search
Back to results

Screening and Stimulation Testing for Residual Secretion of Adrenal Steroid Hormones in Autoimmune Addison's Disease

Primary Purpose

Primary Adrenal Insufficiency

Status
Active
Phase
Not Applicable
Locations
International
Study Type
Interventional
Intervention
Cosyntropin stimulation test
Baseline blood tests
30-hour ambulatory sampling of intestinal fluid
Blood test
Sponsored by
University of Bergen
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional screening trial for Primary Adrenal Insufficiency

Eligibility Criteria

18 Years - 70 Years (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Men and women with AAD, age 18-70 years old. This requires documented adrenal insufficiency and a positive test for 21-hydroxylase autoantibodies (biomarker for autoimmune cause) on at least one occasion.
  • Provided written informed consent
  • In case of concomitant endocrine/autoimmune diseases, the patients should be on stable adequate treatment at least the last 3 months prior to the study period.
  • For Norwegian AD patients: enrolled in ROAS
  • For Swedish AD patients: enrolled in the Swedish Addison registry

Exclusion Criteria:

  • Antihypertensive treatment, with the exception of doxazosin, verapamil, and moxonidine.
  • Active malignant disease, severe heart, kidney or liver failure.
  • Diabetes mellitus type 1.
  • Pregnancy or breast feeding.
  • Pharmacological treatment with glucocorticoids (except their usual cortisone or hydrocortisone replacement therapy) or drugs that interfere with cortisol and catecholamine metabolism (antiepileptics, rifampicin, St. Johns wart).
  • Use of other glucocorticoid replacement medication than cortisone acetate or hydrocortisone.
  • Intake of grapefruit, grapefruit juice, or and liquorice juice the last week before or during the study period.

Sites / Locations

  • Endokrinologie in Charlottenburg
  • Haukeland University Hospital
  • Karolinska Institutet

Arms of the Study

Arm 1

Arm 2

Arm 3

Arm 4

Arm 5

Arm 6

Arm 7

Arm 8

Arm Type

Experimental

Active Comparator

No Intervention

Other

Other

Experimental

Experimental

Active Comparator

Arm Label

Detectable levels of adrenal hormones

Controls with undetectable hormone levels

Undetectable levels of adrenal hormones

Congenital adrenal hyperplasia (CAH) control group

Bilaterally adrenalectomized control group

Diurnal variation in residual adrenocortical hormone levels

Repeated cosyntropin testing in newly diagnosed patients

Cardiovascular and inflammatory biomarkers

Arm Description

Patients with detectable serum levels of adrenal hormones will go through cosyntropin stimulation testing.

Twenty patients without detectable serum levels of adrenal hormones will serve as controls in cosyntropin stimulation testing.

Patients without detectable serum levels of adrenal hormones. Cosyntropin stimulation testing will not be performed.

Mapping adrenal steroid profile in patients with congenital adrenal hyperplasia (CAH) with confirmed total deficiency of 21-hydroxylase.

Mapping adrenal steroid profile in patients who are bilaterally adrenalectomized.

Patients with detectable serum levels of adrenal hormones will go through a 30-hour ambulatory sampling of interstitial fluid for mapping of any diurnal variation in endogenous adrenocortical secretion.

Newly diagnosed patients will be invited to go through repeated cosyntropin testing to delineate the natural progression of adrenocortical failure.

Compare cardiovascular and inflammatory biomarker profiles in patients with and without residual production of adrenocortical steroids

Outcomes

Primary Outcome Measures

The percentage of included patients with residual secretion of cortisol and aldosterone.
Percentage of included patients with detectable levels of adrenal steroid hormones.

Secondary Outcome Measures

Medication-fasting adrenocorticotropic hormone (ACTH)-stimulated levels of metanephrines
Levels in blood samples
Medication-fasting basal levels of cortisol
Levels in blood samples
Medication-fasting basal levels of cortisol
Levels in urine samples
Medication-fasting basal levels of cortisol
Levels in hair samples
Medication-fasting basal levels of cortisol precursors
Levels in blood samples
Medication-fasting basal levels of cortisol precursors
Levels in urine samples
Medication-fasting basal levels of cortisol precursors
Levels in hair samples
Medication-fasting basal levels of cortisol metabolites
Levels in blood samples
Medication-fasting basal levels of cortisol metabolites
Levels in urine samples
Medication-fasting basal levels of cortisol metabolites
Levels in hair samples
Medication-fasting basal levels of aldosterone
Levels in blood samples
Medication-fasting basal levels of aldosterone
Levels in urine samples
Medication-fasting basal levels of aldosterone precursors
Levels in blood samples
Medication-fasting basal levels of aldosterone precursors
Levels in urine samples
Medication-fasting basal levels of aldosterone metabolites
Levels in blood samples
Medication-fasting basal levels of aldosterone metabolites
Levels in urine samples
Medication-fasting basal levels of renin in patients with and without residual function.
Levels in blood samples
Medication-fasting basal levels of renin in patients with and without residual function.
Levels in urine samples
Medication-fasting basal levels of ACTH in patients with and without residual function.
Levels in blood samples
Medication-fasting basal levels of ACTH in patients with and without residual function.
Levels in urine samples
Medication-fasting basal levels of metanephrines in patients with and without residual function
Levels in blood samples
Medication-fasting basal levels of metanephrines in patients with and without residual function
Levels in urine samples
Medication-fasting ACTH-stimulated levels of cortisol
Levels in blood samples
Medication-fasting ACTH-stimulated levels of cortisol precursors
Levels in blood samples
Medication-fasting ACTH-stimulated levels of cortisol metabolites
Levels in blood samples
Medication-fasting ACTH-stimulated levels of aldosterone
Levels in blood samples
Medication-fasting ACTH-stimulated levels of aldosterone precursors
Levels in blood samples
Medication-fasting ACTH-stimulated levels of aldosterone metabolites
Levels in blood samples
Cortisol replacement doses, including stress doses in patients with and without residual function.
Total daily dosage
Cortisol stress doses in patients with and without residual function.
No. stress doses the last week
Fludrocortisone replacement doses in patients with and without residual function.
Total daily dosage.
In patients with and without residual function: disease-specific quality-of-life
Total score ranging from 30 to 120 in disease-specific quality-of-life questionnaire, Addison Quality of Life (AddiQoL). For every question, scoring is translated in points (1 = 1 point, 2 and 3 = 2 points, 4 and 5 = 3 points, 6 = 4 points) and the algebraic sum of points is calculated. A higher score reflects better health-related quality-of-life.
In patients with and without residual function, generic health-related quality of life by the Short Form (36) Health Survey
The Short Form (36) Health Survey is a generic tool comprising 36 items evaluating patient reported quality of life concerning eight domains (physical functioning, role functioning physical, bodily pain, general health perception, vitality, social functioning, role functioning emotional, and mental health and general perception of change in health). Scores are expressed on a 0-100 scale with higher scores associated with better quality of life. The result of each domain is presented separately.
Number of adrenal crises pr. 100 patient years
Number of crises pr. 100 patient years for all included patients as well as in patients with versus without residual adrenal function

Full Information

First Posted
November 6, 2018
Last Updated
November 3, 2022
Sponsor
University of Bergen
Collaborators
Karolinska Institutet, Charite University, Berlin, Germany
search

1. Study Identification

Unique Protocol Identification Number
NCT03793114
Brief Title
Screening and Stimulation Testing for Residual Secretion of Adrenal Steroid Hormones in Autoimmune Addison's Disease
Official Title
Residual Secretion of Adrenal Steroid Hormones in Addison's Disease
Study Type
Interventional

2. Study Status

Record Verification Date
November 2022
Overall Recruitment Status
Active, not recruiting
Study Start Date
September 26, 2018 (Actual)
Primary Completion Date
December 2023 (Anticipated)
Study Completion Date
April 2024 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
University of Bergen
Collaborators
Karolinska Institutet, Charite University, Berlin, Germany

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
No

5. Study Description

Brief Summary
In autoimmune adrenal insufficiency, or Addison's disease (AD), the immune system attacks the adrenal cortex. As a result, the adrenal cells producing hormones such as cortisol and aldosterone are destroyed, leaving the body with insufficient levels to meet its needs. The common perception is that upon diagnosis of Addison's disease, basically all adrenal hormone production has ceased. There have, however, been found a few individuals who preserve some residual secretion of cortisol even years after diagnosis. The objectives of this study is to find out how common it is, and to explore if residual function have impact on patient outcome. That is, do patients with and without residual function differ when it comes to quality of life, working ability, medication dosages, and risk of adrenal crisis?
Detailed Description
Autoimmune destruction of the adrenal cortex is the main cause of primary adrenal insufficiency (Addison's disease, AD). Autoimmune AD (AAD) becomes clinically manifest when 90 % of cortex of adrenal gland is destroyed. Current dogma says that adrenal insufficiency ultimately is complete, that is the adrenal cortex stops producing steroids altogether. However, several case reports indicate that there might be a subgroup of patients that retain some steroid production, even years after the diagnosis. This ability could be beneficial as it could protect against adrenal crises, ease medication, and leave the patient with better quality of life. The objective of the study is to systematically assess to what extent patients with AAD have residual adrenocortical function, and to characterize this subgroup. The study will be an open non-randomized three-stage multicenter clinical trial comprising patients from the Norwegian Registry for organ-specific autoimmune disease (ROAS), the Swedish Addison registry, and Germany. In stage 1, patients will be asked to fill out questionnaires and deliver medication-fasting samples for analyses of adrenal steroids. In addition, patients with congenital adrenal hyperplasia (CAH) and bilaterally adrenalectomized will serve as negative controls for adrenal steroids. In stage 2, AAD patients with residual steroid production will be invited to a cosyntropin stimulation test to estimate the maximum steroid output from the adrenal glands. Twenty patients with no sign of residual function will also be tested as a control group. In stage 3, AAD patients with confirmed residual function will be invited to go through a 30-hour ambulatory sampling of interstitial fluid for investigation of diurnal variation in adrenocortical hormone levels. Also, newly diagnosed AAD patients will be invited to repeated cosyntropin testing as a means of delineating the natural progression of adrenocortical failure.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Primary Adrenal Insufficiency

7. Study Design

Primary Purpose
Screening
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Non-Randomized
Enrollment
200 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Detectable levels of adrenal hormones
Arm Type
Experimental
Arm Description
Patients with detectable serum levels of adrenal hormones will go through cosyntropin stimulation testing.
Arm Title
Controls with undetectable hormone levels
Arm Type
Active Comparator
Arm Description
Twenty patients without detectable serum levels of adrenal hormones will serve as controls in cosyntropin stimulation testing.
Arm Title
Undetectable levels of adrenal hormones
Arm Type
No Intervention
Arm Description
Patients without detectable serum levels of adrenal hormones. Cosyntropin stimulation testing will not be performed.
Arm Title
Congenital adrenal hyperplasia (CAH) control group
Arm Type
Other
Arm Description
Mapping adrenal steroid profile in patients with congenital adrenal hyperplasia (CAH) with confirmed total deficiency of 21-hydroxylase.
Arm Title
Bilaterally adrenalectomized control group
Arm Type
Other
Arm Description
Mapping adrenal steroid profile in patients who are bilaterally adrenalectomized.
Arm Title
Diurnal variation in residual adrenocortical hormone levels
Arm Type
Experimental
Arm Description
Patients with detectable serum levels of adrenal hormones will go through a 30-hour ambulatory sampling of interstitial fluid for mapping of any diurnal variation in endogenous adrenocortical secretion.
Arm Title
Repeated cosyntropin testing in newly diagnosed patients
Arm Type
Experimental
Arm Description
Newly diagnosed patients will be invited to go through repeated cosyntropin testing to delineate the natural progression of adrenocortical failure.
Arm Title
Cardiovascular and inflammatory biomarkers
Arm Type
Active Comparator
Arm Description
Compare cardiovascular and inflammatory biomarker profiles in patients with and without residual production of adrenocortical steroids
Intervention Type
Diagnostic Test
Intervention Name(s)
Cosyntropin stimulation test
Other Intervention Name(s)
Synacthen stimulation test
Intervention Description
Blood samples are taken before (0 min), and 30 and 60 min after intravenously administration of 250 µg cosyntropin (tetracosactide acetate) with the patient placed in the recumbent position. The test will be performed non-fasting (but medication-fasting) between 08:00 and 10:00 a.m.
Intervention Type
Diagnostic Test
Intervention Name(s)
Baseline blood tests
Intervention Description
Medication-fasting morning levels of adrenocortical hormones.
Intervention Type
Device
Intervention Name(s)
30-hour ambulatory sampling of intestinal fluid
Intervention Description
30-hour ambulatory sampling of intestinal fluid for analysis of adrenocortical hormones.
Intervention Type
Other
Intervention Name(s)
Blood test
Intervention Description
Cardiovascular and inflammatory biomarker profiles
Primary Outcome Measure Information:
Title
The percentage of included patients with residual secretion of cortisol and aldosterone.
Description
Percentage of included patients with detectable levels of adrenal steroid hormones.
Time Frame
1 day
Secondary Outcome Measure Information:
Title
Medication-fasting adrenocorticotropic hormone (ACTH)-stimulated levels of metanephrines
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting basal levels of cortisol
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting basal levels of cortisol
Description
Levels in urine samples
Time Frame
1 day
Title
Medication-fasting basal levels of cortisol
Description
Levels in hair samples
Time Frame
1 day
Title
Medication-fasting basal levels of cortisol precursors
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting basal levels of cortisol precursors
Description
Levels in urine samples
Time Frame
1 day
Title
Medication-fasting basal levels of cortisol precursors
Description
Levels in hair samples
Time Frame
1 day
Title
Medication-fasting basal levels of cortisol metabolites
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting basal levels of cortisol metabolites
Description
Levels in urine samples
Time Frame
1 day
Title
Medication-fasting basal levels of cortisol metabolites
Description
Levels in hair samples
Time Frame
1 day
Title
Medication-fasting basal levels of aldosterone
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting basal levels of aldosterone
Description
Levels in urine samples
Time Frame
1 day
Title
Medication-fasting basal levels of aldosterone precursors
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting basal levels of aldosterone precursors
Description
Levels in urine samples
Time Frame
1 day
Title
Medication-fasting basal levels of aldosterone metabolites
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting basal levels of aldosterone metabolites
Description
Levels in urine samples
Time Frame
1 day
Title
Medication-fasting basal levels of renin in patients with and without residual function.
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting basal levels of renin in patients with and without residual function.
Description
Levels in urine samples
Time Frame
1 day
Title
Medication-fasting basal levels of ACTH in patients with and without residual function.
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting basal levels of ACTH in patients with and without residual function.
Description
Levels in urine samples
Time Frame
1 day
Title
Medication-fasting basal levels of metanephrines in patients with and without residual function
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting basal levels of metanephrines in patients with and without residual function
Description
Levels in urine samples
Time Frame
1 day
Title
Medication-fasting ACTH-stimulated levels of cortisol
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting ACTH-stimulated levels of cortisol precursors
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting ACTH-stimulated levels of cortisol metabolites
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting ACTH-stimulated levels of aldosterone
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting ACTH-stimulated levels of aldosterone precursors
Description
Levels in blood samples
Time Frame
1 day
Title
Medication-fasting ACTH-stimulated levels of aldosterone metabolites
Description
Levels in blood samples
Time Frame
1 day
Title
Cortisol replacement doses, including stress doses in patients with and without residual function.
Description
Total daily dosage
Time Frame
1 day
Title
Cortisol stress doses in patients with and without residual function.
Description
No. stress doses the last week
Time Frame
1 day
Title
Fludrocortisone replacement doses in patients with and without residual function.
Description
Total daily dosage.
Time Frame
1 day
Title
In patients with and without residual function: disease-specific quality-of-life
Description
Total score ranging from 30 to 120 in disease-specific quality-of-life questionnaire, Addison Quality of Life (AddiQoL). For every question, scoring is translated in points (1 = 1 point, 2 and 3 = 2 points, 4 and 5 = 3 points, 6 = 4 points) and the algebraic sum of points is calculated. A higher score reflects better health-related quality-of-life.
Time Frame
1 day
Title
In patients with and without residual function, generic health-related quality of life by the Short Form (36) Health Survey
Description
The Short Form (36) Health Survey is a generic tool comprising 36 items evaluating patient reported quality of life concerning eight domains (physical functioning, role functioning physical, bodily pain, general health perception, vitality, social functioning, role functioning emotional, and mental health and general perception of change in health). Scores are expressed on a 0-100 scale with higher scores associated with better quality of life. The result of each domain is presented separately.
Time Frame
1 day
Title
Number of adrenal crises pr. 100 patient years
Description
Number of crises pr. 100 patient years for all included patients as well as in patients with versus without residual adrenal function
Time Frame
1 day
Other Pre-specified Outcome Measures:
Title
Adrenocortical hormones in congenital adrenal hyperplasia (CAH) controls
Description
Presence or absence of adrenocortical hormones in congenital adrenal hyperplasia (CAH) controls in a medication fasting morning baseline blood sample
Time Frame
1 day
Title
Adrenocortical hormones in bilaterally adrenalectomized controls
Description
Presence or absence of adrenocortical hormones in bilaterally adrenalectomized controls in a medication fasting morning baseline blood sample
Time Frame
1 day
Title
Change in response to cosyntropin testing
Description
Response to cosyntropin testing at 3, 6, 12, and 24 months after diagnosis
Time Frame
4 days
Title
Diurnal variation in adrenocortical hormone secretion
Description
Variation in endogenous adrenocortical hormone secretion during 30 hour continuous sampling
Time Frame
2 days

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
70 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Men and women with AAD, age 18-70 years old. This requires documented adrenal insufficiency and a positive test for 21-hydroxylase autoantibodies (biomarker for autoimmune cause) on at least one occasion. Provided written informed consent In case of concomitant endocrine/autoimmune diseases, the patients should be on stable adequate treatment at least the last 3 months prior to the study period. For Norwegian AD patients: enrolled in ROAS For Swedish AD patients: enrolled in the Swedish Addison registry Exclusion Criteria: Antihypertensive treatment, with the exception of doxazosin, verapamil, and moxonidine. Active malignant disease, severe heart, kidney or liver failure. Diabetes mellitus type 1. Pregnancy or breast feeding. Pharmacological treatment with glucocorticoids (except their usual cortisone or hydrocortisone replacement therapy) or drugs that interfere with cortisol and catecholamine metabolism (antiepileptics, rifampicin, St. Johns wart). Use of other glucocorticoid replacement medication than cortisone acetate or hydrocortisone. Intake of grapefruit, grapefruit juice, or and liquorice juice the last week before or during the study period.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Eystein S Husebye, M.D, Prof
Organizational Affiliation
University of Bergen
Official's Role
Principal Investigator
Facility Information:
Facility Name
Endokrinologie in Charlottenburg
City
Berlin
ZIP/Postal Code
10627
Country
Germany
Facility Name
Haukeland University Hospital
City
Bergen
ZIP/Postal Code
5021
Country
Norway
Facility Name
Karolinska Institutet
City
Stockholm
ZIP/Postal Code
171 77
Country
Sweden

12. IPD Sharing Statement

Plan to Share IPD
No
IPD Sharing Plan Description
Upon informed and signed content, biological samples will be stored in the biobank for research on endocrine disorders. Any new analyses will not be performed without approval from the Regional committee for medical and health research ethics.
Citations:
PubMed Identifier
32392298
Citation
Saevik AB, Akerman AK, Methlie P, Quinkler M, Jorgensen AP, Hoybye C, Debowska AJ, Nedrebo BG, Dahle AL, Carlsen S, Tomkowicz A, Sollid ST, Nermoen I, Gronning K, Dahlqvist P, Grimnes G, Skov J, Finnes T, Valland SF, Wahlberg J, Holte SE, Simunkova K, Kampe O, Husebye ES, Bensing S, Oksnes M. Residual Corticosteroid Production in Autoimmune Addison Disease. J Clin Endocrinol Metab. 2020 Jul 1;105(7):2430-41. doi: 10.1210/clinem/dgaa256.
Results Reference
derived

Learn more about this trial

Screening and Stimulation Testing for Residual Secretion of Adrenal Steroid Hormones in Autoimmune Addison's Disease

We'll reach out to this number within 24 hrs