholarly journals Retrospective review of Synacthen testing in infants

2018 ◽  
Vol 103 (10) ◽  
pp. 984-986 ◽  
Author(s):  
Timothy Shao Ern Tan ◽  
Claire Manfredonia ◽  
Rakesh Kumar ◽  
Julie Jones ◽  
Elaine O’Shea ◽  
...  
Keyword(s):  
Gestational Age ◽  
Small For Gestational Age ◽  
Retrospective Review ◽  
Hypothalamic Pituitary Adrenal Axis ◽  
Cortisol Response ◽  
Adrenocorticotrophic Hormone ◽  
Hypothalamic Pituitary Adrenal ◽  
Adrenal Axis ◽  
Synacthen Test ◽  
Pituitary Adrenal Axis

BackgroundA subnormal cortisol response (30 min level (C30min)<550 nmol/L) to synthetic adrenocorticotrophic hormone/Synacthen test (SDST) in all infants does not necessarily indicate underlying or persistent hypothalamic–pituitary–adrenal axis pathology.MethodsWe retrospectively evaluated the diagnoses and outcomes in 68 infants who had a SDST at age <6 months from 2011 to 2014.Results29 (43%) infants had a subnormal SDST. Causative pathology was identified in 9/29 (31%). In 20/29 (69%) with no identified pathology, repeat SDST was normal in 18/20 (90%) at median age 0.6 (range 0.1–3.2) years but persistently subnormal in 2. Those with a transient abnormality were more likely to be small for gestational age (P=0.03) and had higher initial SDST C30min (390 nmol/L vs 181 nmol/L, P=0.01) than those with pathology.ConclusionSpecific aetiology can be identified in a third of infants with a subnormal SDST. When the aetiology remains elusive, adrenal function should be reassessed as the problem can be transient.

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