Sunitinib for metastatic progressive phaeochromocytomas and paragangliomas: results from FIRSTMAPPP, an academic, multicentre, international, randomised, placebo-controlled, double-blind, phase 2 trial

Background: No randomised controlled trial has ever been done in patients with metastatic phaeochromocytomas and paragangliomas. Preclinical and first clinical evidence suggested beneficial effects of sunitinib. We aimed to evaluate the safety and efficacy of sunitinib in patients with metastatic phaeochromocytomas and paragangliomas. Methods: FIRSTMAPPP is a multicentre, international, randomised, placebo-controlled, double-blind, phase 2 trial done at 14 academic centres across four European countries. Eligible participants were adults (aged ≥18 years) with sporadic or inherited progressive metastatic phaeochromocytomas and paragangliomas. Patients were randomly assigned (1:1) to receive either oral sunitinib (37·5 mg per day) or placebo. Randomisation was stratified according to SDHB status (mutation present vs wild type) and number of previous systemic therapies (0 vs ≥1). Primary endpoint was the rate of progression-free survival at 12 months according to real-time central review (Response Evaluation Criteria in Solid Tumours version 1.1). On the basis of a two-step Simon model, we aimed for the accrual of 78 patients, assuming a 20% improvement of the 12-month progression-free survival rate from 20% to 40%, to conclude that sunitinib is effective. Crossover from the placebo group was allowed. This trial is registered with ClinicalTrials.gov, number NCT01371201, and is closed for enrolment. Findings: From Dec 1, 2011, to Jan 31, 2019, a total of 78 patients with progressive metastatic phaeochromocytomas and paragangliomas were enrolled (39 patients per group). 25 (32%) of 78 patients had germline SDHx variants and 54 (69%) had used previous therapies. The primary endpoint was met, with a 12-month progression-free survival in 14 of 39 patients (36% [90% CI 23-50]) in the sunitinib group. In the placebo group, the 12-month progression-free survival in seven of 39 patients was 19% (90% CI 11-31), validating the hypotheses of our study design. The most frequent grade 3 or 4 adverse events were asthenia (seven [18%] of 39 and one [3%] of 39), hypertension (five [13%] and four [10%]), and back or bone pain (one [3%] and three [8%]) in the sunitinib and placebo groups, respectively. Three deaths occurred in the sunitinib group: these deaths were due to respiratory insufficiency, amyotrophic lateral sclerosis, and rectal bleeding. Only the latter event was considered drug related. Two deaths occurred in the placebo group due to aspiration pneumonia and septic shock. Interpretation: This first randomised trial supports the use of sunitinib as the medical option with the highest level of evidence for anti-tumour efficacy in progressive metastatic phaeochromocytomas and paragangliomas. Funding: French Ministry of Health, through the National Institute for Cancer, German Ministry of Education and Research, and the German Research Foundation within the CRC/Transregio 205/2, EU Seventh Framework Programme, and a private donator grant

Regulation of the epithelial sodium channel of the kidney (ENaC) by androgens

Mit Beginn der Pubertät steigt der normale Blutdruck bei Jungen bzw. Männern stärker an als der bei Mädchen bzw. Frauen. Diese Differenz bleibt im Erwachsenenalter zunächst bestehen, bis sich schließlich die Blutdruckwerte zwischen den Geschlechtern im höheren Lebensalter wieder angleichen. In verschiedenen Rattenmodellen fielen ebenfalls geschlechtsspezifische Blutdruckunterschiede auf, welche durch Kastration der männlichen Tiere aufgehoben werden konnten. Des Weiteren ist bekannt, dass Geschlechtshormone komplexe Effekte auf das renale und kardiovaskuläre System ausüben und eine Rolle bei der Blutdruckregulation spielen. Der epitheliale Natriumkanal (ENaC) moduliert Natrium- und Wasserreabsorption in der Niere. Aldosteron ist einer der Hauptregulatoren des ENaC. Eine geschlechtsspezifische Regulation des ENaC insbesondere über Androgene war bislang nicht ausreichend untersucht. Androgene selbst wirken über den Androgen-Rezeptor (AR). Dessen Autoregulation durch Androgene ist sehr gewebsspezifisch und abhängig von der untersuchten Spezies sowie von deren Entwicklungsstadium. Gegenstand dieser Arbeit ist die Frage, ob es in vivo geschlechtsspezifische Expressionsunterschiede von ENaC und AR basal sowie nach Hormonstimulation gibt. Außerdem wurde überprüft, ob es im Promoter der untersuchten Zielproteine potentielle Regionen gibt, die eine Regulation durch Geschlechtshormone erklären. Dies erfolgte am Rattenmodell in vivo sowie in vitro an den renalen Zelllinien M1 und RCCD2 wie auch an primären Gefäßmuskelzellen der Ratte (VSMC). Dabei wurden mittels semiquantitativer und quantitativer PCR und Western Immunoblot die Expressionsniveaus aller ENaC-Untereinheiten sowie des AR auf mRNA- und Protein-Ebene untersucht. Die basale renale Expression der ENaC-Untereinheiten sowie des AR unterschied sich zwischen gonadektomierten Männchen und Weibchen nicht. Die Behandlung der männlichen Ratten mit Testosteron 500 mg/kg KG (TUD500) führte zu einer moderaten Heraufregulation von alpha-ENaC mRNA. Ebenso war alpha-ENaC Protein nach Behandlung der Männchen mit Testosteron oder 5alpha-Dihydrotestosteron (DHT) heraufreguliert. Die Expression von beta- und gamma-ENaC war bei männlichen Ratten durch Androgene unbeeinflusst, es zeigten sich keine quantitativen Unterschiede von mRNA oder Protein in PCR oder Western Blot im Vergleich zu gonadektomierten männlichen Kontrolltieren. Im Gegensatz zu den männlichen Tieren zeigte sich bei weiblichen Wistar-Ratten eine Herunterregulation der mRNA-Expression aller ENaC-Untereinheiten durch Androgene im Vergleich zu ovariektomierten weiblichen Kontrolltieren. Dieser Effekt war signifikant nach Behandlung der Weibchen mit DHT. Die Western Blots für alpha-und beta-ENaC Protein konnten diesen Effekt bei den weiblichen Tieren bestätigen, während die Expression von gamma-ENaC Protein insgesamt sehr gering war. In gleicher Art und Weise ergaben sich geschlechtsspezifische Unterschiede in der Autoregulation des AR. Die Gabe von TUD500 führte zu einer signifikant stärkeren Expression von renaler AR mRNA und AR Protein bei männlichen Wistar-Ratten. Im Western Blot zeigte sich zudem eine erhöhte Expression von AR Protein nach DHT Behandlung bei den Männchen. Im Gegensatz dazu bestand bei weiblichen Wistar-Ratten eher ein Trend in Richtung Suppression von AR mRNA und Protein im Vergleich zu weiblichen Kontrolltieren. Estradiol (E2) führte schließlich zu einer signifikanten Herunterregulation von AR mRNA. Die in dieser Arbeit genutzten Zelllinien zeigten diverse Einschränkungen, die eine Untersuchung der Androgen-abhängigen Regulation des ENaC in vitro sehr erschwerte. Die renale Zelllinie M1 exprimiert zwar alle Untereinheiten des ENaC, hat allerdings ihre physiologische Antwort auf Aldosteron-Stimulation bereits verloren und stellt mangels Expression des AR kein optimales Modell zur Untersuchung geschlechtsspezifischer Mechanismen der ENaC-Regulation dar. Die renale Sammelrohr-Zelllinie RCCD2 exprimiert ebenfalls alle drei ENaC-Untereinheiten und zeigt im Gegensatz zu M1 eine Aldosteron- und MR-abhängige Stimulation von alpha-ENaC. Dennoch wird auch auf RCCD2-Zellen AR Protein nicht ausreichend exprimiert, so dass eine Behandlung mit Androgenen bei diesen Zellen ebenfalls keinen Einfluss auf die Expression von ENaC mRNA hatte. Da bekannt ist, dass der AR auf glatten Gefäßmuskelzellen (VSMC) exprimiert wird, wurden diese zusätzlich hinsichtlich der Expression von ENaC und dessen Regulation untersucht. VSMC zeigte lediglich eine Expression von alpha-ENaC, wobei sich auch hier keine Regulation durch Androgene fand. Zusammenfassend lässt sich sagen, dass ENaC und AR geschlechtsspezifisch durch Androgene reguliert werden. Obgleich die in dieser Arbeit beschriebenen Expressionsunterschiede signifikant, aber relativ gering sind, könnten Androgene auf diese Weise in der Lage sein, die renale Natriumreabsorption zu beeinflussen und sich somit auf den Blutdruck auszuwirken. Dies würde eine mögliche Erklärung für die beobachtbaren physiologischen Blutdruckunterschiede zwischen den Geschlechtern liefern.With the beginning of puberty blood pressure increases more in men than in women. This difference persists in adulthood until blood pressure finally becomes equal between men and women in the elderly population. Sex-differences in blood pressure have been shown to exist in different rat models, as well. Interestingly, castration of the males abolished the difference in blood pressure. It is well known that sex hormones have complex effects on the renal and cardiovascular system and that they play an important role in blood pressure regulation. The epithelial sodium channel consists of three subunits and modulates sodium and water reabsorption in the kidney. Aldosterone is one of ENaC’s main regulators. So far a possible sex-specific regulation of ENaC, especially by androgens has not been investigated in detail. Androgens bind to the androgen receptor (AR). Its autoregulation by androgens is tissue-specific and depends on the studied species and their age. The aim of this work was to determine sex-dependent differences in ENaC and AR expression in vivo in baseline and after hormone treatment. In addition, the promoter region of the target genes were analyzed for potential binding sites that may explain a regulation by sex hormones. Therefore, an in vivo rat model was used and in vitro experiments with the renal cell lines M1 and RCCD2 as well as with primary vascular smooth muscle cells of the rat (VSMC) were performed. mRNA and protein expression levels of ENaC subunits and AR were analyzed by using semiquantitative and quantitative PCR and Western immunoblot. Gonadectomized male and female Wistar rats showed no difference in baseline expression of renal ENaC subunits or AR. Treatment of male rats with testosterone 500 mg/kg body weight (TUD500) led to a moderate upregulation of alpha-ENaC mRNA. Similarly, alpha-ENaC protein expression was elevated in males that had been treated with testosterone or 5alpha-dihydrotestosterone (DHT). The expression of beta- and gamma-ENaC was not influenced by androgen treatment in male rats. There was no change in mRNA or protein expression compared to gonadectomized male control animals. In contrast to males, androgens downregulated mRNA expression of all ENaC subunits in ovariectomized females. This effect was significant after treatment of the females with DHT. Western immunoblot for alpha- and beta-ENaC protein confirmed this observation in female animals, while expression of gamma-ENaC protein was overall very low. Similarly, sex- specific differences in autoregulation of the renal AR were observed. Treatment with TUD500 led to a significantly enhanced expression of renal AR mRNA and AR protein in male Wistar rats. In addition, in Western immunoblot an increased expression of AR protein could be seen after treatment of male rats with DHT. In contrast, there was a trend towards suppression of AR mRNA and protein by androgens in female rats compared to female control animals. Estradiol (E2) led to a significant suppression of AR mRNA. The cell lines that have been used in this work revealed several characteristics that limited an investigation of an androgen-dependent regulation of ENaC in vitro. The renal cell line M1 expresses all subunits of ENaC, but lost its physiological response to aldosterone-stimulation. Since it also lacks the AR it is no optimal model for studying sex-specific mechanisms in ENaC-regulation. The renal collecting duct cell line RCCD2 also expresses all subunits of ENaC, but in contrast to M1 shows an aldosterone- and MR-dependent stimulation of alpha- ENaC. However, AR protein is not expressed on RCCD2-cells sufficiently. Therefore, androgen treatment of these cells had no effect on expression of ENaC mRNA. As it is known that the AR is expressed on vascular smooth muscle cells (VSMC), these cells were studied for expression of ENaC and its regulation. VSMC showed only an expression of alpha-ENaC, and a regulation by androgens could not be seen. In sum, ENaC and AR seem to be regulated by androgens in a sex-specific manner. The expression differences between males and females are small, yet significant. By these means androgens might influence sodium reabsorption and therefore blood pressure. This could be a possible mechanism for determining physiological differences in blood pressure observed between men and women

Prednisolone is associated with a worse bone mineral density in primary adrenal insufficiency

Context: Patients with primary adrenal insufficiency (PAI) or congenital adrenal hyperplasia (CAH) receive life-long glucocorticoid (GC) therapy. Daily GC doses are often above the physiological cortisol production rate and can cause long-term morbidities such as osteoporosis. No prospective trial has investigated the long-term effect of different GC therapies on bone mineral density (BMD) in those patients. Objectives: To determine if patients on hydrocortisone (HC) or prednisolone show changes in BMD after follow-up of 5.5 years. To investigate if BMD is altered after switching from immediate- to modified-release HC. Design and patients: Prospective, observational, longitudinal study with evaluation of BMD by DXA at visit1, after 2.2 ± 0.4 (visit2) and after 5.5 ± 0.8 years (visit3) included 36 PAI and 8 CAH patients. Thirteen patients received prednisolone (age 52.5 ± 14.8 years; 8 women) and 31 patients received immediate-release HC (age 48.9 ± 15.8 years; 22 women). Twelve patients on immediate-release switched to modified-release HC at visit2. Results: Prednisolone showed significantly lower Z-scores compared to HC at femoral neck (−0.85 ± 0.80 vs −0.25 ± 1.16, P < 0.05), trochanter (−0.96 ± 0.62 vs 0.51 ± 1.07, P < 0.05) and total hip (−0.78 ± 0.55 vs 0.36 ± 1.04, P < 0.05), but not at lumbar spine, throughout the study. Prednisolone dose decreased by 8% over study time, but no significant effect was seen on BMD. BMD did not change significantly after switching from immediate- to modified-release HC. Conclusions: The use of prednisolone as hormone replacement therapy results in significantly lower BMD compared to HC. Patients on low-dose HC replacement therapy showed unchanged Z-scores within the normal reference range during the study period

BclI polymorphism of the glucocorticoid receptor and adrenal crisis in primary adrenal insufficiency

Context: Patients with primary adrenal insufficiency (PAI) or congenital adrenal hyperplasia (CAH) are at a high risk of adrenal crisis (AC). Glucocorticoid sensitivity is at least partially genetically determined by polymorphisms of the glucocorticoid receptor (GR). Objectives: To determine if a number of intercurrent illnesses and AC are associated with the GR gene polymorphism BclI in patients with PAI and CAH. Design and patients: This prospective, longitudinal study over 37.7 ± 10.1 months included 47 PAI and 25 CAH patients. During the study period, intercurrent illness episodes and AC were documented. Results: The study period covered 223 patient years in which 21 AC occurred (9.4 AC/100 pat years). There were no significant differences between BclI polymorphisms (CC (n = 29), CG (n = 34) and GG (n = 9)) regarding BMI, hydrocortisone equivalent daily dose and blood pressure. We did not find a difference in the number of intercurrent illnesses/patient year among BclI polymorphisms (CC (1.5 ± 1.4/pat year), CG (1.2 ± 1.2/pat year) and GG (1.6 ± 2.2/pat year)). The occurrence of AC was not significantly different among the homozygous (GG) genotype (32.5 AC/100 pat years), the CC genotype (6.7 AC/100 pat years) and the CG genotype (4.9 AC/100 pat years). Concomitant hypothyroidism was the highest in the GG genotype group (5/9), compared to others (CC (11/29) and CG (11/34)). Conclusions: Although sample sizes were relatively small and results should be interpreted with caution, this study suggests that the GR gene polymorphism BclI may not be associated with the frequencies of intercurrent illnesses and AC

Daily adjustment of glucocorticoids by patients with adrenal insufficiency

BACKGROUND Patients with adrenal insufficiency (AI) require lifelong glucocorticoid (GC) replacement. AI patients need to adjust GC dosage in response to stressful events and illness in order to prevent life-threatening adrenal crisis (AC). AIM To evaluate self-management of patients with AI. METHODS Four German centres, which are using patient's diary as part of their routine clinical practice, instructed AI patients to prospectively document any discomfort, intercurrent illness or stressful events as well as changes in GC therapy on a daily basis. Diaries of 80 patients (44 females, 52.9 ± 15.9 years, 34 primary AI) were collected and analysed. A symptom score sheet was used to evaluate severity of discomfort. RESULTS In total, 34 074 patient days (93.4 years) were recorded. 4622 days with discomfort were documented. On 35% of those days (n = 1621), patients increased their GC dose (4.8% of all days). Patients who recorded discomfort had a median of four episodes of discomfort, which lasted a median of 2 days. Women documented significantly more episodes of discomfort than men (P = 0.014). Low-to-median symptom scores resulted in GC increase by 50%-60%, whereas high symptom scores and/or fever resulted in doubling GC daily dose. However, dose increase was only 55% in situations indicating gastrointestinal (GI) infection. CONCLUSION Severe discomfort did not always result in dose increase, especially in GI infection. However, low symptom scores resulted in an inappropriate GC increase in some patients. This underscores an urgent need for improved training methods. Keeping daily records might be a useful tool for continued and individualized patient education

Palliative treatment of uncontrollable hypercalcemia due to parathyrotoxicosis: denosumab as rescue therapy

Parathyroid carcinoma is a rare disease leading to severe hypercalcemia due to hyperparathyroidism. Surgery is the primary treatment option. A more progressive form of the disease is characterized by parathyrotoxicosis, and subsequent hypercalcemia is the most common cause of death. We report a case presenting with severe hypercalcemia due to parathyrotoxicosis from parathyroid carcinoma treated for the first time using the monoclonal antibody denosumab as a rescue therapy and present long-term follow-up data. The 71-year-old patient presented with severe hypercalcemia due to metastatic parathyroid carcinoma. Despite undergoing treatment with bisphosphonates, cinacalcet hydrochloride, and forced diuresis, the patient's condition deteriorated rapidly due to resistant hypercalcemia. Surgery performed because of spinal metastasis and forced diuresis lowered calcium levels, albeit they remained in the hypercalcemic range and significantly increased when forced diuresis was stopped. Considering a palliative situation to overcome hypercalcemia, we decided to administer denosumab, a monoclonal antibody that binds to the receptor activator of nuclear factor-kappa B ligand. After a single subcutaneous administration of 60 mg denosumab, calcium levels normalized within one day. Subsequent denosumab injections led to permanent control of serum calcium for more than 2 years despite rising parathyroid hormone levels and repeated surgeries. Together with recent cases in the literature supporting our observation, we believe that denosumab is relevant for future trials and represents an effective tool to control hypercalcemia in patients with advanced stages of parathyroid cancer

Current management and outcome of pregnancies in women with adrenal insufficiency: experience from a multi-center survey

CONTEXT Appropriate management of adrenal insufficiency (AI) in pregnancy can be challenging due to the rarity of the disease and lack of evidence-based recommendations to guide glucocorticoid- and mineralocorticoid dosage adjustment. OBJECTIVE Multi-center survey on current clinical approaches in managing AI during pregnancy. DESIGN Retrospective anonymized data collection from 19 international centers from 2013-2019. SETTING AND PATIENTS 128 pregnancies in 113 women with different causes of AI: Addison disease (44%), secondary AI (25%), congenital adrenal hyperplasia (25%) and acquired AI due to bilateral adrenalectomy (6%). RESULTS Hydrocortisone (HC) was the most commonly used glucocorticoid in 82.9% (97/117) of pregnancies. Glucocorticoid dosage was increased at any time during pregnancy in 73/128 (57%) of cases. In these cases, difference of the daily dose of HC equivalent between baseline and the third trimester was 8.6±5.4 [range: 1, 30] mg. Fludrocortisone dosage was increased in fewer cases (7/54 during the first trimester, 9/64 during the second trimester and 9/62 cases during the last trimester). Overall, an adrenal crisis was reported in 9/128 (7%) pregnancies. Caesarian section was the most frequent mode of delivery at 58% (69/118). Fetal complications were reported in 3/120 (2.5%) and minor maternal complications in 15/120 (12.5%) pregnancies without fatal outcomes. CONCLUSIONS This survey confirms good maternal and fetal outcome in women with AI managed in specialized endocrine centers. An emphasis on careful endocrine follow up and repeated patient education is likely to have reduced the risk of adrenal crisis and resulted in positive outcomes

Management of glucocorticoid replacement in adrenal insufficiency shows notable heterogeneity - data from the EU-AIR

Context and objectiveTreatment for adrenal insufficiency (AI) remains suboptimal. Despite glucocorticoid replacement, patients with AI have reduced life expectancy and quality of life. This study aimed to describe the spectrum of management of glucocorticoid replacement in patients with AI enrolled in the European Adrenal Insufficiency Registry (EU-AIR). Design, setting and patientsEU-AIR is a prospective, multinational, multicentre, observational study initiated in August 2012 to monitor the long-term safety of glucocorticoid replacement in routine clinical practice in Germany, the Netherlands, Sweden and the UK (ClinicalTrials.gov identifier: NCT01661387). This analysis included 1166 patients with primary and secondary AI (mean disease duration 16amp;lt;boldamp;gt;amp;lt;/boldamp;gt;1 11amp;lt;boldamp;gt;amp;lt;/boldamp;gt;6 years) receiving long-term glucocorticoid replacement therapy. Main outcome measureGlucocorticoid type, dose, frequency and treatment regimen were examined. ResultsMost patients (87amp;lt;boldamp;gt;amp;lt;/boldamp;gt;4%) were receiving hydrocortisone. The most common dose range, taken by 42amp;lt;boldamp;gt;amp;lt;/boldamp;gt;2% of patients, was 20 to amp;lt;25 mg/day; however, 12amp;lt;boldamp;gt;amp;lt;/boldamp;gt;6% were receiving doses of 30 mg/day. Hydrocortisone was being taken once daily by 5amp;lt;boldamp;gt;amp;lt;/boldamp;gt;5%, twice daily by 48amp;lt;boldamp;gt;amp;lt;/boldamp;gt;7%, three times daily by 43amp;lt;boldamp;gt;amp;lt;/boldamp;gt;6% and four times daily by 2amp;lt;boldamp;gt;amp;lt;/boldamp;gt;1%. Patients with primary AI received higher replacement doses than those with secondary AI (23amp;lt;boldamp;gt;amp;lt;/boldamp;gt;4 +/- 8amp;lt;boldamp;gt;amp;lt;/boldamp;gt;9 and 19amp;lt;boldamp;gt;amp;lt;/boldamp;gt;6 +/- 5amp;lt;boldamp;gt;amp;lt;/boldamp;gt;9 mg/day, respectively). Twenty-five different regimens were being used to deliver a daily hydrocortisone dose of 20 mg. ConclusionsWe have shown significant heterogeneity in the type, dose, frequency and timing of glucocorticoid replacement in real-world clinical practice. This reflects dose individualization based on patient symptoms and lifestyle in the absence of data supporting the optimal regimen.Funding Agencies|Shire Development LLC</p