the what, why and how of cah - cares foundationactions of cortisol • allows the body to deal with...
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The WHAT, WHY and HOW of
CAH
2016 Congenital Adrenal Hyperplasia Patient
& Family Summit
Riley Hospital for Children at IU Health
November 12th, 2016
Indianapolis, IN
Erica A. Eugster, MD
Professor of Pediatrics
Topic Overview• WHAT causes CAH?
• WHAT are the different forms of CAH?
• HOW is it inherited?
• WHY does it affect girls and boys differently?
• HOW is it diagnosed?
• WHY are some people diagnosed early and
others late?
• HOW is it treated?
• WHAT are some of the challenges &
controversies in the care of patients with CAH?
• CAH is caused by the deficiency of an
enzyme needed to produce CORTISOL
Actions of Cortisol
• Allows the body to deal with stress
• Keeps blood sugar normal
• Maintains normal function of the heart and
blood vessels
• Energy and sense of well-being
• Cortisol is critical for life!
– many different enzymes are needed to produce cortisol
– >95% of people with CAH have a deficiency of the 21
hydroxylase enzyme
– 21-hydroxylase deficiency is caused by a genetic mutation
usually inherited from both parents
HORMONES OF THE ADRENAL GLANDS
Cortisol-glucocorticoids
Aldosterone-mineralocorticoids (salt and water balance)
Androgens-male sex hormones
• One in 4 chance (25%) that
each child will be affected
with CAH
• There are many different
mutations in the gene for
the 21 hydroxylase enzyme
• The specific mutation
determines the severity of
the CAH
• Classic vs non-classic CAH
Adrenal Hormone Production
CHOLESTEROL
ALDOSTERONE
(salt & water)
CORTISOL
(stress & CV fct)17-HYDROXY
PROGESTERONE
=21-hydroxylase enzyme
ANDROGENS
• Classic CAH before birth:
– Girls-masculinization of the external genitals; internal
structures unaffected
– Boys-no physical consequences
• Classic CAH after birth:
– Girls-possible salt-wasting crisis, ongoing virilization
– Boys-possible salt-wasting crisis, early puberty
– Both-rapid growth, advanced skeletal maturation
• Nonclassic CAH before birth:
– Girls and Boys- no physical consequences
• Nonclassic CAH after birth:
– Girls-early pubic/underarm hair, body odor, acne,
irregular periods, unwanted hair
– Boys-early pubic/underarm hair, body odor, acne
Behavioral Consequences of
Classic CAH• Girls
– tend to be more tomboyish than their sisters
without CAH
– some studies have found higher scores in certain
skills
– majority have typical female gender identity
• Boys
– no different from brothers without CAH
– typical male gender identity
Diagnosis of CAH
• Newborn screening
– followed by confirmatory blood draw for 17OHP
– CAH added to newborn screen in Indiana in 2000
• Random 17-hydroxyprogesterone
• ACTH stimulation testing
• Genetic analysis of the 21OHase gene
• Prenatal testing
Medical treatment of Classic CAH
• Glucocorticoid therapy
– hydrocortisone during childhood
– stress steroid coverage for illness or surgery
• Mineralocorticoid therapy
– fludrocortisone
• Salt until ~age 3
• Medical treatment of Nonclassic CAH
• Glucocorticoid therapy if the decision is
made to treat
Challenges & Controversies• Safety concerns
– need for stress steroid coverage
– medic-alert
– emergency injection
• Optimal medical treatment
– over vs under treatment
– new therapeutic approaches
• Additional health challenges in CAH
– hypertension, weight gain, psychological issues
• Early genital surgery in girls
Summary and Conclusions
• CAH exists within a spectrum of severity
• Consequences are very different depending on
– male vs female
– classic vs nonclassic form
• Diagnosis may be made at any stage of life
• Many opportunities for advancement of
knowledge and improvement in care