Mineralocorticoid Replacement in Addison's Disease

Thompson, Darrall; Mason, April C.; Goodwin, F. J.

doi:10.1111/j.1365-2265.1979.tb02107.x

Cited by 27 publications

(12 citation statements)

References 8 publications

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“…Conversely, Thompson et al showed that PRA was unable to distinguish between adequate and over-replacement and therefore raised doubts about its utility in MC dose optimization (19).…”

Section: Discussionmentioning

confidence: 99%

Plasma Renin Measurements are Unrelated to Mineralocorticoid Replacement Dose in Patients With Primary Adrenal Insufficiency

Pofi

Prete

Thornton-Jones

et al. 2019

The Journal of Clinical Endocrinology &Amp; Metabolism

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Context No consensus exists for optimization of mineralocorticoid therapy in patients with primary adrenal insufficiency. Objective To explore the relationship between mineralocorticoid (MC) replacement dose, plasma renin concentration (PRC), and clinically important variables to determine which are most helpful in guiding MC dose titration in primary adrenal insufficiency. Design Observational, retrospective, longitudinal analysis. Patients A total of 280 patients (with 984 clinical visits and plasma renin measurements) with primary adrenal insufficiency were recruited from local databases and the international congenital adrenal hyperplasia (CAH) registry (www.i-cah.org). Thirty-seven patients were excluded from the final analysis due to incomplete assessment. Data from 204 patients with salt-wasting CAH (149 adults and 55 children) and 39 adult patients with Addison disease (AD) were analysed. Main outcome measures PRC, electrolytes, blood pressure (BP), and anthropometric parameters were used to predict their utility in optimizing MC replacement dose. Results PRC was low, normal, or high in 19%, 36%, and 44% of patients, respectively, with wide variability in MC dose and PRC. Univariate analysis demonstrated a direct positive relationship between MC dose and PRC in adults and children. There was no relationship between MC dose and BP in adults, while BP increased with increasing MC dose in children. Using multiple regression modeling, sodium was the only measurement that predicted PRC in adults. Longitudinally, the change in MC dose was able to predict potassium, but not BP or PRC. Conclusions The relationship between MC dose and PRC is complex and this may reflect variability in sampling with respect to posture, timing of last MC dose, adherence, and concomitant medications. Our data suggest that MC titration should not primarily be based only on PRC normalization, but also on clinical parameters such as BP and electrolyte concentration.

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“…Conversely, Thompson et al showed that PRA was unable to distinguish between adequate and over-replacement and therefore raised doubts about its utility in MC dose optimization (19).…”

Section: Discussionmentioning

confidence: 99%

Plasma Renin Measurements are Unrelated to Mineralocorticoid Replacement Dose in Patients With Primary Adrenal Insufficiency

Pofi

Prete

Thornton-Jones

et al. 2019

The Journal of Clinical Endocrinology &Amp; Metabolism

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“…While titration of PRA into the upper normal range has been recommended in order to achieve optimum FC replacement (Oelkers et al, 1992), in another study hypokalaemia was the only indicator of FC over-replacement in PAI patients as PRA levels did not distinguish between adequate and excessive mineralocorticoid replacement (Thompson et al, 1979). Indeed, low PRA levels were seen in only 2 of 5 patients with low potassium levels induced by FC over-replacement and in only 4 of 6 patients with oedema of the ankles (Smith et al, 1984).…”

Section: Discussionmentioning

confidence: 99%

The role of plasma renin activity in evaluating the adequacy of mineralocorticoid replacement in primary adrenal insufficiency

Flad

Conway

Cunningham

et al. 1996

Clinical Endocrinology

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These results indicate that when plasma renin activity is estimated in patients with primary adrenal insufficiency replaced with daily doses of fludrocortisone, the time of day of blood sampling is not critical. Lowering elevated plasma renin activity levels to normal in patients who were considered to be otherwise normal may lead to over-treatment in some patients. Therefore, optimal fludrocortisone replacement may be associated with mildly elevated plasma renin activity levels. The information obtained by monitoring plasma renin activity adds little to the assessment of patients based on clinical evaluation and measurement of urea and electrolyte levels in blood.

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“…Aldosterone pills are not available; rather, the mineralocorticoid agonist 9-αfluorocortisol (fludrocortisone) is used (255). Patients with secondary adrenal insufficiency usually do not require mineralocorticoid replacement (again, because the renin-angiotensin-aldosterone system is intact).…”

Section: Adrenal Insufficiencymentioning

confidence: 99%

Physiological Basis for the Etiology, Diagnosis, and Treatment of Adrenal Disorders: Cushing's Syndrome, Adrenal Insufficiency, and Congenital Adrenal Hyperplasia

Raff

Sharma

Nieman

2014

Comprehensive Physiology

121

105

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The hypothalamic-pituitary-adrenal (HPA) axis is a classic neuroendocrine system. One of the best ways to understand the HPA axis is to appreciate its dynamics in the variety of diseases and syndromes that affect it. Excess glucocorticoid activity can be due to endogenous cortisol overproduction (spontaneous Cushing’s syndrome) or exogenous glucocorticoid therapy (iatrogenic Cushing’s syndrome). Endogenous Cushing’s syndrome can be subdivided into ACTH-dependent and ACTH-independent, the latter of which is usually due to autonomous adrenal overproduction. The former can be due to a pituitary corticotroph tumor (usually benign) or ectopic ACTH production from tumors outside the pituitary; both of these tumor types overexpress the proopiomelanocortin gene. The converse of Cushing’s syndrome is the lack of normal cortisol secretion and is usually due to adrenal destruction (primary adrenal insufficiency) or hypopituitarism (secondary adrenal insufficiency). Secondary adrenal insufficiency can also result from a rapid discontinuation of long-term, pharmacological glucocorticoid therapy because of HPA axis suppression and adrenal atrophy. Finally, mutations in the steroidogenic enzymes of the adrenal cortex can lead to congenital adrenal hyperplasia and an increase in precursor steroids, particularly androgens. When present in utero, this can lead to masculinization of a female fetus. An understanding of the dynamics of the HPA axis is necessary to master the diagnosis and differential diagnosis of pituitary-adrenal diseases. Furthermore, understanding the pathophysiology of the HPA axis gives great insight into its normal control.

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Mineralocorticoid Replacement in Addison's Disease

Cited by 27 publications

References 8 publications

Plasma Renin Measurements are Unrelated to Mineralocorticoid Replacement Dose in Patients With Primary Adrenal Insufficiency

Plasma Renin Measurements are Unrelated to Mineralocorticoid Replacement Dose in Patients With Primary Adrenal Insufficiency

The role of plasma renin activity in evaluating the adequacy of mineralocorticoid replacement in primary adrenal insufficiency

Physiological Basis for the Etiology, Diagnosis, and Treatment of Adrenal Disorders: Cushing's Syndrome, Adrenal Insufficiency, and Congenital Adrenal Hyperplasia

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