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Inadequacies of glucocorticoid replacement and improvements by physiological circadian therapy

M Debono, University of Sheffield, Sheffield, United Kingdom
R Ross, AUDEM, UNIVERSITY OF SHEFFIELD, SHEFFIELD, United Kingdom
J Newell-Price, Room OU142, University of Sheffield, Sheffield, S102JF, United Kingdom

Correspondence: John Newell-Price, Email: j.newellprice{at}sheffield.ac.uk

Abstract

Patients with adrenal insufficiency need lifelong glucocorticoid replacement, but many suffer from poor quality of life, and overall there is increased mortality. Moreover, it appears that use of glucocorticoids at the higher end of the replacement dose-range is associated with increased risk for cardiovascular and metabolic bone disease. These data highlight some of the inadequacies of current regimes.

The cortisol production rate is estimated to be equivalent to 5.7 to 7.4mg/m2/day, and a major difficulty for replacement regimes is the inability to match the distinct circadian rhythm of circulating cortisol levels, which are low at the time of sleep onset, rise between 0200h and 0400h, peaking just after waking and then fall during the day. Another issue is that current dose-equivalents of glucocorticoids used for replacement are based on anti-inflammatory potency, and few data exist as to doses needed for equivalent cardiovascular and bone effects. Weight-adjusted, thrice-daily dosing using hydrocortisone reduces glucocorticoid over-exposure and represents the most refined regime for current oral therapy, but does not replicate the normal cortisol rhythm. Recently, proof-of-concept studies have shown that more physiological circadian glucocorticoid therapy using hydrocortisone infusions and newly developed oral formulations of hydrocortisone have the potential for better biochemical control in patients with adrenal insufficiency. Whether such physiological replacement will have an impact on the complications seen in patients with adrenal insufficiency will need to be analyzed in future clinical trials.

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