Diagnosis and treatment of adrenal insufficiency including adrenal crisis: a Japan Endocrine Society clinical practice guideline [Opinion]

Yanase, Toshihiko; Tajima, Toshihiro; Katabami, Takuyuki; Iwasaki, Yoshinobu; Tanahashi, Yusuke; Sugawara, Akira; Hasegawa, Tomonobu; Mune, Tomoatsu; Osuga, Yutaka; Nakagawa, Yuichi; Miyamura, Nobuhiro; Shimizu, Chisato; Otsuki, Michio; Nomura, Masatoshi; Akehi, Yuko; Tanabe, Makito; Kasayama, Soji

doi:10.1507/endocrj.ej16-0242

Cited by 76 publications

(102 citation statements)

References 98 publications

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“…While a rapid ACTH test should have been carried out for a definitive diagnosis (29), the duration from the onset of symptoms to the diagnosis was extremely long; thus, diagnostic treatment was prioritized. The endocrine system tests revealed that among the anterior pituitary hormones, only the levels of ACTH were lower than normal, with the levels of other anterior pituitary hormones, such as PRL, LH, FS and TSH, being higher than normal; furthermore, the cortisol levels were also lower than normal.…”

Section: Discussionmentioning

confidence: 99%

Isolated adrenocorticotropic hormone deficiency potentially induced by nivolumab following pseudo‑progression in clear cell renal cell carcinoma: A case report

et al. 2018

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Nivolumab is a monoclonal immunoglobulin G antibody blocking programmed death receptor-1 (PD-1) that promotes the restoration of the natural T-cell-mediated immune response against cancer cells; however, it also causes a number of autoimmune-related adverse events (irAEs) that often involve the endocrine system. The present report describes a 71-year-old man with clear cell renal cell carcinoma metastasis in the lung. Following the 14th course of nivolumab therapy, the patient complained of general malaise, loss of appetite and mild consciousness disturbance. Laboratory tests revealed a severely elevated eosinophil ratio (26.2%) and low sodium value (122 mmol/l). Endocrine system tests revealed that the patient's adrenocorticotropic hormone (ACTH; 4.5 pg/ml) and cortisol (0.1 µg/dl) levels were lower than normal, while those of other pituitary hormones were higher than normal. This case was therefore diagnosed as isolated ACTH deficiency induced by nivolumab. Magnetic resonance imaging (MRI) showed normal pituitary glands. Hydrocortisone replacement therapy improved the clinical symptoms early and enabled the patient to restart nivolumab therapy. Isolated ACTH deficiency due to nivolumab, a PD-1 immune checkpoint inhibitor antibody, is a rare occurrence. This report may be useful for avoiding delays in the diagnosis and treatment of this life-threatening irAE even if no pituitary abnormalities are identified via MRI. NOBUKI FURUBAYASHI, TAKAHITO NEGISHI, TOMOHARU UOZUMI, DAI TAKAMATSU, KOICHI SHIRAISHI

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Section: Discussionmentioning

confidence: 99%

Isolated adrenocorticotropic hormone deficiency potentially induced by nivolumab following pseudo‑progression in clear cell renal cell carcinoma: A case report

et al. 2018

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“…Adrenal insufficiency is possible, if basal cortisol is <3 to 4 μg/dL or post stimulation cortisol is <18 μg/dL. [17] …”

Section: Discussionmentioning

confidence: 99%

“…However, serum ACTH level induced by 250 μg ACTH administration is 1000 to 60,000 pg/dL, higher over the physiological concentration. [17–19] …”

Section: Discussionmentioning

confidence: 99%

Mineralocorticoid responsive hyponatremia of the elderly

Katayama

Tokuda²

2017

Medicine

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Background:Mineralocorticoid responsive hyponatremia of the elderly (MRHE) is an emerging concept of hyponatremia in aged people. Diagnosis of MRHE requires exclusion of syndrome of inappropriate antidiuresis and adrenal dysfunction. Thus we aimed to evaluate the characteristics of all patients with suspected MRHE available for a review.Methods:We conducted a systematic review using MEDLINE and Google scholar. We included published case reports of adult patients diagnosed as MRHE, written by English and Japanese language. Serum and urine electrolytes as well as the levels of antidiuretic hormone (ADH), cortisol, plasma renin activity (PRA), and aldosterone were analyzed.Results:A total of 27 MRHE patients were identified in 9 reports. In these patients, average age was 79 years, median serum sodium was 117 mEq/L. The median levels of ADH, cortisol, PRA, and aldosterone were 0.9 pg/mL, 18.7 μg/dL, 0.37 ng/mL/h, and 39.6 pg/mL, respectively. Water restriction test was conducted in 7 patients. Random sample cortisol measurements did not exceed satisfactory levels to rule out adrenal dysfunction in four cases. No cases underwent low-dose adrenocorticotropic hormone stimulation test. Only 27 patients from 9 case reports in Japanese were eligible for inclusion in our study.Conclusion:All published cases of MRHE as a cause of hyponatremia are described for the first time. In these cases, latent adrenal sufficiency might have been hidden and should have been excluded.

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“…The replacement period has been reported to be average 1 year and 8 months. In the case of SCS, the same protocol is recommended, but the replacement period may be shorter than that of CS because of the relatively weaker suppression of hypothalamic-pituitary adrenal (HPA) axis [35].…”

Section: Treatment Guidelines For Scsmentioning

confidence: 99%

New diagnostic criteria of adrenal subclinical Cushing’s syndrome: opinion from the Japan Endocrine Society

et al. 2018

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Abstract. New diagnostic criteria and the treatment policy for adrenal subclinical Cushing's syndrome (SCS) are proposed on behalf of the Japan Endocrine Society. The Japanese version has been published, and the essential contents are presented in this English-language version. The current diagnostic criteria for SCS have elicited two main problems: (i) the relatively low reliability of a low range of serum cortisol essential for the diagnosis by an overnight 1-mg dexamethasone suppression test (DST); (ii) different cutoff values for serum cortisol after a 1-mg DST compared with those of other countries. Thus, new criteria are needed. In the new criteria, three hierarchical cortisol cutoff values, 5.0, 3.0 and 1.8 μg/dL, after a 1-mg DST are presented. Serum cortisol ≥5 μg/dL after a 1-mg DST alone is considered sufficient to judge autonomous cortisol secretion for the diagnosis of SCS, and the current criterion based on serum cortisol ≥3 μg/dL after a 1-mg DST can continue to be used. Clinical evidence suggests that serum cortisol ≥1.8-2.9 μg/dL after a 1-mg DST is not always normal, so cases who meet the cutoff value as well as a basal adrenocorticotropic hormone (ACTH) level <10 pg/mL (or poor ACTH response to corticotropin-releasing hormone (CRH)) and nocturnal serum cortisol ≥5 μg/dL are proposed to have SCS. We suggest surgery if cases show serum cortisol ≥5 μg/dL after a 1-mg DST (or are disheartened by treatment-resistant problems) or suspicious cases of adrenal cancer according to tumor imaging. [7,8] and a reduction in bone quality when evaluated by the Spinal Density Index [9]. However, with changes in the measurement system (from radioimmunoassay to enzyme immunoassay) of cortisol in blood, four main discussions have arisen: (i) the relatively low reliability of a low range of cortisol concentrations (<3 μg/dL) essential for the diagnosis after an overnight 1-mg DST [10]; (ii) the inconsistency of the screening criteria of SCS with those proposed by the American Endocrine Society (serum cortisol ≥1.8 μg/dL after a 1-mg DST) [11] or other countries [1]; (iii) the "globalization" of diagnostic criteria; (iv) the necessity of a 8-mg DST for the SCS diagnosis [12]. Thus, new diagnostic criteria for adrenal SCS have become an important agenda for the Japan Endocrine Society (JES).The current task force was organized officially in 2012 and multicenter collaborative research was done to collect evidence for a revision. Based on the results of the research and peer reviews of articles focusing on SCS, the final new diagnostic criteria for adrenal SCS and the treatment policy were proposed. These evidence-based diagnostic criteria and the treatment policy for adrenal SCS were reviewed by a JES subcommittee and approved. These documents were also approved by Research Committee on Disorders of Adrenal Hormones from the MHLW, Japan and Japan Hormonal Steroid Association. The Japanese version has been published and the English-language version has been described here. The new diagnostic criteria for adrenal SCS ...

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Diagnosis and treatment of adrenal insufficiency including adrenal crisis: a Japan Endocrine Society clinical practice guideline [Opinion]

Cited by 76 publications

References 98 publications

Isolated adrenocorticotropic hormone deficiency potentially induced by nivolumab following pseudo‑progression in clear cell renal cell carcinoma: A case report

Isolated adrenocorticotropic hormone deficiency potentially induced by nivolumab following pseudo‑progression in clear cell renal cell carcinoma: A case report

Mineralocorticoid responsive hyponatremia of the elderly

New diagnostic criteria of adrenal subclinical Cushing’s syndrome: opinion from the Japan Endocrine Society

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