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1. In patients with benign adrenal tumors, women are more likely to be diagnosed with mild autonomous cortisol secretion (MACS). 2. Patients with MACS have a higher prevalence and severity of cardiometabolic disease, namely hypertension and type 2 diabetes. Evidence Rating Level: 2 (Good) Study Rundown: While benign adrenal tumors are routinely incidentally discovered by imaging, not all these tumors have pathological effects, existing as nonfunctional adrenal tumors (NFAT). However, others overproduce steroids resulting in mild autonomous cortisol secretion (MACS) or Cushing’s syndrome (CS) if severe. The clinical impact of these diseases on cardiometabolic disease is poorly described. This study, therefore, sought to characterize the cardiometabolic disease burden and steroid excretion in this population via a cross-sectional study. Patients with benign adrenal tumors were classified with NFAT, MACS-1 (possible), MACS-2 (definite), or CS based upon clinical assessment and 1-mg overnight dexamethasone suppression test. Results revealed that MACS-2 and CS were more prevalent among women. Compared to patients in the NFAT group, patients with MACS-2 and CS were more likely to have hypertension, require antihypertensives, type 2 diabetes, and require insulin therapy. Taken together, this study supports that women with benign adrenal tumors are more likely to be diagnosed with MACS and are consequently at greater risk for hypertension and type 2 diabetes, warranting regular cardiometabolic assessment for this population. This study was limited by its cross-sectional study design and predefined clinical outcomes biased for cardiometabolic outcomes. Click to read the study in Annals of Internal Medicine Relevant Reading: Natural History of Adrenal Incidentalomas With and Without Mild Autonomous Cortisol Excess: A Systematic Review and Meta-analysis In-Depth [cross-sectional study]: In this prospective, cross-sectional study, 1305 patients diagnosed with incidental benign adrenal adrenocortical adenoma were selected across 14 participating centers. Patients with other diagnoses of cortisol excess such as primary aldosteronism or on cortisol-altering medications were excluded. Following clinical assessment and 1-mg overnight dexamethasone-suppression, patients were categorized into having a nonfunctional adrenal tumor (NFAT) (morning serum cortisol <50 nmol/L), possible mild autonomous cortisol secretion (MACS-1) (morning serum cortisol: 50-138 nmol/L), definite MACS (MACS-2) (morning serum cortisol: >138 nmol/L), or Cushing’s syndrome (CS) (presence of overt clinical symptoms of CS). The results found that while women made up the majority of the study cohort (67.3%), the proportion of females was more pronounced in the MACS-2 (73.6%) and CS (86.2%) groups. With respect to cardiometabolic disease, patients in the MACS-2 group were more likely to have hypertension (adjusted prevalence ratio [aPR], 1.15; 95% confidence interval [CI], 1.04-1.27), require three or more hypertensives (aPR, 1.31; 95% CI, 1.02-1.68) and requirement for insulin therapy (aPR, 1.89; 95% CI, 1.01 – 3.52) when compared to patients in the NFAT group. The same trend was found with greater significance for those in the CS group. The prevalence of dyslipidemia was not found to be significantly different between all groups. Additionally, these findings were not found to be attributed to other factors such as 1-mg DSG results, the presence of bilateral tumor, or adrenal tumor size. Finally, urinary steroid profiling found that patients with MACS and CS were more likely to have lower excretion levels of androgen metabolites and increased excretion levels of glucocorticoids. Overall, this study supports increased cardiometabolic disease burden amongst women with MACS. RELATED REPORTS Autonomous cortisol secretion correlated with mortality for adrenal incidentalomas Mutations in PKA catalytic subunit associated with Cushing’s syndrome Image: PD ©2022 2 Minute Medicine, Inc. All rights reserved. No works may be reproduced without expressed written consent from 2 Minute Medicine, Inc. Inquire about licensing here. No article should be construed as medical advice and is not intended as such by the authors or by 2 Minute Medicine, Inc. Tags: adrenal incidentalomaautonomouscardiometabolic diseasecortisol secretioncushing's syndromedexamethasone suppression From https://www.2minutemedicine.com/women-with-mild-autonomous-cortisol-secretion-are-at-greater-risk-for-cardiometabolic-disease/
Justine Herndon, PA-C, and Irina Bancos, MD, on Post-Operative Cushing Syndrome Care – Curative procedures led to widespread resolution or improvement of hyperglycemia by Scott Harris , Contributing Writer, MedPage Today January 18, 2022 In a recent study, two-thirds of people with Cushing syndrome (CS) saw resolved or improved hyperglycemia after a curative procedure, with close post-operative monitoring an important component of the process. Among 174 patients with CS included in the longitudinal cohort study (pituitary in 106, ectopic in 25, adrenal in 43), median baseline HbA1c was 6.9%. Of these, 41 patients were not on any therapy for hyperglycemia, 93 (52%) took oral medications, and 64 (37%) were on insulin. At the end of the period following CS remission (median 10.5 months), 37 (21%) patients had resolution of hyperglycemia, 82 (47%) demonstrated improvement, and 55 (32%) had no change or worsened hyperglycemia. Also at the end of follow-up, HbA1c had fallen 0.84% (P<0.0001), with daily insulin dose decreasing by a mean of 30 units (P<0.0001). Justine Herndon, PA-C, and Irina Bancos, MD, both endocrinology researchers with Mayo Clinic in Minnesota, served as co-authors of the report, which was published in the Journal of the Endocrine Society. Here they discuss the study and its findings with MedPage Today. The exchange has been edited for length and clarity. What was the study's main objective? Herndon: As both a hospital diabetes provider and clinic pituitary/gonadal/adrenal provider, I often hear questions from colleagues about how to manage a patient's diabetes post-operatively after cure from CS. While clinical experience has been helpful in guiding these discussions, the literature offered a paucity of data on diabetes/hyperglycemia specifically after surgery. There was also a lack of data on specific subgroups of CS, whether by sub-type or severity. Therefore, we felt it was important to see what our past patient experiences showed in terms of changes in laboratory data, medications, and which patients were more likely to see improvement in their diabetes/hyperglycemia. The overall goal was to help clinicians provide appropriate patient education and care following a curative procedure. In addition to its primary findings, the study also identified several factors associated with resolution or improvement of hyperglycemia. What were these factors? Bancos: Both clinical and biochemical severity of CS, as well as Cushing subtype, were associated with improvement. We calculated severity based on symptoms and presence of comorbidities, and we calculated biochemical severity based on hormonal measurements. As clinical and biochemical scores were strongly correlated, we chose only one (biochemical) for multivariable analysis. In the multivariable analysis of biochemical severity of Cushing, subtype of Cushing, and subtype of hyperglycemia, we found that patients with a severe biochemical severity score were 2.4 fold more likely to see improved hyperglycemia than people with a moderate or mild severity score (OR 2.4 (95% CI 1.1-4.9). We also found that patients with the nonadrenal CS subtype were 2.9 fold more likely to see improved hyperglycemia when compared to people with adrenal CS (OR of 2.9 (95% CI 1.3-6.4). The type of hyperglycemia (diabetes versus prediabetes) was not found to be significant. Did anything surprise you about the study results? Herndon: I was surprised to see improvement in hyperglycemia in patients who were still on steroids, as you would expect the steroids to still have an impact. This shows how much a CS curative procedure truly leads to changes in the comorbidities that were a result of the underlying disease. Also, I was surprised that the type of hyperglycemia was not a predictor of improvement after cure, although it was quite close. We also had a few patients whose hyperglycemia worsened, and we could not find a specific factor that predicted which patients did not improve. What are the study's implications for clinicians who treat people with CS? Bancos: We think our study shows the clear need for closer follow-up -- more frequently than the typical three-to-six months for diabetes. This can be accomplished through review of more than just HbA1c, such as reviewing blood glucose logbooks, asking about hypoglycemia symptoms, and so forth. Patients with severe CS who are being treated with insulin or hypoglycemic medications are especially likely to decrease their medications to avoid hypoglycemia during postoperative period. Read the study here. Bancos reported advisory board participation and/or consulting with Strongbridge, Sparrow Pharmaceutics, Adrenas Therapeutics, and HRA Pharma outside the submitted work. Herndon did not disclose any relevant financial relationships with industry. Primary Source Journal of the Endocrine Society Source Reference: Herndon J, et al "The effect of curative treatment on hyperglycemia in patients with Cushing syndrome" J Endocrine Soc 2022; 6(1): bvab169. From https://www.medpagetoday.com/reading-room/endocrine-society/adrenal-disorders/96709