Autoimmune polyendocrine syndrome medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Autoimmune polyendocrine syndrome}} | {{Autoimmune polyendocrine syndrome}} | ||
{{CMG}}; {{AE}} | {{CMG}}; {{AE}}{{Akshun}} | ||
==Overview== | ==Overview== | ||
Medical [[therapy]] for autoimmune polyendocrine syndrome (APS) depends upon the sub-type and the [[organ system]] involved. In APS, the focus is to treat the presenting [[Disorder (medicine)|disorder]] which can either be [[mucocutaneous]] [[candidiasis]], [[hypoparathyroidism]], [[adrenal insufficiency]] or [[autoimmune thyroiditis]]. The goal of treatment is to correct [[hormone]] deficiencies, prevent [[complications]], and reduce [[morbidity]]. Treatment includes monitoring of [[glandular]] functions for early detection of glandular failure, lifelong [[hormone replacement therapy]] for established [[glandular]] failure, and [[familial]] [[Screening (medicine)|screening]]. | |||
==Medical Therapy== | ==Medical Therapy== | ||
Medical [[therapy]] for autoimmune polyendocrine syndrome (APS) depends upon the sub-type and the [[organ system]] involved. | |||
*In APS the focus is to treat the presenting [[Disorder (medicine)|disorder]] which can either be [[mucocutaneous]] [[candidiasis]], [[hypoparathyroidism]], [[adrenal insufficiency]] or [[autoimmune thyroiditis]]. | |||
*[[Patient]] [[education]] is an important part of treatment in APS. Patients with APS who present with [[mucocutaneous]] [[candidiasis]] may take upto 5-10 years to develop [[hypoparathyroidism]] and another 10 years to show manifestations of [[adrenal insufficiency]]. Therefore, [[patients]] with [[family history]] of APS or an early age onset of APS should be advised to undergo regular surveillance. | |||
* Treatment of APS includes:<ref name="pmid26938200">{{cite journal |vauthors=Bilezikian JP, Brandi ML, Cusano NE, Mannstadt M, Rejnmark L, Rizzoli R, Rubin MR, Winer KK, Liberman UA, Potts JT |title=Management of Hypoparathyroidism: Present and Future |journal=J. Clin. Endocrinol. Metab. |volume=101 |issue=6 |pages=2313–24 |year=2016 |pmid=26938200 |pmc=5393596 |doi=10.1210/jc.2015-3910 |url=}}</ref><ref name="pmid27810905">{{cite journal |vauthors=Gan EH, Pearce SH |title=MANAGEMENT OF ENDOCRINE DISEASE: Regenerative therapies in autoimmune Addison's disease |journal=Eur. J. Endocrinol. |volume=176 |issue=3 |pages=R123–R135 |year=2017 |pmid=27810905 |doi=10.1530/EJE-16-0581 |url=}}</ref><ref name="pmid25138826">{{cite journal |vauthors=Inder WJ, Meyer C, Hunt PJ |title=Management of hypertension and heart failure in patients with Addison's disease |journal=Clin. Endocrinol. (Oxf) |volume=82 |issue=6 |pages=789–92 |year=2015 |pmid=25138826 |doi=10.1111/cen.12592 |url=}}</ref><ref name="pmid24766944">{{cite journal |vauthors=Tucci V, Sokari T |title=The clinical manifestations, diagnosis, and treatment of adrenal emergencies |journal=Emerg. Med. Clin. North Am. |volume=32 |issue=2 |pages=465–84 |year=2014 |pmid=24766944 |doi=10.1016/j.emc.2014.01.006 |url=}}</ref><ref name="pmid24755997">{{cite journal |vauthors=Napier C, Pearce SH |title=Current and emerging therapies for Addison's disease |journal=Curr Opin Endocrinol Diabetes Obes |volume=21 |issue=3 |pages=147–53 |year=2014 |pmid=24755997 |doi=10.1097/MED.0000000000000067 |url=}}</ref><ref name="pmid24031090">{{cite journal |vauthors=Grossman A, Johannsson G, Quinkler M, Zelissen P |title=Therapy of endocrine disease: Perspectives on the management of adrenal insufficiency: clinical insights from across Europe |journal=Eur. J. Endocrinol. |volume=169 |issue=6 |pages=R165–75 |year=2013 |pmid=24031090 |pmc=3805018 |doi=10.1530/EJE-13-0450 |url=}}</ref><ref name="pmid23177474">{{cite journal |vauthors=Napier C, Pearce SH |title=Autoimmune Addison's disease |journal=Presse Med |volume=41 |issue=12 P 2 |pages=e626–35 |year=2012 |pmid=23177474 |doi=10.1016/j.lpm.2012.09.010 |url=}}</ref><ref name="pmid22907517">{{cite journal |vauthors=Quinkler M |title=[Addison's disease] |language=German |journal=Med Klin Intensivmed Notfmed |volume=107 |issue=6 |pages=454–9 |year=2012 |pmid=22907517 |doi=10.1007/s00063-012-0112-3 |url=}}</ref><ref name="pmid24434360">{{cite journal |vauthors=Caturegli P, De Remigis A, Rose NR |title=Hashimoto thyroiditis: clinical and diagnostic criteria |journal=Autoimmun Rev |volume=13 |issue=4-5 |pages=391–7 |year=2014 |pmid=24434360 |doi=10.1016/j.autrev.2014.01.007 |url=}}</ref><ref name="pmid25266247">{{cite journal |vauthors=Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM |title=Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement |journal=Thyroid |volume=24 |issue=12 |pages=1670–751 |year=2014 |pmid=25266247 |pmc=4267409 |doi=10.1089/thy.2014.0028 |url=}}</ref> | |||
**'''Mucocutaneous candidiasis''': | **'''Mucocutaneous candidiasis''': | ||
***Preferred regimen(1): Fluconazole 800 mg (12 mg/kg) on day 1, then 400 mg daily (6 mg/kg/day) for 14 days after first negative blood culture and resolution of signs/symptoms | ***Preferred regimen (1): [[Fluconazole]] 800 mg (12 mg/kg) on day 1, then 400 mg daily (6 mg/kg/day) for 14 days after first negative [[blood culture]] and resolution of [[Signs and Symptoms|signs/symptoms]] | ||
***Alternative regimen (1): Ketoconazole 200-400 mg/day | ***Alternative regimen (1): [[Ketoconazole]] 200-400 mg/day [[Oral|PO]] may increase to 400 mg once daily if response is insufficient. Continue until active [[fungal infection]] is resolved; some [[infections]] may require a treatment duration of up to 6 months. | ||
**'''Hypoparathyroidism''': Conventional therapy for hypoparathyroidism: | **'''Hypoparathyroidism''': Conventional therapy for [[hypoparathyroidism]]: | ||
*** Oral calcium: Preferred regimen (1): [[Calcium carbonate]] (40% [[elemental calcium]]) (better absorption with meals) | *** Oral [[calcium]]: Preferred regimen (1): [[Calcium carbonate]] (40% [[elemental calcium]]) (better absorption with meals) | ||
***:* Alternative regimen (1): [[Calcium citrate]] (21% [[elemental calcium]]) (more effective in patients with [[achlorhydria]] and [[Proton pump inhibitor|proton pump inhibitors]]' use, worsening [[constipation]]) | ***:* Alternative regimen (1): [[Calcium citrate]] (21% [[elemental calcium]]) (more effective in patients with [[achlorhydria]] and [[Proton pump inhibitor|proton pump inhibitors]]' use, worsening [[constipation]]) | ||
***Vitamin D supplementation | ***[[Vitamin D]] supplementation | ||
***:* Preferred regimen (1): [[Calcitriol]] 0.25 to 2 μg q24h (>.75 μg administered in divided doses) | ***:* Preferred regimen (1): [[Calcitriol]] 0.25 to 2 μg q24h (>.75 μg administered in divided doses) | ||
***:* Preferred regimen (2): [[Cholecalciferol]] (parent vitamin D3) | ***:* Preferred regimen (2): [[Cholecalciferol]] (parent vitamin D3) | ||
| Line 25: | Line 25: | ||
***:* Alternative regimen (2): [[Dihydrotachysterol]] (used outside the United States) | ***:* Alternative regimen (2): [[Dihydrotachysterol]] (used outside the United States) | ||
***::Note(1): Serum [[calcium]] ([[Hypoparathyroidism laboratory findings|corrected for albumin]]), [[phosphorus]], and [[creatinine]] concentrations should be measured weekly to monthly during dose adjustments, and twice annually once a stable regimen has been reached. | ***::Note(1): Serum [[calcium]] ([[Hypoparathyroidism laboratory findings|corrected for albumin]]), [[phosphorus]], and [[creatinine]] concentrations should be measured weekly to monthly during dose adjustments, and twice annually once a stable regimen has been reached. | ||
***::Note(2): 24 | ***::Note(2): 24-hour [[urinary]] [[calcium]] and [[creatinine]] should be considered during dose adjustments and should be measured twice annually on a stable regimen to evaluate for [[renal]] toxicity. | ||
**'''Adrenal insufficiency (Addison's disease)''': | **'''Adrenal insufficiency (Addison's disease)''': | ||
***Glucocorticosteroid: Preferred regimen (1): [[Cortisone]] 10 to 37.5 mg q12h [[Orally ingested|orally]] given in 2 divided [[doses]] with two-thirds of the total [[dose]] given in the morning and one third in the afternoon | ***[[Glucocorticosteroid]]: Preferred regimen (1): [[Cortisone]] 10 to 37.5 mg q12h [[Orally ingested|orally]] given in 2 divided [[doses]] with two-thirds of the total [[dose]] given in the morning and one third in the afternoon | ||
***:*Preferred regimen (2): [[Hydrocortisone]] : 15-30 mg/day orally given in 2 divided [[doses]] with two-thirds of the total [[dose]] given in the morning and one third in the afternoon | ***:*Preferred regimen (2): [[Hydrocortisone]] : 15-30 mg/day orally given in 2 divided [[doses]] with two-thirds of the total [[dose]] given in the morning and one third in the afternoon | ||
***:*Preferred regimen (3): [[Dexamethasone]] : 0.25 to 0.75 mg orally once daily | ***:*Preferred regimen (3): [[Dexamethasone]] : 0.25 to 0.75 mg orally once daily | ||
***:*Preferred regimen (4): [[Prednisone]] : 2.5 to 5 mg orally once daily | ***:*Preferred regimen (4): [[Prednisone]] : 2.5 to 5 mg orally once daily | ||
***Mineralocorticosteroid: Preferred regimen (1): [[Fludrocortisone]] : 0.1 to 0.2 mg orally once daily | ***[[Mineralocorticoids|Mineralocorticosteroid]]: Preferred regimen (1): [[Fludrocortisone]] : 0.1 to 0.2 mg orally once daily | ||
***Patients of Addison's disease with mild-to-moderate stress: | ***Patients of [[Addison's disease]] with mild-to-moderate [[Stress (medicine)|stress]]: | ||
***:*Alternative regimen (1): [[Cortisone]] 50-100 mg/day [[Orally ingested|orally]] given in 2 divided [[doses]] with two-thirds of the total [[dose]] given in the morning (around 8 a.m.) and one third in the afternoon (noon to 4 p.m.) for 3 days | ***:*Alternative regimen (1): [[Cortisone]] 50-100 mg/day [[Orally ingested|orally]] given in 2 divided [[doses]] with two-thirds of the total [[dose]] given in the morning (around 8 a.m.) and one third in the afternoon (noon to 4 p.m.) for 3 days | ||
***:*Alternative regimen (2): [[Hydrocortisone]] 30-90 mg/day [[Orally ingested|orally]] given in 2 divided [[doses]] with two-thirds of the total [[dose]] given in the morning (around 8 a.m.) and one third in the afternoon (noon to 4 p.m.) for 3 days | ***:*Alternative regimen (2): [[Hydrocortisone]] 30-90 mg/day [[Orally ingested|orally]] given in 2 divided [[doses]] with two-thirds of the total [[dose]] given in the morning (around 8 a.m.) and one third in the afternoon (noon to 4 p.m.) for 3 days | ||
***:*Alternative regimen (3): [[Dexamethasone]] 0.50 to 2.25 mg [[Orally ingested|orally]] once daily for 3 days | ***:*Alternative regimen (3): [[Dexamethasone]] 0.50 to 2.25 mg [[Orally ingested|orally]] once daily for 3 days | ||
***:*Alternative regimen (4): [[Prednisone]] 5-15 mg [[Orally ingested|orally]] once daily for 3 days | ***:*Alternative regimen (4): [[Prednisone]] 5-15 mg [[Orally ingested|orally]] once daily for 3 days | ||
***Patients of Addison's disease with severe stress: | ***Patients of [[Addison's disease]] with severe [[Stress (medicine)|stress]]: | ||
***:*Alternative regimen (5): [[Hydrocortisone]] sodium succinate 100 mg [[intravenously]] every 6-8 hours | ***:*Alternative regimen (5): [[Hydrocortisone]] sodium succinate 100 mg [[intravenously]] every 6-8 hours | ||
**'''Autoimmune thyroiditis''': | **'''Autoimmune thyroiditis''': | ||
***:*Preferred regimen (1) [[Levothyroxine (oral)|Synthetic levothyroxine]] (L-[[T4]]) 1.6–1.8 μg/kg of body weight per day orally. | ***:*Preferred regimen (1) [[Levothyroxine (oral)|Synthetic levothyroxine]] (L-[[T4]]) 1.6–1.8 μg/kg of body weight per day orally. | ||
For complete [[therapy]] | * '''For complete [[therapy]] for [[hypopituitarism]] please [[Hypopituitarism medical therapy|click here.]]''' | ||
For complete [[therapy]] | * '''For complete [[therapy]] for [[diabetes mellitus type 1]] please [[diabetes mellitus type 1 medical therapy|click here.]]''' | ||
==References== | ==References== | ||
Latest revision as of 20:00, 30 October 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akshun Kalia M.B.B.S.[2]
Overview
Medical therapy for autoimmune polyendocrine syndrome (APS) depends upon the sub-type and the organ system involved. In APS, the focus is to treat the presenting disorder which can either be mucocutaneous candidiasis, hypoparathyroidism, adrenal insufficiency or autoimmune thyroiditis. The goal of treatment is to correct hormone deficiencies, prevent complications, and reduce morbidity. Treatment includes monitoring of glandular functions for early detection of glandular failure, lifelong hormone replacement therapy for established glandular failure, and familial screening.
Medical Therapy
Medical therapy for autoimmune polyendocrine syndrome (APS) depends upon the sub-type and the organ system involved.
- In APS the focus is to treat the presenting disorder which can either be mucocutaneous candidiasis, hypoparathyroidism, adrenal insufficiency or autoimmune thyroiditis.
- Patient education is an important part of treatment in APS. Patients with APS who present with mucocutaneous candidiasis may take upto 5-10 years to develop hypoparathyroidism and another 10 years to show manifestations of adrenal insufficiency. Therefore, patients with family history of APS or an early age onset of APS should be advised to undergo regular surveillance.
- Treatment of APS includes:[1][2][3][4][5][6][7][8][9][10]
- Mucocutaneous candidiasis:
- Preferred regimen (1): Fluconazole 800 mg (12 mg/kg) on day 1, then 400 mg daily (6 mg/kg/day) for 14 days after first negative blood culture and resolution of signs/symptoms
- Alternative regimen (1): Ketoconazole 200-400 mg/day PO may increase to 400 mg once daily if response is insufficient. Continue until active fungal infection is resolved; some infections may require a treatment duration of up to 6 months.
- Hypoparathyroidism: Conventional therapy for hypoparathyroidism:
- Oral calcium: Preferred regimen (1): Calcium carbonate (40% elemental calcium) (better absorption with meals)
- Alternative regimen (1): Calcium citrate (21% elemental calcium) (more effective in patients with achlorhydria and proton pump inhibitors' use, worsening constipation)
- Vitamin D supplementation
- Preferred regimen (1): Calcitriol 0.25 to 2 μg q24h (>.75 μg administered in divided doses)
- Preferred regimen (2): Cholecalciferol (parent vitamin D3)
- Preferred regimen (3): Ergocalciferol (parent vitamin D2)
- Alternative regimen (1): 1α-Hydroxyvitamin D (alfacalcidol) (used outside the United States)
- Alternative regimen (2): Dihydrotachysterol (used outside the United States)
- Note(1): Serum calcium (corrected for albumin), phosphorus, and creatinine concentrations should be measured weekly to monthly during dose adjustments, and twice annually once a stable regimen has been reached.
- Note(2): 24-hour urinary calcium and creatinine should be considered during dose adjustments and should be measured twice annually on a stable regimen to evaluate for renal toxicity.
- Oral calcium: Preferred regimen (1): Calcium carbonate (40% elemental calcium) (better absorption with meals)
- Adrenal insufficiency (Addison's disease):
- Glucocorticosteroid: Preferred regimen (1): Cortisone 10 to 37.5 mg q12h orally given in 2 divided doses with two-thirds of the total dose given in the morning and one third in the afternoon
- Preferred regimen (2): Hydrocortisone : 15-30 mg/day orally given in 2 divided doses with two-thirds of the total dose given in the morning and one third in the afternoon
- Preferred regimen (3): Dexamethasone : 0.25 to 0.75 mg orally once daily
- Preferred regimen (4): Prednisone : 2.5 to 5 mg orally once daily
- Mineralocorticosteroid: Preferred regimen (1): Fludrocortisone : 0.1 to 0.2 mg orally once daily
- Patients of Addison's disease with mild-to-moderate stress:
- Alternative regimen (1): Cortisone 50-100 mg/day orally given in 2 divided doses with two-thirds of the total dose given in the morning (around 8 a.m.) and one third in the afternoon (noon to 4 p.m.) for 3 days
- Alternative regimen (2): Hydrocortisone 30-90 mg/day orally given in 2 divided doses with two-thirds of the total dose given in the morning (around 8 a.m.) and one third in the afternoon (noon to 4 p.m.) for 3 days
- Alternative regimen (3): Dexamethasone 0.50 to 2.25 mg orally once daily for 3 days
- Alternative regimen (4): Prednisone 5-15 mg orally once daily for 3 days
- Patients of Addison's disease with severe stress:
- Alternative regimen (5): Hydrocortisone sodium succinate 100 mg intravenously every 6-8 hours
- Glucocorticosteroid: Preferred regimen (1): Cortisone 10 to 37.5 mg q12h orally given in 2 divided doses with two-thirds of the total dose given in the morning and one third in the afternoon
- Autoimmune thyroiditis:
- Preferred regimen (1) Synthetic levothyroxine (L-T4) 1.6–1.8 μg/kg of body weight per day orally.
- Mucocutaneous candidiasis:
- For complete therapy for hypopituitarism please click here.
- For complete therapy for diabetes mellitus type 1 please click here.
References
- ↑ Bilezikian JP, Brandi ML, Cusano NE, Mannstadt M, Rejnmark L, Rizzoli R, Rubin MR, Winer KK, Liberman UA, Potts JT (2016). "Management of Hypoparathyroidism: Present and Future". J. Clin. Endocrinol. Metab. 101 (6): 2313–24. doi:10.1210/jc.2015-3910. PMC 5393596. PMID 26938200.
- ↑ Gan EH, Pearce SH (2017). "MANAGEMENT OF ENDOCRINE DISEASE: Regenerative therapies in autoimmune Addison's disease". Eur. J. Endocrinol. 176 (3): R123–R135. doi:10.1530/EJE-16-0581. PMID 27810905.
- ↑ Inder WJ, Meyer C, Hunt PJ (2015). "Management of hypertension and heart failure in patients with Addison's disease". Clin. Endocrinol. (Oxf). 82 (6): 789–92. doi:10.1111/cen.12592. PMID 25138826.
- ↑ Tucci V, Sokari T (2014). "The clinical manifestations, diagnosis, and treatment of adrenal emergencies". Emerg. Med. Clin. North Am. 32 (2): 465–84. doi:10.1016/j.emc.2014.01.006. PMID 24766944.
- ↑ Napier C, Pearce SH (2014). "Current and emerging therapies for Addison's disease". Curr Opin Endocrinol Diabetes Obes. 21 (3): 147–53. doi:10.1097/MED.0000000000000067. PMID 24755997.
- ↑ Grossman A, Johannsson G, Quinkler M, Zelissen P (2013). "Therapy of endocrine disease: Perspectives on the management of adrenal insufficiency: clinical insights from across Europe". Eur. J. Endocrinol. 169 (6): R165–75. doi:10.1530/EJE-13-0450. PMC 3805018. PMID 24031090.
- ↑ Napier C, Pearce SH (2012). "Autoimmune Addison's disease". Presse Med. 41 (12 P 2): e626–35. doi:10.1016/j.lpm.2012.09.010. PMID 23177474.
- ↑ Quinkler M (2012). "[Addison's disease]". Med Klin Intensivmed Notfmed (in German). 107 (6): 454–9. doi:10.1007/s00063-012-0112-3. PMID 22907517.
- ↑ Caturegli P, De Remigis A, Rose NR (2014). "Hashimoto thyroiditis: clinical and diagnostic criteria". Autoimmun Rev. 13 (4–5): 391–7. doi:10.1016/j.autrev.2014.01.007. PMID 24434360.
- ↑ Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM (2014). "Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement". Thyroid. 24 (12): 1670–751. doi:10.1089/thy.2014.0028. PMC 4267409. PMID 25266247.