Is hydrocortisone really better
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《美国医学杂志》
Department of Endocrinology, Diabetes and Metabolism,Christian Medical College, Vellore, Tamil Nadu, India
In the April 2005 issue of the Indian Journal of Pediatrics , Khadilkar et al have addressed an important issue in management of congenital adrenal hyperplasia (CAH) patients in India and the availability of oral hydrocortisone.[1] Gone are the days when hydrocortisone tablets had to be procured through the 'grey' market. However, the conclusions in the article on efficacy of hydrocortisone is a bit premature. I would like to point out some facts related to the article.
Although, the mean values of 17-hyroxyprogesterone (17-OHP) are comparable and well within the target range, the frequency of 17-OHP monitoring is not mentioned. The easy availability of 17-OHP assays in commercial laboratories might have increased the frequency of monitoring in the new cohort of patients diagnosed after 2001 and hence frequent titration of drug doses.
As mentioned in the article, when the patients were changed from Pednisolone to Hydrocortisone, there was an increase in height standard deviation score (SDS) in the tune of -0.22, +7.09, +7.46, +2.06 and + 5.25 in the five patients respectively. Achieving height SDS of over 7 is suggestive of rapid growth acceleration due to uncontrolled hyperandrogenemia and should be interpreted only in the context of a change in the skeletal age during the same period. It is also likely that these patients would have had progressed to 'secondary' central precocious puberty which might have caused acceleration of the height.
The authors have not mentioned the skeletal age of their patients. The authors could have used height SDS for bone age rather than height SDS for chronological age. This could help the readers understand the height velocity SDS in a proper perspective.
Improved height velocity SDS or height SDS would be a poor surrogate of final height, the real outcome we are interested in. The authors indeed could have used final predicted height to substantiate their claims of superiority of hydrocortisone, or wait till their cohort reach their final height.
In this context, it is worthwhile noting that titrated doses of dexamethasone could achieve normal growth in children with CAH.[2]
References
1. Khadilkar VV, Khadilkar AV, Maskati GB. Impact of availability of oral hydrocortisone on growth of children with CAH. Indian J Pediatr 2005; 72 : 301-303.
2. Rivkees SA, Crawford JD. Dexamethasone Treatment of Virilizing Congenital Adrenal Hyperplasia: The Ability to Achieve Normal Growth. Pediatrics 2000; 106: 767-773.(Mathew John, Sudeep K)
In the April 2005 issue of the Indian Journal of Pediatrics , Khadilkar et al have addressed an important issue in management of congenital adrenal hyperplasia (CAH) patients in India and the availability of oral hydrocortisone.[1] Gone are the days when hydrocortisone tablets had to be procured through the 'grey' market. However, the conclusions in the article on efficacy of hydrocortisone is a bit premature. I would like to point out some facts related to the article.
Although, the mean values of 17-hyroxyprogesterone (17-OHP) are comparable and well within the target range, the frequency of 17-OHP monitoring is not mentioned. The easy availability of 17-OHP assays in commercial laboratories might have increased the frequency of monitoring in the new cohort of patients diagnosed after 2001 and hence frequent titration of drug doses.
As mentioned in the article, when the patients were changed from Pednisolone to Hydrocortisone, there was an increase in height standard deviation score (SDS) in the tune of -0.22, +7.09, +7.46, +2.06 and + 5.25 in the five patients respectively. Achieving height SDS of over 7 is suggestive of rapid growth acceleration due to uncontrolled hyperandrogenemia and should be interpreted only in the context of a change in the skeletal age during the same period. It is also likely that these patients would have had progressed to 'secondary' central precocious puberty which might have caused acceleration of the height.
The authors have not mentioned the skeletal age of their patients. The authors could have used height SDS for bone age rather than height SDS for chronological age. This could help the readers understand the height velocity SDS in a proper perspective.
Improved height velocity SDS or height SDS would be a poor surrogate of final height, the real outcome we are interested in. The authors indeed could have used final predicted height to substantiate their claims of superiority of hydrocortisone, or wait till their cohort reach their final height.
In this context, it is worthwhile noting that titrated doses of dexamethasone could achieve normal growth in children with CAH.[2]
References
1. Khadilkar VV, Khadilkar AV, Maskati GB. Impact of availability of oral hydrocortisone on growth of children with CAH. Indian J Pediatr 2005; 72 : 301-303.
2. Rivkees SA, Crawford JD. Dexamethasone Treatment of Virilizing Congenital Adrenal Hyperplasia: The Ability to Achieve Normal Growth. Pediatrics 2000; 106: 767-773.(Mathew John, Sudeep K)