My name is Alina Turku. I'm an associate professor at University of Michigan. I am a physician scientist and both in the lab and the clinic I focus on the genome disorders including congenital genome hyperplasia. I don't have any disclosures that are relevant to this talk. So I want to ask you all to scan this code. We will have a few cases and I would like you to participate and as I will poll the audience for those cases. I will show the code again later in case you miss it. So we have two objectives for today. First is to discuss both the established but most importantly the novel therapies for patients with congenital genome hyperplasia and the second goal for today is to see how we can best utilize established and novel biomarkers in assessing disease control and also in guiding for the therapy management in patients with CHC. So a few basic concepts about CH. You all know CH is a group of autosomal recessive disorders that affect usually one but sometimes more enzymes needed for cortisol synthesis and this interrupts the typical negative feedback to the hypothalamus and pituitary which will enhance their output of CRH and ACTH and then ACTH tries to overcome the blockage and restore the cortisol synthesis and it also has a trophic effect on the adrenal tissue. So it leads to adrenal tissue enlargement. So this gives the name of the disease congenital because it's inherited adrenal hyperplasia. So the vast majority of CH cases are caused by defects in 21-hydroxylase and 21-hydroxylase deficiency like most other forms of CH run a spectrum from complete or nearly complete to mild enzymatic defects and this usually corresponds to a spectrum of clinical manifestations. So by convention we say that forms of CH in which we have cortisol deficiency are called classic CH forms and forms in which the cortisol synthesis is compensated or non-classic CH forms. But in all forms of CH we will see some degrees of ACTH elevation and what ACTH will do will try to force the stereogenic flux towards pathways that remain unobstructed and in 21-hydroxylase deficiency the only open pathway is that towards formation of androgens. And the most dramatic manifestation of androgen excess is seen in newborn girls with classic CH which can be easily recognized at birth with virilized external genitalia and in milder forms of CH we could see it present either in children with premature adenarchy or premature puberty or even later in adulthood especially obvious in women where we might see hercetism, acne, irregular periods and infertility and this overlaps very much with PCOS. So I'd like to start with a case. We have a 61-year-old woman with classic CH due to 21-hydroxylase deficiency and by the way I will use these terms interchangeably today. We'll only speak about 21-hydroxylase deficiency. She presents to your office to establish care because she relocated in in your area and she is particularly concerned about diffuse alopecia and facial hercetism. Her medical history also includes type 2 diabetes mellitus, osteoporosis, dyslipidemia, obesity, obstructive sleep apnea, anxiety and insomnia. So for CH she takes hydrocortisone 10 milligrams in the morning and 5 milligrams at 2 p.m. And she also takes dexamethasone 0.25 milligrams at bedtime. You can see her labs on the board. She has an elevated ACTH, an elevated 17-hydroxyprogesterone and testosterone and DAGS is suppressed. If you didn't have a chance, please scan this code now so you can vote on the question that follows. So my question to the audience is which of the of the following treatment options would you consider next? A. Add spironolactin 25 milligrams daily. B. Enroll in a clinical trial of a corticotropin releasing factor type 1 receptor antagonist. C. Increase bedtime dexamethasone dosage to 0.5 milligrams. D. Stop dexamethasone and enroll in a clinical trial for abiraterone acetate. And E. Either one of B or D. Show the code. Which question is going to? Oh boy. What's to see? No? It's working? Okay. Okay, so go ahead and try to take a vote. It's a different question? I'm afraid I'm not I don't know how to fix the problem. Hopefully it will work for the next question. I'm not sure. Do you know how to fix it? Apparently it shows the wrong question. Sorry about this. Yeah. Well, should we do a quick show of hands? Anybody for A? A few takers for A. Anybody for B? Anybody for C? A lot of people for C. Anybody for D? Okay. And how about E? Quite a few options for E. Okay. Thank you. All right, so we have two major goals in treating patients with CH. On one hand, we need to replace the hormones that are deficient. So that would be for patients with classic CH. And on the other hand, we need to suppress the excessive glucocorticoids. And for the most part this has been done with I'm sorry, the excessive androgen excess. The excessive androgen production from the adrenal gland. And this for the most part has been achieved with glucocorticoids. But suppressing the adrenal androgens is relatively difficult without the use of overdosing, giving super physiological doses of glucocorticoids. So in trying to strike the perfect balance between suppressing the androgen versus avoiding exposure to excessive glucocorticoids, patients often end up with a poor hormonal control. Either having really high androgens, which will reflect in their clinical manifestations that we discussed about. Also poor quality of life. Or oftentimes we see suppressed androgen. And this comes at the expense of using supra-physiological doses and administration time of glucocorticoids. And in addition, the need to give multiple daily doses often comes with poor compliance. And increased depression and anxiety. And these patients have higher rates of mortality as well. Mostly due to adrenal insufficiency. So the first case of classic CH appears in the literature in an autopsy report that was published in 1865. But it wasn't until the 1950s when glucocorticoids became available for therapeutic use. After their crystallization by Kendall and Hench at the Mayo Clinic and the Swiss Rheinstein. For which they were awarded the Nobel Prize. And soon after, pharma companies quickly made these products available for mass use. And I'm sure all of you are familiar with these products, which we still use today. So the shortest acting is hydrocortisone. Dosed usually twice or three times a day. Prednisone and prednisolone have about a four to five times potency compared with hydrocortisone. And this can be dosed twice daily. And then dexamethasone is the most potent. Twenty to twenty-five times compared with hydrocortisone. And fludrocortisone is the only mineralocorticoid available for replacement. So we usually take a step therapy in patients with CAH. Like in any other forms of adrenal insufficiency, we use hydrocortisone for replacement. Typically a little higher dose in the morning, 10 to 15 milligrams upon awakening. And then we use a smaller dose, 5 to 10 milligrams in early afternoon. And in order to suppress the early morning rise in ACTH, which drives the excessive adrenal androgen production, we use a bedtime glucocorticoid. Usually a longer acting. And that would be prednisolone or prednisone. Prednisolone is preferred over prednisone because it's all already active. And when compliance is a problem, we can use prednisone or prednisolone twice a day. Once in the morning for replacement and a lower dose at bedtime to suppress the morning ACTH rise. And then dexamethasone is the most effective in suppressing ACTH. However, it comes with higher risk of iatrogenic Cushing manifestations. In children and adolescents, at least until the growth plates close, we prefer a short-acting glucocorticoid, so hydrocortisone. In pregnancy, we, at least for replacement, we avoid glucocorticoids that would not be inactivated by the placental 11 beta-HSD type 2. So that would be dexamethasone. And that is to avoid fetal exposure. And then in patients with non-classic CH, as we said by definition, they have compensated cortisol production. They don't need replacement, but we might need to use glucocorticoids to suppress androgens, either in children who have precocious development or in women with infertility. So, although the development of glucocorticoids was a life-changing treatment for many patients with adrenal insufficiency and CH, progress for therapies in CH was stagnant for over half a decade. So only recently we have began to see efforts to develop therapeutics that would attack the excessive adrenal androgen production at various levels. So one strategy is to deliver glucocorticoids in a more physiological fashion. And so this slide shows the physiological circadian rhythm of cortisol, which peaks in early morning. This is in patients who have a normal daytime routine and sleep during the night. And then a second peak early in the afternoon. And so a dual release hydrocortisone, which consists of an extended release core surrounded by an immediate release coating, was initially developed for use in patients with adrenal insufficiency administered just once daily. But that was insufficient in patients with CH to suppress the early morning ACTH and 17-hydroxyprogesterone. So this is a phase two open-label study of 16 adults with classic CH, in which a modified release hydrocortisone was administered twice daily, initially at 10 milligrams at 7 a.m., and a higher dose of 20 milligrams at 11 p.m. And the dose was titrated over six months based on androstenedione, 17-hydroxyprogesterone, and clinical assessment. And all these patients were on stable glucocorticoid and mineralocorticoid dosage for three months prior to entering the study. And what you see is that compared to conventional therapy, which is slightly lighter gray, chronocort, which is this modified release hydrocortisone, was able to decrease androstenedione and 17-hydroxyprogesterone, particularly in the morning window, but also the area under the curve for 24 hours. And there was no significant changes in quality of life or fatigue, because baseline score were relatively good at the entrance of the study. And then studies of chronocort were extended to a six-month randomized this time, so not open-label, but randomized trial, comparing the modified release hydrocortisone versus standard glucocorticoid therapy. You see in open circles. And this study enrolled 122 adults with classic CH from 10 centers from seven countries. And here you see that the modified release hydrocortisone was better in suppressing the 17-hydroxyprogesterone levels between 7 in the morning to 3 p.m., whereas the conventional therapy was not able to suppress this peak. So even more precise titration of glucocorticoid delivery can be achieved with continuous hydrocortisone infusion. This is an initial small study that administered hydrocortisone intravenously, so this is difficult to achieve in outpatient. And after describing the cortisol pattern in healthy individual, this was mimicked in patients with adrenal insufficiency and in patients with CH by continuous intravenous infusion of hydrocortisone. And what you see is that with this approach, both ACTH and 17-hydroxyprogesterone were nicely suppressed, particularly in the early morning, which is really hard to achieve without administering super physiological doses at bedtime with oral products. Now this is a face-to-open-label study of eight adults with classic CH that compared the delivery of continuous subcutaneous hydrocortisone through a pump. And all of these patients had poor control, so elevated to genosteroids and at least one comorbidity at study entry. And what was achieved with a continuous hydrocortisone delivery through the pump was a close to physiologic cortisol secretion. And what you see is that compared to baseline, six months of pump delivery resulted in decreased morning and 24-hour area under the curve for ACTH and ristine dione and also for 17-hydroxyprogesterone and progesterone. So with this, I'll move on to a second strategy to suppress ACTH. So the rationale is to use something that's non-steroidal to overcome the ACTH elevation in the morning. And this can be achieved through oral small molecules that suppress this, antagonize the CRH receptor. So this is a pilot study of phase one, single-blind, placebo-controlled. It enrolled eight women with classic 21-hydroxylase deficiency and followed three sequential treatments separated by three weeks each. So we had placebo followed by 300 milligrams of the CRH receptor antagonist and then 600 milligrams of the CRH receptor antagonist. And we found that in six of eight participants, ACTH and 17-hydroxyprogesterone were suppressed in the morning windows and the effect was dependent on the dose administered. So with better results when using the higher dose of 600 milligrams. This is a more recent phase two open-label study that enrolled 18 patients with classic CAH from different centers. And this drug is now under the name of Crenosyrfant and it was delivered in four different regimens between 50 milligrams once a day to 100 milligrams twice daily and was given for 14 consecutive days. And with all doses you can see that ACTH, 17-hydroxyprogesterone and androstenedione were reduced, and the effect was also dose-dependent in this study. There is a second CRH receptor antagonist available that's being studied, Tildaster font. This is also a phase two open-label study. And this was administered at doses between 100 milligrams twice daily to 1,000 milligrams daily for various amounts of time. You can see up to 14 weeks with extension to 16 weeks. And in both studies, ACTH and androstenedione were reduced. And the effect was particularly obvious in patients who had a baseline elevation of androstenedione. Okay, so yet a third strategy is to decrease the adrenal androgen synthesis by blocking enzymes that are required for their synthesis. So this is a study of abiraterone acetate. This is a drug that is a potent active side-directed inhibitor of CYP17A1. This enzyme is needed both for androgens and for cortisol synthesis. It is FDA-approved for use in castration-resistant prostate cancer, where it reduces circulating testosterone, and it also increased survival. Now, in patients with prostate cancer, because this drug also inhibits the production of cortisol, patients need to be on glucocorticoid replacement. And also in these patients, you might see elevation of DOC, which leads to high blood pressure and low potassium. But this is not a problem in patients with CAH, because, at least patients with classic CAH, because these patients already take hydrocortisone for replacement. And also, there is no need to worry about increasing DOC, because that is below the enzymatic blockade, so there is no concern there. So, this was a study conducted at University of Michigan, led by Ray Chalkas, and abiraterone acetate was given in two doses, 100 milligrams a day, initially. This was a study conducted in six women. What you see is that, with the initial dose, androstenedione decreased sharply, and was normalized in 50% of the participant. And then, when the dose was increased to 250 milligrams a day, androstenedione was normalized in five of six participants. And you can also see a decrease in testosterone and androgen metabolites overall. With abiraterone, you also see that the effect is dose-dependent. So, there are many other strategies, but these are in earlier development, still stages. You can develop ACTH antibodies, ACTH receptor antagonists, adrenolytic agents have been used and published, but in very small studies, androgen receptor antagonists, other inhibitors of androgen enzymes, and gene therapy and cell reprogramming, which could be curative for these patients. So, to summarize what we have in the pipeline, and might be available, and it is available on some countries in the world, especially in Europe, modified-release hydrocortisone. This is available both as the trade name, plenadrine for adrenal insufficiency, and now cronocort. For patients with adrenal insufficiency, it does require twice a day administration, while for patients with adrenal insufficiency, once daily in the morning is sufficient. So, these drugs are given orally, and they are quite effective in suppressing the early morning ACTH. But they still carry some potential for Cushing syndrome. Given at too high doses. Second, we're not too far in these studies, but subcutaneous hydrocortisone infusion, in a fashion similar to insulin pumps, have been looked at, and likely will evolve in the future, if the number of patients in interest from pharma companies will evolve. And with this strategy, you can closely mimic the circadian circulatory patterns of cortisol. And if you couple that with measuring ACTH in real time, which is a little bit more difficult to do, you could even mimic the ultradyne pulsatility replication of cortisol delivery. Like with insulin pump, this strategy comes with complexity and high cost, probably especially up front. And it also carries the potential of malfunction and irritation. Fairly advanced strategy that is non-glucocorticoid, or CRH receptor type one antagonist. And we have two different drugs in the pipeline, Crenasirfant and Tildasirfant. They are administered once or twice daily, and they can prevent ACTH rise in the morning. But we are still in stages where we are collecting long term safety data. With androgen biosynthetic enzymatic blockage like CYP17 inhibitors, sabiraterone acetate is a drug that has been looked at. It is highly effective to suppress morning ACTH and is well tolerated. It does not lower ACTH, and it also inhibit gonadal sex steroids. So it's not the ideal treatment for patients in reproductive ages, because they will inhibit the production of sex steroids. So now let's look back at our patient. So now let's look back at our patient. So this patient clearly has poorly controlled CAH, as you can see in the elevated ACTH, and 17-hydroxyprogesterone, but also high testosterone, and she has clinical evidence of androgen excess. But she also has a number of comorbidities that could be related with excessive glucocorticoid use. So this was a meta-analysis that compared glucocorticoid replacement in patients with CAH, and dexamethasone had higher risk of higher BMI and lower bone density compared to hydrocortisone and prednisone. So for this patient, increasing the dexamethasone further would probably come with a lot of side effects, and it's not the ideal option for this patient. Spironolactone, as you know, is primarily a mineralocorticoid receptor antagonist. At higher doses, but usually higher than 100 milligrams a day can also inhibit the androgen receptor. So increasing the, using spironolactone dose of 25 or even 50 milligrams is not gonna be effective in this patient. So you can choose to enroll the patient in a clinical trial. If you go on clinicaltrials.gov and type CAH, and even if you type the drug of choice, you will see several studies that are currently enrolling, both for adults and for children. Okay, so with this, I'm gonna move to the second case. For anybody who came in late, hopefully if you scan this code, it's gonna work for the right question this time. Okay. Okay, so this is a 24-year-old Caucasian woman. She presents complaining of hirsutism and acne. She also struggles with losing weight. Her menarche was at age 10, and she always had irregular periods. She takes no medications. So in physical exam, she has uniform distribution of her adiposity. She has no plethora, bruises, or stria. She has some mild acanthosis nigricans at neckline. Her BMI is high, at 32 kilograms per meter square. Her blood pressure is low normal, not atypical for young women, and heart rate is normal. And if you look at her hormonal workup, you see a testosterone that is normal, so 48 nanograms per ml. ACTH is normal, and DAGS is low normal as well. So my question to you is, what is the best next step in managing this patient? A would be start an oral contraceptive pill with a third-generation progestin. B, use metformin. C, start spironolactone. D, check 17-hydroxyprogesterone. And E, recommend weight loss strategy and refer to dermatology. Still doesn't work? What changes is it? Looks like it works. Okay, so most people in the audience would check 17-hydroxyprogesterone, and some would just begin empiric treatment with a contraceptive pill. And again, we can have a free discussion at the end, and there's no perfectly right or perfectly wrong answer, but I think it would be reasonable to check 17-hydroxyprogesterone in this patient to exclude congenital genohypoplasia, just because PCOS and non-classic CH have an overlapping clinical presentation. So 17-hydroxyprogesterone was checked, and it was elevated at 5.3 nanograms per ml. This is highly suggestive of non-classic CH, and it can be confirmed further with an ACTH stimulation test. So a little rhetorical question is, why does she have signs of hyperandrogenism if her testosterone is normal? So in women, the two sources of androgens are the adrenal glands and the gonads. And testosterone and androstenedione are produced relatively equally from the two glands after puberty. And then DAGA and DAGS occur primarily from the adrenal gland, with smaller contribution from the ovaries. So in the top box, you see the currently available biomarkers for androgen excess, which we use routinely in clinical practice. So testosterone and androstenedione, sometimes we use DAGA and DAGS. But these, what we call traditional biomarkers, have many limitations. So DAGA and androstenedione correlate relatively poorly with 17-hydroxyprogesterone. DAGS in patients with CH, even when in poor control, can be suppressed paradoxically, as I will show you in a few slides. Androstenedione and testosterone are not particularly useful because they also arise from the gonads, and in fact, they correlate really poorly with clinical signs of androgen excess, as you saw in the patient I presented. And also keep in mind that other than testosterone, all of the others are precursors that don't have any bioactivity. So the adrenal gland makes some unique androgens. So it has this enzyme shown in red. It's called 11-hydroxylase, or CYP11B1, which is the enzyme that executes the last step in the synthesis of cortisol. And this enzyme is not highly expressed anywhere else but in the adrenal gland. What is less recognized is that CYP11B1 can also use androstenedione and testosterone as substrates, leading to 11-hydroxyandrostenedione and 11-hydroxytestosterone, and these two can be further oxidized primarily in periphery to their 11-keto metabolites, 11-keto-A and 11-keto-T in short. So together, these androgens are referred to as 11-oxyandrogens. So 11-keto-T has been studied for many years and is recognized to be the primary gonadal androgen in theliosed fish, and it's bioactive. But in humans, 11-keto-testosterone comes from derivatives from the adrenal gland. And we know, I'm not showing data here, we have recent data, we measured 11-oxyandrogens in paired gonadal vein and peripheral vein, and the output from the gonadal vein is null, basically. And we also have data from adults with paired adrenal vein and peripheral vein blood, showing that the output of 11-oxyandrogens is dramatic from the adrenal glands. And what I'm showing you here is peripheral concentrations of steroids from adults in reproductive ages, where, of course, testosterone is gonna be much higher in males compared to females. Yet the testosterone derivatives, 11-OHT and 11-keto-T, circulate in equal concentrations in both sexes. So the gonadal testosterone does not convert to 11-OHT or 11-keto-T. So DAGS is the primary adrenal androgen precursor quantitatively, but it really doesn't have any bioactivity, as I mentioned earlier. But 11-keto-testosterone has a maximal bioactivity similar to that of testosterone. And more than that, 11-keto-testosterone can be 5-alpha reduced, like testosterone, to 11-keto-DHT, which is very potent, similar to DHT. So this is a study we conducted back in 2016, looking at patients with classic 21-hydroxylase deficiency compared to sex and age-matched controls. And what you see is that even when these patients with classic CH take their usual replacement therapy, including the glucocorticoids at bedtime, all of the 11-oxyandrogens are three to four-fold higher compared to unaffected individuals. And I wanna underline here that both testosterone and androstenedione are similarly elevated in patients with classic CH, but this is not the case for patients with non-classic CH. So this is a study we conducted in 86 consecutive patients who underwent ACTH stimulation tests because of suspected non-classic CH. What you see is that androstenedione and testosterone are relatively similar between patients with or without CH, but 11-hydroxyandrostenedione and 11-ketotestosterone are both higher in patients with non-classic CH compared to controls. And then if we look to the subset of just women with CH versus those with PCOS, you can also see that all of the 11-oxyandrogens are two to three-fold higher in those with non-classic CH versus PCOS. And if you look at the relative numbers, please note that 11-keto-T in women with non-classic CH is higher than testosterone, but in PCOS, actually testosterone is higher than 11-keto-T. 11-oxyandrogens can also be useful when the message we get from traditional biomarkers is somewhat divergent. So this is a study of natural history in CH patients, which is conducted by Dr. Debbie Mark at the NIH. And of over 2,700 laboratory measurements, about 17% showed discrepant results based on either 17-OHP or androstenedione. And then patients were classified based on clinical assessment as having either good control or poor control. And what was seen was that poor control was predicted by how much 11-OHT was elevated compared to matched controls. So you can actually order 11-keto-T. It's now available at LabCorp, and the turnaround time is about 14 days. But you could definitely order it. All right, we'll move on to case number three. It should be the same quote. So if you did scan it, then you don't have to scan it again. But just for those who came in late, this will help you connect to the question. So this is a male this time, 34-year-old. He has class 60 age, also 21-hydroxyphase deficiency. He comes to see you for infertility. He and his wife have been trying to conceive for about a year. On exam, he has small bilateral testicular adrenal rest tumors, which have been stable based on the ultrasound you obtained. For CH, he takes hydrocortisone, 10 milligrams in the morning, 10 milligrams at 2 p.m., and he also takes prednisolone at bedtime, two milligrams. Physical exam, he's well-verbalized. blood pressure is low normal, pulse rate is normal, height is relatively short, 173, BMI is 29.2. He has a generous testicular volume of approximately 26 ml, and his testes are heterogeneous and firm. So his testosterone is normal, 393 nanogram per deciliter, although a little low for his age, but within the normal range. ACTH and 17-hydroxyprogesterone are elevated as is androstenedione, and DAGS is low normal. So for this patient, what would be the next best step in his management? A, measure gonadotropins and 11-ketotestosterone, B, measure 17-hydroxyprogesterone, C, recommend fertility evaluation for a patient's wife, because his testosterone concentration is normal, so it must be his wife, and D, refer for surgery for testicular adenorectal tumor removal. How's it work again? A, anybody? Okay. B? Probably no takers. C? Anybody want to blame the wife? No. Anybody wants to be aggressive with surgery? Oh, now it seems like... This shows a completely different question. Not sure why. Okay. So I think I got a sense of what people would like to do. So questions that would come to mind relative to this patient would be, well, why does he have infertility, because he has normal testosterone, and could gonadotropins be useful in the context of normal testosterone, especially since we're not suspecting secondary disease, right? So as opposed to reproductive age females and reproductive age males, most of testosterone will come from the testes. Very little contribution, negligible from the adrenal glands, which is why even in patients with classic CAH, we don't really see major manifestations on physical exam in males. And so many of these male patients are never diagnosed if they have milder disease, non-classic CAH that is not caught at birth. But in these patients, the adrenal glands will have a dramatic contribution to androgen production, testosterone to some extent, but also 11 oxyandrogens. And what these will do will suppress the gonadotropins. And if a CAH is uncontrolled for a long period of time, sustained and dramatic elevations of ACTH would lead to massive adrenal enlargement and development of myelolipomas, as you can see in this CT scan. And also, ACTH will promote the development of any adrenal tissue, including ectopic adrenal tissue, which can be found in the gonads, and these patients develop adrenal rest tumors. And both the adrenal glands and the testicular adrenal rest tumors will contribute to the production of excessive amounts of androgens. This study was led by Mariska Schroeder, and she looked at paired spermatic vein and peripheral vein blood in males with classic CAH and testicular adrenal rest tumors. And as expected, from spermatic vein, we will see dramatic elevation of both 17 and 16 hydroxy progesterone, and you also see about a 96-fold higher concentration of 11 hydroxy testosterone and 47 concentration of 11 keto testosterone coming from the spermatic vein relative to periphery. So as it turns out, these androgens correlate quite well with surrogates of poor disease control in patients with CAH, and that includes adrenal volume. Presence of testicular adrenal rest tumors and menstrual irregularities. We didn't see a correlation with bone age, and this is not surprising because this is also influenced by the doses of glucocorticoids used. And another important aspect I want to underline here is that in females of all ages and in prepubertal males, we see a direct correlation between all 11 oxyandrogens and testosterone. But if you look at post-pubertal males, so after the gonads begin to contribute to testosterone production, 11 oxyandrogens correlate inversely with testosterone. So that tells us that as the CAH control is poor, the 11 oxyandrogen production increases, suppresses gonadotropins, and the testicular production of testosterone declines. This is shown nicely in this study of 78 children with CAH and 62 matched healthy controls. These were followed in 13 centers in the UK. So what you want to note here is that testosterone at the top panel is higher in girls of any age compared to controls, but in boys after age 12, testosterone is lower than in controls, but it's higher before puberty. And 11 ketotestosterone is higher in all ages and in both sexes compared to controls. So that's why testosterone is not a very good biomarker for disease control in CAH. And another really nice aspect of this study was that they measured paired plasma and saliva, 11-hydroxyandrostenedione and 11-ketotestosterone, and you can see they correlate really nicely. So having the ability to measure saliva, 11-oxyandrogens would be really helpful in children, and any time we want to assess nighttime hormonal measurements, so for home kids. When measuring these hormones, keep in mind that they do have a circadian rhythm that follows ACTH and resembles the circadian rhythm of cortisol. The exception here is DHES because it has a long half-life and a relatively flat pattern. And as you can see, also testosterone doesn't have the large excursions driven by ACTH. So coming back to the study from the NIH that was led by Dr. Debbie Merck, comparing conventional glucocorticoid therapy with continuous subcutaneous hydrocortisone infusion through a pump, with a pump, as I mentioned earlier, most androgens were really nicely suppressed, but the best responder to ACTH suppression was 11-ketotestosterone. And a really interesting aspect here is that while all of the androgens decreased in females, in males, you can see in blue that testosterone actually increased with the use of pump. This is in contrast with 11-ketotestosterone, which is lower with better glucocorticoid, with continuous glucocorticoid therapy and better ACTH control. So this patient clearly has poorly disease-controlled, poorly controlled ACTH. ACTH is elevated, 17-hydroxyprogesterone is elevated, and so is androstenedione. But testosterone is within normal range, yet it's not the most useful biomarker here. So if you look at the gonadotropins, they were suppressed. We did not measure 11-ketotestosterone here, but we would expect it to be elevated. So to conclude the biomarker story, 11-oxyandrogens are androgens that derive primarily from the adrenal androstenedione in testosterone, but not from the gonadal hormones. And of the 11-oxyandrogens, 11-ketotestosterone has a potency similar to testosterone, and 11-ketoDHT is even more potent, similar to DHT. So in women of most ages, 11-ketoT is the dominant bioactive androgen. And also you will see that these are more sensitive to ACTH suppression than either in testosterone and androstenedione, because these two also have a component that arises from the gonads, and that is not going to be immediately responsive to ACTH suppression. And certainly you can use 11-ketoT as a biomarker for all patients with CH to assess disease control, particularly so in men, because testosterone is going to be often normal in these patients. So with this, I thank you all for your attention, and I'd like to acknowledge my adrenal team from University of Michigan, especially Rich August, who was my long-time mentor in Belarania as well, and collaborators from the NIH, Dr. Debbie Merck and her team, and also Dr. Valduz from the Mayo Clinic. And I'm very thankful for the funding we have received over the recent years. And I'm hoping that this will spark some discussion. Thanks again for coming and for your attention. Please go ahead. Gordon Cutler. Have you tried gonadotropins in the TART patients, and does it help fertility? Sorry, it was a little noisy. Can you please repeat the question? Yeah. Have you given HCG and Pergonal or recombinant FSH to the TART patients, and does it help fertility? And do you think it would? We have not tried that approach, at least not in our clinic. But people have tried the adrenolytic agents, and with one case in New England Journal of Medicine, and with that they saw decrease of testicular adrenal arrest tumors, and fertility was achieved after two years of use of Mitotain. Thank you. Hi. Hi. This is Dr. Abbas from Pakistan. I have a more clinical question regarding the three cases that you presented, in which we saw in high ACTH levels, and we saw the high 17-hydroxypergesterone, and they were on a pretty high, decent doses of steroids. Is there a way that we can look into these patients and see if the compliance is the issue? Because these are younger people, and again, you don't know if they're, is there a way that you can differentiate between the compliance versus not effective dose? That's a very good question. I have patients in whom I'm not certain that compliance is followed as instructed. At the same time, I have patients who are relatively dedicated, come at every visit, and they are on the same doses of glucocorticoids, controlled for a number of years, and then suddenly, all of the biomarkers go up, and we can't really identify a reason. Sometimes, we make sure that the stock of their medications is not expired, or nothing else really happened, or they don't have malabsorption because of other reasons. But I think the only way to see is to just measure the glucocorticoid after they have taken the drug. And you can measure either cortisol after dosing hydrocortisone, or you can measure the dexamethasone level and see if that is at the expected levels. Thank you. Thank you. Hello, Richard Ross from the University of Sheffield. Thank you very much. Very nice presentation. So, I've got one further answer for your first case, which is to enter them into a trial of modified-release hydrocortisone, because it's just opened in the U.S. And the European experience is that we achieved very good control. So, 80% of patients on twice-daily modified-release hydrocortisone were controlled with a 17-hydroxyprogesterone just above the upper limit of normal, so well within the optimal range, on a median dose of hydrocortisone of 20 milligrams. So, the majority are not needing excess, and I don't think, therefore, we'll need other treatments. And it has been associated with improved fertility, women getting pregnant, restoration and menstruation, and improved sperm count. So, yes, I'd like to suggest that as an extra arm to your questions. Thank you. I take your suggestion. I didn't want to put a very obvious suggestion, so it gave me an opportunity to discuss the study, including yours, but a modified-release hydrocortisone is not yet available in the U.S. I know it's available in Europe and the U.K. But there is a study starting. Thank you. Thank you very much for this overview, Tina Cater from Montreal, Canada. So, you just made me think of a case, if I could spare you for a few minutes, of a lady that I've known for 20 years with classical adrenal hyperplasia, and we've been through two pregnancies together, so we're quite close, always compliant. She had a weird episode of C. diff, and after that, all her androgens went sky high, stopped menstruating. I thought maybe she wasn't absorbing it, so I switched her from Dex to Cortef. She swears compliance, and everything came down after a few months, and then it went up again. And I know it's rare, but could she have an adrenal arrest tumor? That's what I'm thinking, because she had some imaging of her ovaries, everything was fine, but just ultrasound. Saw her gynecologist. Should I be doing MRI of adrenals and ovaries looking for this? Yes. So, adrenal arrest tumors are probably just as likely in women as they are in men. We just find them more commonly in men because they are external and we can palpate them in women because the gonads are internally located. They are more difficult to find, but Dr. Debbie Merck published a study from NIH, and she located the adrenal arrest tumor near the ovaries with nuclear imaging, so you could definitely do that. And then it's up to you. It's probably very difficult to, if this is a person who still wants to be fertile, would be difficult to. No. Okay. She's done. She's done. There she is. Okay. Then you could simply offer oophorectomy. Offer her? Oophorectomy, bilateral oophorectomy. Okay. She won't want that either. But it's weird because it comes down when I increase the dose, which would be bizarre. You would think it would be consistently high. So, if you increase the dose of bedtime glucocorticoids, that would be successful in suppressing the androgen production by just suppressing ACTH. Right. But hopefully, now you'd be able to use either modified release hydrocortisone to not need to escalate the dose of glucocorticoid at bedtime. Okay. Thank you very much. Thank you. Thank you. Manwusalam from Washington University, St. Louis. You mentioned the use of 11-keto-testosterone as a surrogate marker for androgen production from adrenals. What about the testosterone? It's not a surrogate. It's a real biomarker. Yeah. What about the testosterone-androstenedione ratio? Could this be used as a surrogate marker for also 17-hedroxyprogesterone? For disease control? Yeah. Yeah. So, in Class VI-C age, androstenedione and testosterone will correlate quite tightly with 11-oxyandrogens, including 11-ketotestosterone in women with Class VI-C age. In men with Class VI-C age, they usually don't correlate, definitely not after puberty. So, their testosterone can be normal and 11-ketotestosterone could be elevated. But in women, because the adrenal androgen excess is the primary driver, you will see elevation about of the same fold of both 11-oxyandrogens and of testosterone and androstenedione. So, in women, it's more reliable to use either one of the two, but not so much in men with Class VI-C age. In non-Class VI-C age, you will see normal testosterone often, despite clinical evidence of androgen excess, and in those cases, 11-ketoT could be helpful if you'd be considering treatment options. Even though now in non-Class VI-C age, we still offer OCPs as a first-line of treatment, perhaps if we have a better and deeper understanding of the contribution of the adrenal androgens, we could develop different strategies of treatment for these patients instead of using OCPs, which are likely to not be super effective for suppressing the adrenal androgens.

Alina Turcu

University of Michigan

congenital adrenal hyperplasia

CAH

cortisol synthesis

ACTH

adrenal androgen production

treatment goals

modified-release hydrocortisone