Autoimmune Addison’s Disease

Journal Pre-proof Autoimmune Addison’s Disease Serena Saverino, Alberto Falorni

PII:

S1521-690X(20)30006-3

DOI:

https://doi.org/10.1016/j.beem.2020.101379

Reference:

YBEEM 101379

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Best Practice & Research Clinical Endocrinology & Metabolism

Please cite this article as: Saverino S, Falorni A, Autoimmune Addison’s Disease, Best Practice & Research Clinical Endocrinology & Metabolism, https://doi.org/10.1016/j.beem.2020.101379. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.

AUTOIMMUNE ADDISON’S DISEASE

Serena Saverino and Alberto Falorni

Section of Internal Medicine and Endocrine and Metabolic Sciences Department of Medicine University of Perugia Perugia, Italy

Corresponding author: Alberto Falorni, MD, PhD Section of Internal Medicine and Endocrine and Metabolic Sciences Department of Medicine Piazza Lucio Severi, 1 – 06129 PERUGIA, Italy [email protected]

KEYWORDS: Adrenal insufficiency, autoimmunity, hydrocortisone, osteoporosis, premature ovarian insufficiency, therapy

Words count: 6,679 Table: 1 References: 104 (10 highlighted in bold) Practice points + Research agenda 1

ABSTRACT

Primary adrenal insufficiency (PAI) occurs in 1/5,000-1/7,000 individuals in the general population. Autoimmune Addison’s disease (AAD) is the major cause of PAI and is a major component of autoimmune polyendocrine syndrome type 1 (APS1) and type 2 (APS2). Presence of 21-hydroxylase autoantibodies (21OHAb) identifies subjects with ongoing clinical or pre-clinical adrenal autoimmunity. AAD requires life-long substitutive therapy with two-three daily doses of hydrocortisone (HC) (15-25 mg/day) or one daily dose of dualrelease HC and with fludrocortisone (0.5-2.0 mg/day). The lowest possible HC dose must be identified according to clinical and biochemical parameters to minimize long-term complications that include osteoporosis and cardiovascular and metabolic alterations. Women with AAD have lower fertility and parity as compared to age-matched healthy controls. Patients must be educated to double-triple HC dose in the case of fever or infections and to switch to parenteral HC in the case of vomiting, diarrhoea or acute hypotension.

Keywords: 21-hydroxylase antibodies, adrenal crisis, autoimmune polyendocrine syndrome, cortisol, fludrocortisone, gene polymorphism, hydrocortisone

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Historical notes Adrenal glands were discovered in 1553 by Bartolomeo Eustachi. Eustachi’s work had initially no large diffusion until when a large part of his original anatomical 47 tables were recovered and published in 1714. The function of the adrenal glands remained obscure until 1855, when Thomas Addison published its On the Constitutional and Local Effects of Disease of the Suprarenal Capsules and reported clinical and anatomical findings in 11 subjects who died for what would afterwards be called “Addison’s disease”. Among the 11 Thomas Addison cases, one presented with vitiligo and a different anatomical aspect of the adrenal glands and is considered to be the first case of autoimmune Addison’s disease (AAD) reported in scientific literature. Patients with Addison’s disease continued to have a very short life expectancy until the 1940s (1). The first clinical trial of therapy in patients with Addison’s disease in 1930 (2) was not proven successful: 20 cases of Addison’s disease and 20 other (nonrheumatologic) patients were treated with an adreno-cortical substance, but replacement therapy was only transiently successful (2). In 1939 deoxycorticosterone acetate became available as first treatment for patients with Addison’s disease. In 1947, Lewis H. Sarett developed the first practical protocol for the large-scale production of Edward Kendall’s compound E, renamed cortisone, used by Philip Showalter Hench in a clinical trial of patients with rheumathoid arthritis. Thanks to the positive effects with that therapy, Kendall, Reichstein and Showalter Hench were awarded jointly the Nobel Prize in Medicine in 1950. Between 1948 and 1958 the major steroid molecules still used today in therapy were first used in clinics, including hydrocortisone. In 1951, JW Conn and coworkers demonstrated that compound F (17-hydroxycorticosterone), later named cortisol, is the hormone produced by the normal human adrenal cortex (3).

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Epidemiology of Addison’s disease Initial studies from 1970s, from UK and Denmark, estimated the prevalence of PAI at 3860 cases per million inhabitants (4,5). Subsequent studies, increased that initial estimate at 93-110 cases per million (6,7), however without providing secondary sources of data or the degree of ascertainment of the analysis. An Italian study, from our group, performed at the end of the 1990s reported a prevalence of 117 cases/million, by using two independent data sources and with a 97% degree of ascertainment (8). More specifically, the disease resulted more frequent among females (127 cases per million) than among males (106 cases per million) (8). A few years later, a nation-wide study estimated a prevalence of 144 cases per million in Norway (9) and reported also what is still the only available estimate of the incidence of the disease: 6 new cases/million inhabitants/year. A more recent study from Iceland calculated a frequency of 221 PAI cases per million in the adult population (10). It must be noted, that the previous Italian and Norwegian studies had been performed in the entire population and that PAI is considered far less common in children than in adults. Hence, the prevalence observed in Iceland may only slightly higher than those from previous estimates, when corrected for the adult population. Nevertheless, a German analysis derived from databases from insurance companies has indeed documented a 1.8%/year increase of the disease prevalence between 2008 and 2012 (11). Limited epidemiological data are available from the rest of the world, but lower prevalence estimates have typically been reported, with the lowest being 5 cases/million from Japan (12). Global variations in prevalence of PAI could be influenced by several variables including genetic variation, environmental factors, adequate diagnosis and degree of ascertainment of all cases, also because nationwide patient registry data of good quality are not frequently available.

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All the above prevalence estimates refer to PAI in all its different forms that include AAD, but also genetic diseases (such as X-linked adrenoleukodystrophy, adrenal hypolasia congenita, triple A syndrome, familiar glucocorticoid deficiency, Smith-Lemli-Opitz syndrome or Kearns-Sayre syndrome), post-tuberculosis, post-paracoccidiomicosis, HIV infection, sepsis, adrenal haemorrhages, surgery, metastasis and drugs. Autoimmune adrenalitis accounts for the majority of cases in industrialized countries, but the estimates of the percent of AAD, as calculated by determination of adrenal-specific autoantibodies, range from 26% in India to >80% of all cases of PAI in Europe (13-17).

Genetics of AAD With the exception of autoimmune polyendocrine syndrome type 1 (APS1), genetic testing have no role in clinical diagnosis and management of AAD. However, research in genetics of AAD has provided important contributions for the understanding of the molecular mechanisms responsible for the development of adrenal autoimmunity. Several studies have demonstrated that the major histocompatibility complex plays a major role in genetic susceptibility for AAD (rev in 18). More specifically, DR3-DQ2 (DRB1*0301DQB1*0201) and DR4-DQ8 (DRB1*04-DQB1*0302) are strongly and primarily associated with AAD (18). Discordant results were initially reported regarding the association of DQB1*0301 and *0302 with AAD, but the controversy was resolved by two European studies published in 2002 (19) and 2005 (20). In a Norwegian study (19), a strong and statistically significant association was detected for DRB1*04-DQA1*0301-DQB1*0302 (DR4-DQ8), showing also an association with some DRB1*04 subtypes, as *0404, but not *0401. Among the other HLA haplotypes, DRB1*01-DQA1*01-DQB1*0501 and DRB1*13-DQA1*0103DQB1*0603 were negatively and significantly associated with the risk for AAD (19). Our subsequent Italian study from 2005 (20) confirmed that both DQA1*0501-DQB1*0201 and

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DQA1*0301-DQB1*0302 are strongly and significantly associated with both isolated AAD and AAD as a part of autoimmune polyendocrine syndrome type 2 (APS2). We also demonstrated that the subtype DRB1*0403 is protective for AAD, being assent in AAD and T1DM patients, but present in 27% DRB1*04-positive Italian healthy individuals. MHC class I chain-related genes (MIC) represent a distinct family of MHC genes located within the class III region (21). MIC family includes 2 functional genes, MICA and MICB. MICA have no role in antigen presentation, but trigger a range of effector mechanisms, including cellular cytotoxicity, cytokine secretion and cellular proliferation (22). A trinucleotide repeat (GCT) microsatellite polymorphism is present within the coding sequence for transmembrane MICA region (23). MICA5.1 was found positively associated and MICA6 negatively associated with AAD (24). A subsequent independent study from US confirmed the association of MICA5.1 with the disease (25). Nevertheless, the strong linkage disequilibrium within the DRB1*03-DQA1*0501-DQB1*0201-MICA5.1-HLA-B extended haplotype has strongly limited the possibility to demonstrate unequivocally that MICA gene polymorphism is independently associated with the risk for human autoimmune diseases. The expression of the HLA class II molecules on antigen presenting cells is controlled by the class II transactivator (CIITA), the master regulator for HLA-D gene expression (26). An association of the polymorphism of CIITA (also called MHC2TA) with AAD was shown in an Italian study (27) and confirmed in a subsequent study, from another European population (28). The molecular mechanisms of CIITA/MHC2TA genetic predisposition for AAD remain mostly unknown, though CIITA/MHC2TA polymorphism may influence the expression of MHC molecules and thus the risk for the development of autoimmune and inflammatory diseases. T cell activation requires a signal provided by antigen-TCR engagement, but also costimulatory signals of which a fundamental one is that provided by the interaction of CD28

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with its ligand B7.1/B7.2 on antigen-presenting cells. Cytotoxic T lymphocyte antigen-4 (CTLA-4) is a co-stimulatory molecule also binding to B7.1/B7.2, but provides negative signal to T cell activation via transduction of an intracellular signal and modulation of trypthophan catabolism in B7-expressing dendritic cells (29). An association between the CTLA4 exon 1 polymorphism (49 A/G) and AAD has been found in some studies and confirmed in meta-analyses (30-32). More recently, the EURADRENAL consortium analysed 16 SNPs in the extended CTLA gene locus encompassing CD28, CTLA4, and ICOS in 382 Norwegian and 309 UK AAD patients and found a significant disease association with 4 SNPS in the Norwegian, but not in the UK, population (33). Haplotype analysis revealed that also the CTLA4 haplotype PROMOTER_1661(A)-rs231726 (T)-rs1896286 (T) was significantly associated with AAD, while CD28 and ICOS polymorphisms did not contribute independently (33). In addition to the major genetic associations with HLA class II haplotypes and CTLA-4 alleles, several other gene polymorphisms have been associated, often in single studies, with the risk for AAD (rev in 18). These include vitamin D receptor (VDR), CYP27B1 (the mitochondrial P450 enzyme that catalyzes the conversion of 25-hydroxyvitamin D3 to 1,25(OH)2D3), PTPN22 (that encodes for lymphoid tyrosin phosphatase (LYP), Programmed Death Ligand 1 (PD-L1), NACHT leucine-rich-repeat protein 1 (NLRP1/NALP1), c receptorlike-3 (FCRL3), GPR174, nuclear factor of activated T-cells, cytoplasmic, calcineurindependent 1 (NFATC1), STAT4, GATA3, NFKB1 and IL23A.

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Clinical picture and diagnosis of primary adrenal insufficiency Although clinical diagnosis is often made after an acute manifestation of the disease as adrenal crisis, AAD may have a progressive evolution that can last for years. In the early phases, clinical signs may be evident only in stressful conditions. With the progression of the glandular damage, an increased pituitary release of ACTH and POMC-derived peptides accompanies the reduced glucocorticoid secretion. In addition, the insufficient production of mineraloactive steroids causes an increased plasmatic renin activity (PRA) with excessive generation of angiotensin II. Most clinical signs and symptoms of PAI are non-specific and a correct diagnosis may dangerously be delayed. It has been shown that a correct diagnosis is delayed by one year or more in approximately 50% of patients with PAI (34) (Table 1). Melanodermia is the major and most characteristic clinical sign of PAI. The most intensely coloured areas are those exposed to light (face, neck, back of the hand), those already normally hyperpigmented (areola of the nipple, scrotum, labia), those that undergo friction or microtraumas, the linea alba and the palmar folds. A conspicuous increase of nevi can also be evident. Scars acquired afterwards the development of PAI tend to darken. The pigmentation of the mucosae has important diagnostic significance: small brownish patches appear on the lips, the palate, the tongue and the gingivae at the dental neck. Although melanodermia is often considered an inevitable sign of PAI, a few cases of the so-called “white Addison’s disease”, associated with a high degree of melanosome degradation in secondary lysosomes at skin biopsy, have been reported. Other clinical signs and symptoms include: profound asthenia, weight loss in adults, slowed weight growth in children, hypotension, dizziness, nausea, vomiting, abdominal pain, anemia, oligo-amenhorrea, reduction in the amount of axillary and pubic hair, muscular pain and neurological disturbances, with depression, irritability and inability to concentrate, hypersensitivity to tastes and smells, headache.

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Clinical signs of other associated autoimmune diseases (eg thyroid diseases, vitiligo or others) may also be present. The electrolytic picture is characterized by hyponatremia, hyperkaliemia, hyperchloremic acidosis and hypercalcemia. Hypoglycaemia may also often contribute to the clinical picture (especially in children). Dehydration is a frequent condition and is consequent to the complex hydroelectrolytic equilibrium disorder. Unfortunately, diagnosis is often delayed and formulated only in the presence of an adrenal crisis, with severe hypotension, vomiting, gastrointestinal pain and rapid evolution to coma and death (within 24-48 hrs), if not promptly treated. Once suspected on clinical ground, diagnosis is made according to low serum levels of basal cortisol (<3-5 µg/dl) and increased plasma ACTH levels (>100 pg/ml) (35). Low aldosterone and high plasmatic renin activity are typically present in AAD, but can be absent in other forms of PAI (35). In stressful conditions, such as septic shock, the cut-off level for diagnosis of adrenal insufficiency is higher, at around 15 µg/dl (36). In the case of a strong clinical suspect of adrenal insufficiency, initiation of therapy must never be delayed and diagnosis should be confirmed afterwards. Basal cortisol determination may have a low diagnostic sensitivity for adrenal insufficiency if used as a single test. This is especially true for secondary adrenal insufficiency (37), but it sometimes may be a problem also in AAD. It must be remembered that available tests measure total cortisol concentration and not the biologically active free cortisol, which may lead to falsely normal results in the presence of high concentrations of cortisol-binding globulin (e.g. women receiving oral estrogens or in pregnancy), and falsely low results in the presence of low cortisol-binding globulin (e.g. patients with cirrhosis) (38). Salivary cortisol concentration (which is an indirect measure of free serum cortisol) may be an alternative, but,

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at present, normal cut-off values have not yet been validated and large inter-laboratory variations still exist (38). Urinary free cortisol (UFC) concentration is not helpful for diagnosis of adrenal insufficiency, mainly because of low diagnostic sensitivity; similarly, measurement of basal plasma ACTH concentration is useful for differential diagnosis between primary and secondary adrenal insufficiency (38) and to define the stage of preclinical AAD (39-41), but not for diagnosis of clinical AAD. The ACTH stimulation test has been used over the years as an alternative tool (37). It is based on stimulation of the adrenal glands by pharmacological doses of exogenous ACTH 1-24 peptide, administered intravenously or intramuscularly. Serum cortisol levels are measured at baseline and at 30 and 60 minutes after stimulation. A peak cortisol concentration above 18 mcg/dl (500 nmol/l) is generally considered a normal response, although different cut-offs have been proposed (42). Proper cut-off levels should always be defined within the specific laboratory and clinical settings, and data available from the literature should never be applied uncritically. In AAD, the ACTH test is mostly useful in the preclinical phase to estimate the degree of adrenal dysfunction (39-41), but can also be used to confirm diagnosis in the presence of cortisol levels within the low normal range. Both the classical 250 µg and the low-dose (1 µg) ACTH test (LDT) have been tested in AAD subjects. No significant differences in diagnostic sensitivity and specificity have been documented in AAD (39) between the two different tests and the classical 250 µg test remains the standard reference for stimulation of the adrenal cortex to exclude PAI, even though the LDT can be used with similar diagnostic accuracy. Technical issues – mainly related to the need of diluting the commercially available dose ampoule of 250 µg of 1-24 ACTH to 1 µg can impair test accuracy. On the other hand, 1 µg ACTH test has been indicated as a more

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useful tool for the evaluation of secondary adrenal insufficiency by some authors, though others showed that also this test lacks of sufficient diagnostic sensitivity (42).

Adrenal autoantibodies and etiological diagnosis of primary adrenal insufficiency Adrenal cortex autoantibodies (ACA), as detected by indirect immunofluorescence, were detected in 40-80% patients with clinically idiopathic Addison’s disease (rev in 43). In spite of technical limitations related to differences in the substrate used for detection of autoantibodies and the subjectivity of the interpretation of the results, ACA-IIF represented the gold standard for adrenal autoantibodies until the middle of the 1990s. Studies at the beginning of the 1990’s led to the identification of steroid-21hydroxylase (21OH) as the main autoantigen identified by ACA (44,45) and to the identification of steroid-17-hydroxylase (17OH) (46) and side chain cleavage enzyme (P450scc)(47) as additional autoantigens. The development of radiobinding assays have demonstrated that 21OH autoantibodies (21OHAb) have a high diagnostic sensitivity and specificity for AAD, being detected in over 95% of cases with clinically idiopathic adrenal insufficiency (13). 21OHAb are predominantly IgG1, with a minor expression of IgG2 and IgG4 (48). Similarly to other organ-specific autoantibodies, they have no major pathogenic role in the development of adrenal insufficiency. They can be detected in approximately 0.5% healthy subjects who do not necessarily progress towards clinical adrenal insufficiency. In pregnant women positive for adrenal autoantibodies, 21OHAb cross the placental barrier but do not determine any sign of clinical or pre-clinical adrenal insufficiency in newborn (49). Accordingly, 21OHAb are a highly sensitive and specific immunological marker of the ongoing adrenal autoimmune process, but do not act as an effector of destructive autoimmunity.

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Though 17α-hydroxylase autoantibodies (17OHAb) and P450 side-chain cleavage autoantibodies (P450sccAb) can be detected in a fraction of patients with AAD, these markers are more frequently present in patients with APS1 or in women with autoimmune oophoritis determining autoimmune ovarian insufficiency (50). Interestingly, in women with premature ovarian insufficiency (POI), StCA, 17OHAb and P450sccAb can be detected only in patients positive for 21OHAb (50). The association between autoimmune oophoritis and adrenal autoimmunity is so strong that 21OHAb have a diagnostic sensitivity for autoimmune POI higher than that of StCA or 17OHAb/P450sccAb (50). Around 4-8% of women with clinically idiopathic POI have an autoimmune oophoritis and are positive for 21OHAb. Guidelines by the European Society of Human Reproduction and Embriology (ESHRE) recommend that all women with clinically idiopathic POI be tested for 21OHAb to identify autoimmune cases (51). The strong association between AAD and autoimmune POI has important clinical implications. Since 10-20% patients with AAD develop autoimmune POI (50), StCA, 17OHAb and P450sccAb analyses should be offered to AAD women to identify subjects at risk for future ovarian insufficiency. It can be hypothesized that women with AAD, positive for StCA, 17OHAb or P450sccAb might benefit from ovarian tissue cryopreservation, given their increased risk for POI, though this is not yet supported by any guideline. Autoantibodies against NACHT leucine-rich-repeat protein 5 (NALP5), an autoimmune marker of APS1-related hypoparathyroidism, can be detected in 7% patients with AAD and 12% women with autoimmune POI (52). The immunological relevance of this NALP5-related autoimmunity in AAD is unknown and NALP5Ab have no role in clinical management of patients with AAD, with the exception of APS1 subjects with hypoparathyroidism.

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Clinical use of 21OHAb: diagnosis of AAD and characterisation of pre-clinical AAD The presence of circulating 21OHAb enables the identification of an ongoing adrenal autoimmunity and is used to diagnose autoimmune forms of adrenal insufficiency (35,53). Autoantibody titre is also important as it has been shown that the presence of low titre adrenal autoantibodies does not enable the unequivocal diagnosis of AAD in all cases as ACA and 21OHAb have sporadically been found in patients with documented post-tuberculosis Addison’s disease (14,54). A flow-chart for the etiological classification of PAI, that takes into consideration immunological, biochemical and imaging data, was initially developed (53) and more recently expanded to include childhood forms of PAI (55). According to this flowchart, adrenal autoantibodies are the first marker to be analysed in adult forms of PAI (53). In the case of a simultaneous presence of both ACA and 21OHAb, the probability of an accurate diagnosis of AAD is higher than 99% (53). All patients with AAD may undergo additional autoantibody analyses, such as thyroid autoantibodies, GAD autoantibodies (GADA), steroidcell autoantibodies (StCA), 17OHAb, P450sccAb or parietal cell autoantibodies, as approximately 60 to 80% of AAD patients show clinical or pre-clinical signs of another autoimmune disease (35). AAD represents a major component of APS1 and APS2 (56). Typically, diagnosis of APS1 is made on a clinical basis with at least two of three major disease components (AAD, chronic candidiasis and hypoparathyroidism), or only one in a first-degree relative of an APS1 patient, and confirmed by genetic testing of the AIRE (AutoImmune REgulator) gene. However, the extremely high diagnostic accuracy of antiIFNω autoantibodies for APS 1 (approaching 100%) (57) makes it possible to include this marker in the diagnostic flow-chart to identify atypical or prodromal forms of the syndrome. Autoimmune AAD can be diagnosed also in the presence of medium-high levels of either 21OHAb or ACA (53). At present, no clear and standardised cut-off is available to discriminate between low and medium-high level autoantibody titres. Diagnostic accuracy of 13

the 21OHAb assay is higher than that of the ACA-IIF, and 21OHAb is currently the gold standard for detection of adrenal autoantibodies. In the case of patients positive only for 21OHAb or ACA at low levels, as well as in autoantibody-negative subjects, adrenal imaging should be performed to exclude an infiltrative form of adrenal insufficiency (such as posttuberculosis, sarcoidosis, mycosis or metastatic localization of non-adrenal tumours) (53). Adrenal imaging should not be performed in confirmed AAD because does not add any useful information. In male patients negative for adrenal autoantibody measurement and with normal adrenal imaging, determination of plasmatic very long chain fatty acids (VLCFA) must be performed to exclude X-linked adrenoleukodistrophy (ALD). A low positivity for 21OHAb or ACA can be considered sufficient to formulate an accurate diagnosis of AAD only after adrenal imaging and VLCFA analysis have been performed. In children, 17OH-progesterone should be included as a first-line exam (55), as genetic diseases (and more specifically congenital adrenal hyperplasia) represent frequent causes of PAI. Screening of subjects with endocrine autoimmune diseases for the presence of 21OHAb enables the identification of subjects with so-called preclinical (or subclinical) AAD. 21OHAb can be detected in 0.5-1.5% T1DM patients, 0.5-1.5% patients with autoimmune thyroid diseases, 0.5-1.0% patients with vitiligo, 10-20% patients with autoimmune hypoparathyroidsm and in 4-8% women with POI (43). Appearance of adrenal autoantibodies marks stage 0 of preclinical AAD (58). Often the first dysfunction observed as a consequence of the progression of the autoimmune process is an increase of PRA, at a time when normal ACTH-cortisol axis response is still present (stage 1). In stage 2, an impaired cortisol response to the ACTH stimulation test is documented. Finally, stage 3 represents the last pre-clinical phase characterized by increased ACTH levels, along with the dysfunctions observed in stage 1 and 2.

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Because of the importance of 21OHAb determination for etiological diagnosis of AAD, diagnosis of autoimmune POI and identification of at-risk subjects, standardization of this assay is highly relevant and inter-laboratories concordance studies with serum exchange programs are strongly needed. Two such programs have been performed (59,60) and a high positive-negative concordance among participating laboratories has been shown, but a better standardization of 21OHAb titre estimate is deemed necessary. No preventative therapy is yet available to delay or block the progressive destruction of adrenocortical cells in pre-clinical AAD. No guidelines are available on the clinical management of patients with preclinical AAD. Subjects with stage 0 and stage 1 requires only clinical and biochemical follow-up with hormone analyses on a yearly basis. A substitutive therapy may be considered in stage 3 individuals, in the case of a stressful event, while chronic substitutive treatment may sometimes be associated with clinical signs and symptoms of overtreatment. Similarly, stage 2 subjects should be informed of the potential need for substitutive HC treatment in the case of a major stressful event. Patients with an impaired response to the ACTH stimulation test need a strict follow-up, possibly with hormonal and clinical evaluation every six months. Adrenal autoantibody levels increase during the progression of the adrenal dysfunction (61). The response to the ACTH stimulation test discriminates between early potentially reversible stages (stage 0 and stage 1) and a more advanced and irreversible dysfunction (stage 2 and stage 3) (40,41,61). Globally, the future risk of developing clinical AAD is around 10-15% in subjects with normal response to the ACTH test (stage 0-1) and increases to 50-90% if an ACTH test provides pathologic results (40,41,61). Among the factors increasing significantly the risk of progression towards clinical adrenal insufficiency, in subjects with subclinical AAD, the most important are: male gender, presence of other concomitant autoimmune diseases, impaired response to the ACTH test and a high 21OHAb

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titre (41,61). Finally, no case of spontaneous progression towards clinical AAD has so far been observed after 17 years of follow-up (41).

Therapy and clinical management of AAD

Because of the absolute deficiency of adrenal cortex hormones caused by the destructive autoimmune process, patients with AAD require life-long substitutive treatment with hydrocortisone (HC) (or cortisone acetate in those countries were oral HC is not available) (62). It has been estimated that the adult normal adrenal cortex secretes around 5-10 mg cortisol/sqm of body surface a day, corresponding to approximately 8-17 mg total cortisol/day. Accordingly, international consensus agreements and guidelines recommend to use 15-25 mg HC/day (63,64). The half-life of HC is approximately 90 minutes, and 2-3 daily doses are recommended to mimic the physiologic circadian pattern of cortisol. Half to twothird of the total daily dose of HC should be administered in the morning at waking and the remaining doses given every 6 hours, the smallest not later than 6 hours before bedtime. Since the autoimmune process is destroying the total adrenal cortex, patients with AAD typically require also a mineralocorticoid therapy, with 50-200 µg/day fludrocortisone given once a day early in the morning (62-64). Controversial data are available regarding the relevance of dehydrohepiandrosterone (DHEA) supplementation. Although initial data suggested a potential benefit of DHEA supplementation to improve quality of life, bone structure and female sexuality (65), subsequent studies have not confirmed those findings (66,67). Accordingly, DHEA supplementation is not recommended in all patients with AAD, though it may have a potential clinical application (at doses of 12.5-25 mg/d) in young females which are lamenting a decrease in libido and sexual activity. Treatment with DHEA requires endocrinological follow-up and dose adjustment to avoid signs of hyperandrogenism. 16

Unfortunately, no single biochemical or hormonal marker can be used to adjust the dose of the glucocorticoid substitutive therapy. ACTH is expected to be higher than normal in well compensated patients and its concentration within the normal range is usually the sign of overtreatment. Similarly, basal cortisol levels will always be lower than normal because of the short effect of oral HC that does not enable normal hormone concentrations before morning administration. Accordingly, consensus agreements and international guidelines recommend to not determine routinarely ACTH and cortisol (nor UFC) for the adjustment of HC dose and to use only clinical parameters, such as patient’s well-being, body weight, waist-hip circumference ratio, blood pressure, sodium and potassium levels (63,64). Monitoring of potential complications of long-term glucocorticoid treatment is also important. In well compensated patients, an endocrinological clinical evaluation may be performed on a yearly basis, while unstable patients or patients with recent-diagnosis may require more frequent evaluations. Several studies have focused on long-term complications of chronic HC treatment (68). In many reports, patients with AAD had a significant lower bone mass density (BMD) (66,69,71) as compared to age- and sex-matched healthy population, which supports the recommendation to perform a DXA BMD on a regular basis (every 3-5 years) (63). HC dose seems to be the major variable influencing this risk, as doses of 15-25 mg/day have not been associated with significant reduction of BMD as compared to higher doses (71). This observation is also supported by the linear and inverse correlation between body weight adjusted HC dose and femoral BMD (74) and by the improvement of BMD after reduction of the dose of the substitutive therapy (72) (Table 1). On the other hand, the use of equivalent doses of prednisone is associated with a significant reduction of BMD as compared to patients treated with HC (71). Interestingly, in patients with PAI, the highest risk for fracture is observed around the time of diagnosis (within one year before and one year after diagnosis),

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and is rapidly declining afterwards (73). Hence, factors associated with the disease are also strongly influencing the risk of fragility fractures, including cortisol deficiency, DHEA deficiency, hyponatraemia, loss of body weight, asthenia, with reduced muscular activity and increased propensity to fall, and melanodermia-induced vitamin D insufficiency. Conventional HC substitutive treatment does not normalize health-related quality of life (QoL) (68). Perceived health status and vitality are reduced in AAD patients (74-78). Affective and depressive disorders appear to be more frequent among patients with PAI than in control patient groups with other diseases (74-78). Interestingly, higher doses of HC are associated with a significant deterioration of perceived QoL, regarding more specifically physical function, role physical, general health, vitality, social function, role emotional and mental health (75). The development of an Addison-specific quality of life questionnaire (AddiQoL), which has been validated in several languages (79), has important clinical applications to monitor impairment of subjective health status and to reveal subtle abnormalities that may go unnoticed during a normal clinical evaluation. All these data are indicating that conventional HC replacement does not restore QoL in AAD patients and the use of higher doses is associated with a negative effect on perceived wellbeing. It is very well known that glucocorticoids have a counter-regulatory effect on glucose metabolism, by regulating glycogen synthesis/lysis, increasing gluconeogenesis and inhibiting peripheral glucose utilization. Although only a few data are available, patients with both T1DM and AAD require higher insulin doses than subjects with only T1DM (80) and AAD patients have an unfavourable metabolic and cardiovascular profile in comparison to healthy subjects (81). Moreover, the negative impact of high-dose HC administration on blood glucose levels is significantly higher in the evening than in the morning (82), which supports the practical advice to administer a low dose of HC in the afternoon not later than 6:00-6:30 pm, also to avoid sleep disturbances associated with supra-physiologic cortisol levels.

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Glucocorticoids have also important cardiovascular effects. High HC doses can cause hypertension, salt and water retention and increased excretion of potassium. Changes in body weight and blood pressure due to high HC doses may contribute to the increased number of premature cardiovascular deaths that have been reported in patients with adrenal insufficiency (83-85). In women, fertility is not affected before diagnosis of AAD (86,87). However, after diagnosis, a reduction is observed (86,87). Especially having many children (≥3) is uncommon amongst patients as compared with healthy controls. A large Swedish study which included 1,188 women with AAD provided reassuring data on maternal and neonatal outcome (87). Most offspring were delivered vaginal, at full term, alive and with good Apgar scores. No differences were seen in maternal complications, maternal and infant death or congenital malformations. However, women giving birth after the diagnosis of AD were at increased risk of caesarean delivery and preterm birth (≤37 wk) (87). Another, more recent large populationbased retrospective cohort study from the US (88) compared maternal and neonatal outcome in 552 patients with an ICD-9 PAI diagnosis and 7,772,447 women without AD diagnosis. Also in this study (88), women with AD were more prone to deliver preterm and with caesarean section (OR 1.32;95% CI 1.08-1.61). However, an increased frequency of postpartum complications such as wound complications, infections, need of transfusion, venous thromboembolic disease and prolonged hospital stays was also observed (88). Taken together, the available literature is suggesting a reduced parity in women with AAD. Sexuality in AAD women does not appear to be significantly impaired (86) and several factors, including comorbidities, reluctancy to parenthood because of the chronic disease, but also POI, may contribute to the reduced number of pregnancies reported. In women with well-managed AAD it is nowadays probable to have uneventful pregnancies with favourable outcome and there is no need for physicians to generally advise against pregnancy. At the time of delivery,

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im HC (50-100 mg) should be administered at the beginning of labour or, continuous iv infusion of HC should be used for caesarean section, with a protocol similar to that described for management of adrenal crises. Undiagnosed AAD or inadequate substitution therapy may facilitate preterm delivery and fetal growth restriction (89). From the observation that in physiologic pregnancy there is an increase in serum cortisol levels during the second and third trimester (90), international guidelines suggest to increase HC dose during the third trimester in all AAD pregnant women (64). However, there are no sufficient data from evidence-based clinical studies that strongly support this suggestion and therapy must be adapted to each single individual according to clinical and fetal development data, by an experienced endocrinologist. On the other hand, the high serum progesterone levels observed during the third trimester of pregnancy have an important anti-aldosteronic effect, that may be controlled by cautious and personalised increases of fludrocortisone, though international guidelines suggest to prefer an increase of HC doses (64), still at a low recommendation level of personal clinical opinion. Further, more specific, clinical studies are needed to provide adequate suggestions on treatment of AAD during pregnancy. Prevention and control of an adrenal crisis is a major issue in the management of patients with AAD, since this acute complication is a major cause of death (91) (Table 1). An incidence of 6-8 per 100 patient-years adrenal crises has been reported (68). They are mainly precipitated by gastrointestinal infections (33%), other infections with fever (24%), but also surgery, strenuous physical activity, cessation of glucocorticoid therapy by the patient, psychic distress or accident (92). During their life-time, approximately 47% AAD patients require at least one hospitalization for an adernal crisis after diagnosis (92), in many cases in spite of a correct education and clinical management (93). All patients must be educated to double or triple the HC daily dose in the occurrence of fever (>38 °C) or in the case of minor surgery, while intramuscular or intravenous HC should be used in the case of a major surgery with general

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anaesthesia. In the case of psychic stress (eg for a student’s exam) or mild physical activity (eg amateur sport activity) the need for a small HC dose supplementation must be evaluated for each specific clinical case and no general rule applies. An emergency kit with HC must always be available to the patient to be used in the case of vomiting or diarrhoea (50-100 mg) or in the case of sudden hypotension with lipothymia (100 mg). AAD patients should be advised to carry an emergency card or objects (eg bracelet, necklace or other) informing of the need for saline infusion and im/iv HC administration in the case of emergency. If sever hypotension, lethargy, abdominal pain and vomiting ensue, the patient must rapidly be hospitalized to start iv saline infusion (up to 4-5 lt during the first day, according to cardiovascular and renal conditions) and to administer an iv bolus of 100 mg HC followed by continuous infusion of additional 100-200 mg/24 hr. According to general conditions, the day after, HC may generally be taped down to 100 mg/day (as continuous infusion or as 50 mg boluses every 12 hr) to typically start oral therapy during the third day and to reach the chronic oral treatment during the fourth-fifth day. The timing and dosage of saline infusion and of HC therapy must, however, be adapted to the specific clinical case. It has emerged that not only total HC daily dose, but also disruption of the physiologic cortisol circadian rhythm, is associated with increased risk of impairment of QoL and cardiometabolic alterations (62,68). A dual-release hydrocortisone (DR-HC) formulation has been developed as 20 mg or 5 mg tablets to improve cortisol pharmacokinetics and pharmacodynamics (94). This formulation enables both a rapid increase of cortisol levels in the morning and a prolonged lower release of hydrocortisone, similarly to what occurs in the physiological circadian cortisol rhythm. DR-HC is administered once a day in most patients and in the every-day life, in the absence of concomitant illnesses or stressful events. A phase II open, randomized, two-period, 12-wk crossover multicenter trial documented improved serum cortisol profile as compared to conventional HC and 92% of randomized patients chose

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to continue the treatment with DR-HC after completion of the study (94). Thanks to the more physiologic release of the hormone, DR-HC is associated with 19% lower total cortisol exposure as compared to an identical dose of conventional HC. Several studies have documented beneficial effect of switching from conventional HC to DRHC (Table 1). Improvement of health-related QoL has been documented almost invariably in all studies that used administration of questionnaires, including the specific AddiQoL (94-98). In clinical routine practice, around 80 to 90% of patients indeed report that they feel better, they have more energy and they prefer the DR-HC preparation over conventional HC treatment. Nevertheless, a small fraction of patients (around 10 %) requests to switch back to the initial HC treatment for worsening of the general health status. The reasons for that are unclear, but may include an adaptation period to the different circadian pattern during the first weeks of treatment with DR-HC, a lower receptor sensitivity which may require higher HC doses or the need for a day-to-day small dose adaptation to cope with variable every-day life activities which is not possible with the DR-HC tablet that cannot be subdivided. Several studies have reported data on cardiovascular and metabolic outcomes with DR-HC (94-101). A reduction of HbA1c or improvement of insulin sensitivity in pre-diabetic or diabetic individuals has been almost invariably reported (94-97,99-101). In addition, many studies have also reported reduction of body weight, waist circumference and BMI (94-97,99,101), as well as improvement of lipid profile (95,96,100,101). Modifications in diastolic blood pressure were inconsistent. Interestingly, switch to DR-HC was also associated to a more physiologic immune profile (97) that suggests that use of this preparation may have far larger implications than those observed so far in clinical studies, including risk for infections. Although the DR-HC preparation guarantees a more physiologic cortisol substitution, some limitations also exists: there is 1) general limitation in personal tailoring of the treatment given the fixed available doses, 2) difficulty of using this preparation in the case of variable

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work shifts and unpredictable demands, 3) need of using anyway the classical HC preparation for small on-demand supplementations in mildly (and time-limited) stressful situations, 4) reported asthenia in the late afternoon hours, which is referred by a fraction of patients, 5) preference by a limited number of patients (around 10-15%) of the classical HC preparation, 6) unavailability of a clear and documented protocol of dose adjustment in stressful conditions (eg infections) (normally it is advisable to take a second tablet in the afternoon in the case of fever or intercurrent illness), 7) indication only in adult patients, 8) controindication in patients with altered gastric motility, 9) still non-physiologic hypocortisolism at awakening and 10) higher cost of the treatment, especially for those patients using three daily tablets of 5 mg DR-HC (15 mg/day). An additional modified-release HC preparation, that taken in the evening ensures a quasiphysiologic peak of cortisol early in the morning before awakening, is under intensive study and evaluation by regulatory agencies (102). This preparation will primarily be intended for patients with congenital adrenal hyperplasia, but potential future applications also to the treatment of AAD cannot be excluded. In children, the optimal HC substitution therapy is with 7-8 mg/sqm body surface/day, subdivided in three daily doses. The gold-standard of the physiologic replacement of cortisol is continuous subcutaneous hydrocortisone infusion (CSHI) by using pumps developed for insulin subcutaneous infusion. CSHI was initially proposed in 2007 to document a significant improvement of QoL with normalization of circadian cortisol rhythm (103). CSHI cannot be proposed as a routine clinical treatment of AAD because of reduced compliance by the patient and complexity and high costs of the treatment, but, mainly, because of lack of authorizations from regulatory agencies for using the insulin microinfusion pumps for subcutaneous administration of HC. Nevertheless, this strategy can and should be taken into consideration for complex clinical

23

cases in which oral treatments cannot be performed (104) or are not able to guarantee a minimally satisfactory management of the disease.

Summary AAD is diagnosed by presence of 21OHAb in patients with low basal serum cortisol and high plasma ACTH concentrations. Patients need life-long treatment with HC in two-three daily doses or with a single dose of a dual-release HC preparation. Deficit of mineralcorticoids is almost invariably present and fludrocortisone 0.5-2.0 mg/day must also be given. To date no single biochemical or hormonal marker is available to objectively adjust the dose of the substitutive therapy and management of therapy of AAD is still based on clinical parameters such as body weight, blood pressure, waist/hip circumference ratio, but also sodium and potassium concentrations. Reproduction of the physiologic circadian cortisol rhythm is an important issue, and a dual-release HC preparation is often advantageous in comparison to the conventional HC treatment. Use of excessive HC doses (in most of cases >25 mg/day) and disruption of the physiologic circadian rhythm are associated with increased risk for osteoporosis, cardiometabolic complications, sleep disturbances and alterations of healthrelated QoL. Women with AAD have globally a lower fertility and parity, in comparison to age-matched healthy controls, though pregnancies are in general expected to be uneventful if a proper substitutive treatment is provided by an experienced endocrinologist. However, no sound protocol is available on the adjustment of HC dose during the different trimesters of pregnancy and only personal opinions are available in literature. A major issue remains prevention and management of adrenal crises that require adaptation of HC doses and hospitalization in severe cases that require iv fluid and parenteral HC administration.

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References 1. Dunlop D. Eighty-six cases of Addison’s disease. Br Med J 1963;5362, 887-891. 2. Rowntree LG, Swingle W, Pfiffner JJ et al.: Treatment of Addison’s disease with the cortical hormone of the suprarenal gland: summary of immediate results in twenty cases treated with the preparation made by Swingle and Pfiffner. JAMA, 1931;97, 1446-1453. 3. Conn JW, Louis LH & Fajans SS. The probability that compound F (17hydroxycorticosterone) is the hormone produced by the normal human adrenal cortex. Science 1951;113, 713-714. 4. Mason AS, Meade TW, Lee JAH & Morris JN. Epidemiological and clinical picture of Addison’s disease. Lancet. 1968;II, 744 –747. 5. Nerup J. Addison’s disease. Clinical studies. A report of 108 cases. Acta Endocrinol 1974;76, 127–141. 6. Kong MF & Jeffcoate WJ. Eighty-six cases of Addison’s disease. Clin Endocrinol 1994; 41, 757–761. 7. Willis AC & Vince FP. The prevalence of Addison’s disease in Coventry, UK. Postgrad Med J 1997;73, 286 –288. 8. Laureti S, Vecchi L, Santeusanio F & Falorni A. Is the prevalence of Addison’s disease underestimated? J Clin Endocrinol Metab 1999;84, 1762. 9. Løvås K & Husebye ES. High prevalence and increasing incidence of Addison's disease in western Norway. Clin Endocrinol (Oxf) 2002;56, 787-791. 10.

Olafsson AS & Sigurjonsdottir HA. Increasing prevalence of Addison disease: results

from a nationwide study. Endocr Pract 2016;22, 30-35. 11.

Meyer G, Neumann K, Badenhoop K & Linder R. Increasing prevalence of addison's

disease in German females: Health insurance data 2008-2012. Eur J Endocrinol 2014;170, 367-373.

25

12.

Takayanagi R, Miura K, Nakagawa H & Nawata H. Epidemiologic study of adrenal

gland disorders in japan. Biomed Pharmacother 2000;54 Suppl 1, 164s-168s. 13.

Falorni A, Nikoshkov A, Laureti S et al. High diagnostic accuracy for idiopathic

Addison’s disease with a sensitive radiobinding assay for autoantibodies against recombinant human 21-hydroxylase. J Clin Endocrinol Metab 1995;80, 2752-2755. 14.

Silva RC, Kater CE, Dib SA et al. Autoantibodies against recombinant human

steroidogenic enzymes 21-hydroxylase, side-chain cleavage and 17α-hydroxylase in Addison’s disease and autoimmune polyendocrine syndrome type III. Eur J Endocrinol 2000;142, 187-194. 15.

Nigam R, Bhatia E, Miao D et al. Low prevalence of 21-hydroxylase antibodies in

idiopathic Addison’s disease from India. Clin Endocrinol (Oxf) 2003; 59, 593-598. 16.

Erichsen MM, Lovas K, Skinningsrud B et al. Clinical, immunological, and genetic

features of autoimmune primary adrenal insufficiency: Observations from a norwegian registry. J Clin Endocrinol Metab 2009;94, 4882-4890. 17.

Betterle C, Scarpa R, Garelli S et al. Addison's disease: A survey on 633 patients in

Padova. Eur J Endocrinol 2013;169, 773-784. 18.

*Falorni A, Brozzetti A & Perniola R. From genetic predisposition to molecular

mechanisms of autoimmune primary adrenal insufficiency. Front Horm Res 2016;46, 115-132. 19.

Myhre AG, Undlien DE, Løvås K et al. Autoimmune adrenocortical failure in Norway

autoantibodies and human leukocyte antigen class II associations related to clinical features. J Clin Endocrinol Metab 2002;87, 618-623. 20.

Gambelunghe G, Kockum I, Bini V et al. Retrovirus-like long terminal repeat DQ-

LTR13 and genetic susceptibility to type 1 diabetes mellitus and autoimmune Addison’s disease. Diabetes 2005;54, 900-905.

26

21.

Bahram S. MIC genes: from genetics to biology. Adv Immunol 2000;76, 1-60.

22.

Groh V, Bahram S, Bauer S et al. Cell stress-regulated human major

histocompatibility complex class I gene expressed in gastrointestinal epithelium. Proc Natl Acad Sci USA 1996;93, 12445-12450. 23.

Ota M, Katsuyama Y, Mizuki N et al. Trinucleotide repeat polymorphism within exon

5 of the MICA gene (MHC class I chain-related gene A): allele frequency data in the nine population groups Japanese, Northern Han, Hui, Uygur, Kazakhstan, Iranian, Saudi Arabian, Greek and Italian. Tissue Antigens 1997;49, 448-454. 24.

Gambelunghe G, Falorni A, Ghaderi M et al. Microsatellite polymorphism of the

MHC class I chain-related (MIC-A and MIC-B) genes marks the risk for autoimmune Addison’s disease. J Clin Endocrinol Metab 1999;84, 3701-3707. 25.

Park YS, Sanjeevi CB, Robles D et al. Additional association of intra-MHC genes,

MICA and D6S273, with Addison's disease. Tissue Antigens 2002;60, 155-163. 26.

Harton JA & Ting JP. Class II transactivator: mastering the art of major

histocompatibility complex expression. Mol Cell Biol 2000;20, 6185-6194. 27.

Ghaderi M, Gambelunghe G, Tortoioli C et al. MHC2TA single nucleotide

polymorphism and genetic risk for autoimmune adrenal insufficiency. J Clin Endocrinol Metab 2006;91, 4107-4111. 28.

Skinningsrud B, Husebye ES, Pearce SH et al. Polymorphisms in CLEC16A and

CIITA at 16p13 are associated with primary adrenal insufficiency. J Clin Endocrinol Metab 2008;93, 3310-3317. 29.

Grohmann U, Orabona C, Fallarino F et al. CTLA-4-Ig regulates tryptophan

catabolism in vivo. Nature Immunol 2002;3, 1097-1101.

27

30.

Kemp EH, Ajjan RA, Husebye ES et al. A cytotoxic T lymphocyte antigen-4 (CTLA-

4) gene polymorphism is associated with autoimmune Addison’s disease in English patients. Clin Endocrinol 1998;49, 609–613. 31.

Vaidya B, Imrie H, Geatch DR et al. Association analysis of the cytotoxic T

lymphocyte antigen-4 (CTLA-4) and autoimmune regulator-1 (AIRE-1) genes in sporadic autoimmune Addison's disease. J Clin Endocrinol Metab 2000;85, 688-691. 32.

Brozzetti A, Marzotti S, Tortoioli C et al. Cytotoxic T Lymphocyte Antigen-4 Ala17

polymorphism is a genetic marker of autoimmune adrenal insufficiency: Italian association study and meta-analysis of European studies. Eur J Endocrinol 2010;162, 361-369. 33.

Wolff AS, Mitchell AL, Cordell HJ et al. CTLA-4 as a genetic determinant in

autoimmune Addison’s disease. Genes Immun 2015;16, 430-436. 34.

Bleicken B, Hahner S, Ventz M & Quinkler M. Delayed diagnosis of adrenal

insufficiency is common: a cross-sectional study in 216 patients. Am J Med Sci 2010;339, 525-531. 35.

*Betterle C, Presotto F & Furmaniak J. Epidemiology, pathogenesis, and

diagnosis of Addison's disease in adults. J Endocrinol Invest 2019;42, 1407-1433. 36.

Cooper MS & Stewart PM. Corticosteroid insufficiency in acutely ill patients. N Engl

J Med 2003;348, 727-734. 37.

Guaraldi F, Karamouzis I, Berardelli R et al. Secondary adrenal insufficiency: where

is it hidden and what does it look like? Front Horm Res 2016;46, 159-170. 38.

Crowley RK, Argese N, Tomlinson JW & Stewart PM. Central hypoadrenalism. J Clin

Endocrinol Metab 2014;99, 4027-4036. 39.

Laureti S, Arvat E, Candeloro P et al. Low dose (1 µg) ACTH test in the evaluation of

adrenal dysfunction in pre-clinical Addison’s disease. Clin Endocrinol (Oxf) 2000;53, 107–115.

28

40.

Coco G, Dal Pra C, Presotto F et al. Estimated risk for developing autoimmune

Addison's disease in patients with adrenal cortex autoantibodies. J Clin Endocrinol Metab 2006;91, 1637-1645. 41.

Naletto L, Frigo A, Ceccato F et al. The natural history of autoimmune Addison’s

disease from the detection of autoantibodies to development of the disease: a long followup study on 143 patients. Eur J Endocrinol 2019;180, 223-234. 42.

Kazlauskaite R, Evans AT, Villabona CV et al. Consortium for evaluation of

corticotropin test in hypothalamic-pituitary adrenal insufficiency: corticotropin tests for hypothalamic-pituitary-adrenal insufficiency: a metaanalysis. J Clin Endocrinol Metab 2008;93, 4245-4253. 43.

*Falorni A, Brozzetti A, Calcinaro F et al. Recent advances in adrenal

autoimmunity. Exp Rev Clin Endocrinol Metab 2009;4, 333-348. 44.

Winqvist O, Karlsson FA & Kämpe O. 21-Hydroxylase, a major autoantigen in

idiopathic Addison’s disease. Lancet 1992;339, 1559–1562. 45.

Baumann-Antczak A, Wedlock N, Bednarek J et al. Autoimmune Addison’s disease

and 21-hydroxylase. Lancet 1992;340, 429–430. 46.

Krohn K, Uibo R, Aavik E et al. Identification by molecular cloning of an autoantigen

associated with Addison’s disease as steroid 17α-hydroxylase. Lancet 1992;339, 770–773. 47.

Winqvist O, Gustafsson J, Rorsman F et al. Two different cytochrome P450 enzymes

are the adrenal antigens in autoimmune polyendocrine syndrome type I and Addison’s disease. J Clin Invest 1993;92, 2377–2385. 48.

Brozzetti A, Marzotti S, La Torre D et al. Autoantibody responses in autoimmune

ovarian insufficiency and in Addison disease are IgG1-dominated and suggest a predominant, but not exclusive, Th1 type of response. Eur J Endocrinol 2010;163, 309317.

29

49.

Betterle C, Pra CD, Pedini B et al. Assessment of adrenocortical function and

autoantibodies in a baby born to a mother with autoimmune polyglandular syndrome Type 2. J Endocrinol Invest 2004;27, 618-21. 50.

*La Marca A, Brozzetti A, Sighinolfi G et al. Primary ovarian insufficiency:

autoimmune causes. Curr Op Obst Gynecol 2010;22, 277-282. 51.

European Society for Human Reproduction and Embryology (ESHRE) Guideline

Group on POI, Webber L, Davies M et al. ESHRE Guideline: management of women with premature ovarian insufficiency. Hum Reprod 2016;31, 926-937. 52.

Brozzetti A, Alimohammadi M, Morelli S et al. Autoantibody response against

NALP5/MATER in primary ovarian insufficiency and in autoimmune Addison's disease. J Clin Endocrinol Metab 2015;100, 1941-1948. 53.

Falorni A, Laureti S, De Bellis A et al. Italian Addison Network Study: Update of

diagnostic criteria for the etiological classification of primary adrenal insufficiency. J Clin Endocrinol Metab 2004;89, 1598-1604. 54.

Nomura K, Depura H & Saruta T. Addison’s disease in Japan: characteristics and

changes revealed in a nationwide survey. Intern Med 1994;33, 602–604. 55.

*Bancos I, Hahner S, Tomlinson J & Arlt W. Diagnosis and management of

adrenal insufficiency. Lancet Diabetes Endocrinol 2015;3, 216-26. 56.

*Husebye ES, Anderson MS & Kämpe O. Autoimmune polyendocrine

syndromes. N Engl J Med 2018;378, 1132-1141. 57.

Meloni A, Furcas M, Cetani F et al. Autoantibodies against type I Interferons as an

additional diagnostic criteria for Autoimmune Polyendocrine Syndrome type I. J Clin Endocrinol Metab 2008;93, 4389-4397. 58.

Betterle C, Scalici C, Presotto F et al. The natural history of adrenal function in

autoimmune patients with adrenal autoantibodies. J Endocrinol 1988;117, 467-75.

30

59.

Falorni A, Chen S, Zanchetta R et al. Measuring adrenal autoantibody response:

interlaboratory concordance in the first international serum exchange for the determination of 21-hydroxylase autoantibodies. Clin Immunol 2011;140, 291-299. 60.

Falorni A, Bini V, Betterle C et al. Determination of 21-hydroxylase autoantibodies:

inter-laboratory concordance in the Euradrenal International Serum Exchange Program. Clin Chem Lab Med 2015;53, 1761-1770. 61.

Laureti S, De Bellis A, Muccitelli VI et al. Levels of adrenocortical autoantibodies

correlate with the degree of adrenal dysfunction in subjects with pre-clinical Addison’s disease. J Clin. Endocrinol Metab 1998;83, 3507-3511. 62.

*Falorni A, Minarelli V & Morelli S. Therapy of adrenal insufficiency: an

update. Endocrine 2013;43, 514-528. 63.

*Husebye ES, Allolio B, Arlt W et al. Consensus statement on the diagnosis,

treatment and follow-up o patients with primary adrenal insufficiency. J Internal Medicine 2014;275, 104-115. 64.

*Bornstein SR, Allolio B, Arlt W et al. Diagnosis and Treatment of Primary

Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016;101, 364-389. 65.

Arlt W, Callies F, van Vlijmen JC et al. Dehydroepiandrosterone replacement in

women with adrenal insufficiency. N Engl J Med 1999;341, 1013-1020. 66.

Gurnell EM, Hunt PJ, Curran SE et al. Long-term DHEA replacement in primary

adrenal insufficiency: a randomized, controlled trial. J Clin Endocrinol Metab 2008;93, 400-409. 67.

Løvås K & Husebye ES. Replacement therapy for Addison's disease: recent

developments. Expert Opin Investig Drugs 2008;17, 497-509.

31

68.

*Johannsson G, Falorni A, Skrtic S et al. Adrenal insufficiency: review of clinical

outcomes with current glucocorticoid replacement therapy. Clin Endocrinol (Oxf) 2015;82, 2-11. 69.

Løvås K, Gjesdal CG, Christensen M et al. Glucocorticoid replacement therapy and

pharmacogenetics in Addison's disease: effects on bone. Eur J Endocrinol 2009;160, 9931002. 70.

Camozzi V, Betterle C, Frigo AC et al. Vertebral fractures assessed with dual-energy

X-ray absorptiometry in patients with Addison's disease on glucocorticoid and mineralocorticoid replacement therapy. Endocrine 2018;59, 319-329. 71.

Koetz KR, Ventz M, Diederich S & Quinkler M. Bone mineral density is not

significantly reduced in adult patients on low-dose glucocorticoid replacement therapy. J Clin Endocrinol Metab 2012;97, 85-92. 72.

Schulz J, Frey KR, Cooper MS et al. Reduction in daily hydrocortisone dose improves

bone health in primary adrenal insufficiency. Eur J Endocrinol 2016;174, 531-538. 73.

Björnsdottir S, Sääf M, Bensing S et al. Risk of hip fracture in Addison's disease: a

population-based cohort study. J Intern Med 2011;270, 187-195. 74.

Løvås K, Loge JH & Husebye ES. Subjective health status in Norwegian patients with

Addison’s disease. Clin Endocrinol (Oxf) 2002;56, 581-588. 75.

Hahner S, Loeffler M, Fassnacht M et al. Impaired subjective health status in 256

patients with adrenal insufficiency on standard therapy based on cross-sectional analysis. J Clin Endocrinol Metab 2007;92, 3912-3922. 76.

Tiemensma J, Andela CD, Kaptein AA et al. Psychological morbidity and impaired

quality of life in patients with stable treatment for primary adrenal insufficiency: crosssectional study and review of the literature. Eur J Endocrinol 2014;171, 171-182.

32

77.

Kluger N, Matikainen N, Sintonen H et al. Impaired health-related quality of life in

Addison's disease--impact of replacement therapy, comorbidities and socio-economic factors. Clin Endocrinol (Oxf) 2014;81, 511-518. 78.

Ho W & Druce M. Quality of life in patients with adrenal disease: A systematic

review. Clin Endocrinol (Oxf) 2018;89, 119-128. 79.

Øksnes M, Bensing S, Hulting AL et al. Quality of life in European patients with

Addison's disease: validity of the disease-specific questionnaire AddiQoL. J Clin Endocrinol Metab 2012;97, 568-576. 80.

Elbelt U, Hahner S & Allolio B. Altered insulin requirement in patients with type 1

diabetes and primary adrenal insufficiency receiving standard glucocorticoid replacement therapy. Eur J Endocrinol 2009;160, 919-924. 81.

Giordano R, Marzotti S, Balbo M et al. Metabolic and cardiovascular profile in

patients with Addison’s disease under conventional glucocorticoid replacement. J Endocrinol Invest 2009;32, 917-923. 82.

Plat L, Leproult R, L’Hermite-Baleriaux M et al. Metabolic effects of short-term

elevations of plasma cortisol are more pronounced in the evening than in the morning. J Clin Endocrinol Metab 1999;84, 3082–3092. 83.

Bergthorsdottir R, Leonsson-Zachrisson M, Oden A et al. Premature mortality in

patients with Addison’s disease: a population-based study. J Clin Endocrinol Metab 2006;91, 4849–4853. 84.

Bensing S, Brandt L, Tabaroj F et al. Increased death risk and altered cancer incidence

pattern in patients with isolated or combined autoimmune primary adrenocortical insufficiency. Clin Endocrinol (Oxford) 2008;69, 697–704.

33

85.

Erichsen MM, Løvås K, Fougner KJ et al. Normal overall mortality rate in Addison’s

disease, but young patients are at risk of premature death. Eur J Endocrinol 2009;160, 233– 237. 86.

Erichsen MM, Husebye ES, Michelsen TM et al. Sexuality and fertility in women with

Addison's disease. J Clin Endocrinol Metab 2010;95, 4354-4360. 87.

Björnsdottir S, Cnattingius S, Brandt L et al. Addison's disease in women is a risk

factor for an adverse pregnancy outcome. J Clin Endocrinol Metab 2010;95, 5249-5257. 88.

Schneiderman M, Czuzoj-Shulman N, Spence AR & Abenhaim HA. Maternal and

neonatal outcomes of pregnancies in women with Addison's disease: a population-based cohort study on 7.7 million births. BJOG 2017;124, 1772-1779. 89.

Wadhwa PD, Garite TJ, Porto M et al. Placental corticotropin-releasing hormone

(CRH), spontaneous preterm birth, and fetal growth restriction: a prospective investigation. Am J Obstet Gynecol 2004;191, 1063-1069 90.

Jung C, Ho JT, Torpy DJ et al. A longitudinal study of plasma and urinary cortisol in

pregnancy and postpartum. J Clin Endocrinol Metab 2011;96, 1533-1540. 91.

Rushworth RL, Torpy DJ & Falhammar H. Adrenal crisis. N Engl J Med 2019; 381,

852-861 92.

Hahner S, Loeffler M, Bleicken B et al. Epidemiology of adrenal crisis in chronic

adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol 2010;162, 597-602. 93.

Hahner S, Spinnler C, Fassnacht M et al. High incidence of adrenal crisis in educated

patients with chronic adrenal insufficiency: a prospective study. J Clin Endocrinol Metab 2015;100, 407-416. 94.

Johannsson G, Nilsson AG, Bergthorsdottir R et al. Improved cortisol exposure-time

profile and outcome in patients with adrenal insufficiency: a prospective randomized trial

34

of a novel hydrocortisone dual-release formulation. J Clin Endocrinol Metab 2012;97, 47381. 95.

Quinkler M, Miodini Nilsen R, Zopf K et al. Modified-release hydrocortisone

decreases BMI and HbA1c in patients with primary and secondary adrenal insufficiency. Eur J Endocrinol 2015;172, 619-626. 96.

Giordano R, Guaraldi F, Marinazzo E et al. Improvement of anthropometric and

metabolic parameters, and quality of life following treatment with dual-release hydrocortisone in patients with Addison's disease. Endocrine 2016;51:360-368 97.

Isidori AM, Venneri MA, Graziadio C et al. Effect of once-daily, modified-release

hydrocortisone versus standard glucocorticoid therapy on metabolism and innate immunity in patients with adrenal insufficiency (DREAM): a single-blind, randomized controlled trial. Lancet Diabetes Endocrinol 2018;6, 173-185. 98. Mongioì LM, Condorelli RA, La Vignera S & Calogero AE. Dual-release hydrocortisone

treatment: glycometabolic profile and health-related quality of life. Endocrine Connection 2018;7, 211-219. 99.

Guarnotta V, Ciresi A, Pillitteri G, Giordano C. Improved insulin sensitivity and secretion in

prediabetic patients with adrenal insufficiency on dual-release hydrocortisone treatment: a 36month retrospective analysis. Clin Endocrinol (Oxf) 2018;88, 665-672. 100.

Ceccato F, Selmin E, Sabbadin C et al. Improved salivary cortisol rhythm with dual-release

hydrocortisone. Endocrine Connection 2018;7, 965-974. 101.

Guarnotta V, Di Stefano C, Santoro A et al.. Dual-release hydrocortisone vs conventional

glucocorticoids in adrenal insufficiency. Endocr Connect. 2019;8, 853-862.

102.

Stewart PM. Modified-release hydrocortisone: is it time to change clinical practice? J

Endocr Soc 2019;3, 1150-1153. 103.

Løvås K & Husebye ES. Continuous subcutaneous hydrocortisone infusion in

Addison’s disease. Eur J Endocrinol 2007;157, 109-112. 35

104.

Cardini F, Torlone E, Bini V & Falorni A. Continuous subcutaneous hydrocortisone

infusion in a woman with secondary adrenal insufficiency. Endocrine 2019;63, 398-400.

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Practice points •

Determination of 21OHAb must be offered to all patients with clinically idipopathic primary adrenal insufficiency for a correct diagnosis of autoimmune Addison’s disease

•

Life-long treatment with oral hydrocortisone subdivided in two-three daily doses

•

When possible, a dual-release hydrocortisone preparation should be preferred to better mimic cortisol circadian rhythm

•

Therapy with fludrocortisone 0.5-2.0 mg/day also needed in almost all patients

•

Adapt hydrocortisone dose according to clinical and biochemical parameters such as body weight, blood pressure, waist/hip ratio, sodium and potassium concentrations, identifying the lowest possible dose associated with well-being and normal everyday activities

•

Monitor bone mass density, cardiovascular and metabolic parameters on a regular basis

•

The imperative of a proper education of patients to increase hydrocortisone dose in the case of infections or intercurrent illness and to switch to parenteral hydrocortisone in the case of vomiting, diarrhoea or acute hypotension

•

Rapid hospitalization of patients with adrenal crisis to start generous iv infusion of saline solution and iv infusion of hydrocortisone

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Research agenda •

Development of animal models of spontaneous autoimmune adrenal insufficiency for studies aimed at a better understanding of the molecular mechanisms of the disease

•

Development of novel therapeutic strategies to optimize substitutive glucocorticoid substitution

•

Identification of solid metabolic or hormonal markers to be used in clinical practice to objectively adjust substitutive treatment

•

Clinical trials are needed to define optimal substitutive therapy in pregnancy

•

Clinical trials are needed to test preventative therapies in preclinical Addison’s disease

•

Interlaboratories serum exchange programs are needed to standardize 21OHAb determination

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Table 1. Major practical issues associated with management of AAD ___________________________________________________________________________ Issue

Actions

___________________________________________________________________________ Delay in diagnosis of AAD

Better education of non-specialistic physicians Major awareness on the disease by general population, general practitioners and emergency doctors

Prevention of glucocorticoid-induced osteoporosis

Prefer HC as glucocorticoid treatment Use the lowest possible HC dose Vitamin D supplementation

Sleep disturbances

Administer last HC dose not later than 6 hrs before sleep or switch to dual-release HC preparation

Management of hyperglycemia

Prefer dual-release HC preparation Use the lowest possible HC dose

Reduced health-related QoL

Prefer dual-release HC preparation Use the lowest possible HC dose

Prevention of adrenal crises

Educate the patient to increase HC dose in the case of fever Parenteral administration of HC in the case of vomiting, diarrhoea or acute hypotension

Management of adrenal crises

Educate the patient to always carry an emergency card informing of the disease and the therapy needed in the case of emergency Better education of emergency doctors to promptly administer iv saline infusion and parenteral HC __________________________________________________________________________ AAD: autoimmune Addison’s disease; HC: hydrocortisone; QoL: quality of life

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