Article

Adrenopause und Dehydroepiandrosteron: Pharmakotherapie versus Substitution

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  • german society of anti-aging medicine, Munich
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Abstract

ZusammenfassungHintergrund: Die Adrenopause ist als alterstypische partielle Nebennierenrindeninsuffizienz durch erniedrigte Blutspiegel von Dehydroepiandrosteron (DHEA) und DHEA-Sulfat (DS) bei unverändertem Cortisol charakterisiert. Für DHEA sind eigenständige Wirkungen sowie solche als Vorläufer von Sexualhormonen im ZNS und in der Peripherie etabliert. Günstige epidemiologische Daten höherer DS-Spiegel bei Männern sowie positive klinische Berichte über eine DHEA-Substitution bei beiden Geschlechtern lassen seinen Einsatz zur Prävention und Beeinflussung von Alterungserkrankungen als sinnvoll erscheinen. Bisher wurden tägliche orale Einheitsdosierungen von DHEA mit 50–100 mg bei Männern und 25–50 mg bei Frauen eingesetzt, die meist supraphysiologische Blutspiegel bewirken. Patienten und Methode: Wir berichten über Dosisfindungsstudien über 6–12 Wochen bei jeweils 100 Männern und Frauen zwischen 46 und 74 Jahren mit Adrenopause, um die individuelle DHEA-Dosis zu ermitteln, welche Tageshöchstwerte von DS, gemessen 3–5 h nach morgendlicher DHEA-Gabe, zwischen 2,0 und 2,8 μg/ml bei Frauen und 4 und 5 μg/ml bei Männern erreichen lässt. Dies entspricht den Blutspiegeln gesunder Erwachsener im dritten Lebensdezennium. Ergebnisse: Für diese Vorgaben waren 5, 10, 15, 25 oder 50 mg DHEA bei jeweils 18, 26, 34, 19 und 3&percnt; der Frauen sowie 15, 25, 50, 75 oder 100 mg DHEA bei 5, 13, 51, 17 und 14&percnt; der Männer erforderlich. Hierdurch veränderten sich die Blutspiegel (Mittelwert ± SD) signifikant (p < 0,01): a) bei den Frauen bei DS von 0,7 ± 0,4 auf 2,4 ± 0,5 μg/ml, bei Testosteron von 0,4 ± 0,4 auf 0,9 ± 0,5 pg/ml und bei Androstendion von 0,8 ± 0,4 auf 1,4 ± 0,4 ng/ml sowie b) bei den Männern bei DS von 1,4 ± 0,5 auf 4,1 ± 0,7 μg/ml, bei freiem Testosteron von 10,9 ± 4,1 auf 14,7 ± 4,5 pg/ml, bei Androstendion von 1,2 ± 0,5 auf 2,0 ± 0,6 ng/ml, bei Östron von 28 ± 14 auf 41 ± 19 pg/ml und bei Östradiol von 16 ± 8 auf 31 ± 15 pg/ml. Bei inadäquater Dosis wurden Nebenwirkungen wie Müdigkeit, Ruhelosigkeit, Migräne, Akne/Hirsutismus, Effluvium und Odor bei jeweils 34, 17, 9, 31, 21 und 11&percnt; der Frauen festgestellt, die sich nach Dosisadjustierung auf 8, 2, 4, 6, 7 und 0&percnt; der Frauen signifikant reduzierten (p < 0,05; p < 0,2 bei Migräne). Schlussfolgerung: Wir empfehlen, eine DHEA-Substitution der Adrenopause mit einer individuell adjustierten niedrigen Dosis von 5–50 mg bei Frauen und 15–100 mg bei Männern in den physiologischen Bereich junger Erwachsener hinein durchzuführen. Dies hat sich nach unseren vorläufigen Daten aus den letzten 5 Jahren sowohl klinisch als auch bezüglich der Patienten-Compliance gut bewährt. Eine überphysiologische Pharmakotherapie mit DHEA erscheint dagegen bei speziellen Erkrankungen wie Kollagenosen indiziert.

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DHEA in appropriate replacement doses appears to have remedial effects with respect to its ability to induce an anabolic growth factor, increase muscle strength and lean body mass, activate immune function, and enhance quality of life in aging men and women, with no significant adverse effects. Further studies are needed to confirm and extend our current results, particularly the gender differences.
Article
In 1986 we reported that high levels of plasma dehydroepiandrosterone sulfate (DHEAS) reduced the risk of fatal cardiovascular disease (CVD) in 242 men and increased the risk in 289 women from the Rancho Bernardo cohort who were followed up for 12 years. We report here an update on the epidemiology of DHEAS and CVD based on a 19-year follow-up of 1,029 men and 942 women aged 30-88 years from the same cohort. In cross-sectional analyses, DHEAS levels decreased with age in both sexes and were lower in women than men. Men who were overweight were more likely to have low DHEAS levels; women who had hypercholesterolemia or hypertension or were nonusers of estrogen therapy had higher DHEAS levels. Alcohol intake and cigarette smoking were associated with higher DHEAS levels in both sexes. All differences were no longer statistically significant after adjusting for alcohol intake. All participants were followed for vital status. After 19 years there were 254 CVD deaths in men and 199 CVD deaths in women. DHEAS was not associated with CVD or ischemic heart disease (IHD) deaths in age-adjusted analyses where the comparison group was individuals without CVD or IHD death. In contrast, when the comparison group was survivors, multiply adjusted models showed a statistically significant, modestly reduced risk of fatal CVD (RR = 0.85) in men and a nonsignificant increased risk of fatal CVD (RR = 1.11) in women.
Article
Dehydroepiandrosterone sulfate (DHEAS), the major circulating adrenal hormone, has been suggested to have a role in many aging related diseases and perhaps in aging itself. Its precise biologic effects are still unknown, and data on healthy people over 90 yr of age are not available. We measured serum DHEAS levels in 75 healthy subjects aged 90-106 yr of both sexes and searched for correlations between DHEAS and several endocrine-metabolic parameters (serum thyroid hormones, GH-insulin-like-growth factor I (GH-IGF-I) axis, serum lipid profile, anthropometric indices of body composition) of the same subjects. The resulting data, normalized by logarithmic transformation (geometric mean at age 90-99, 551 ng/mL in men, 364 ng/mL in women; at age > 100 yr, 404 ng/mL in men, 521 ng/mL in women) resulted five-fold lower than DHEAS levels measured in a young control group (geometric mean at < 40 yr of age, 3110 ng/mL in men, 2824 ng/mL in women). In women over ninety yr, DHEAS was positively correlated with serum free triodothyronine (FT3) levels (r = 0.34, P = 0.05) and inversely with triglycerides (r = -0.45, P = 0.05). In men over 90 yr, DHEAS had positive correlations with body mass index (r = 0.41, P < 0.03) and waist-to-hip ratio (r = 0.47, P < 0.01) taken as indices of body's energy reserves (fat). To determine whether low serum DHEAS levels predict poor functional status in the very old, the Activity Daily Living (ADL) test was administered in all over-ninety subjects. Men with the highest functioning levels had the highest DHEAS levels (P < 0.03). Our data suggest that DHEAS levels may influence and/or be influenced by several endocrine and metabolic features of oldest-old people, depending on the sexual steroid milieu. DHEAS seems also to have a strong interrelation with functional activities. A favorable role for DHEAS in successful aging is proposed.
Article
To evaluate the physical ability and psychocognitive status of a population more than 90 years of age with regard to sociodemographic, behavioral, and biomedical variables known to affect functional status in old age. A survey design was used. Emilia Romagna, Northern Italy. Eighty-four healthy community-dwelling subjects aged 90 to 106 years. Sociodemographic variables, health behavior, anthropometric indices, and serum DHEAS levels were recorded. Functional assessment was performed by instruments currently used in geriatric practice: the Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS), and Activities of Daily Living (ADL) scale. A stepwise multiple regression analysis was performed. GDS scores correlated directly with MMSE scores and inversely with ADL severity scores. Poor education, institutionalization, sensory impairment, muscular mass loss, and lower DHEAS levels were the variables with the highest correlation to functional impairment. Smoking, alcohol consumption, and marital status were relatively unimportant. An inverse association was found between DHEAS levels and dependency scores of single ADLs (continence, mobility). Impaired cognitive and physical ability with no increase in depression prevalence was found in a sample of subjects more than 90 years of age free of major age-related disease. Muscular mass and DHEAS levels seem to play a role in maintaining physical independence. In turn, physical independence, as well as social and cultural factors, strongly affect the compliance of long-lived subjects with psychocognitive tests currently used in the clinical evaluation of younger old people, suggesting that these instruments are not reliable for screening for cognitive impairment and depression in the oldest old subjects.
Article
To determine the effect of administering 6 months of oral postmenopausal DHEA therapy on serum DHEA, DHEAS, and T levels and on physiologic endpoints including lipoproteins and insulin-like growth factor-I (IGF-I). Randomized, double-blind, parallel trial. Academic referral practice. Thirteen normal-weight or overweight, healthy, nonsmoking, postmenopausal women. Administration of oral micronized DHEA (25 mg/d). Monthly fasting 23 hours postdose levels of serum DHEA, DHEAS, T, lipoproteins, IGF-I, IGF binding protein-3 (IGFBP-3), and liver function tests. Morphometric indices by dual-energy x-ray absorptiometry scan (percent body fat; lean body mass), immune indices, and insulin sensitivity. Levels of DHEA, DHEAS, and T all rose into premenopausal ranges, but after 6 months, levels of DHEA and T did not differ from baseline or placebo. At 3 months, the ratio of IGF-I to IGFBP-3 rose by 36.1% +/- 12.7%, but it fell to placebo values by 6 months. High-density lipoprotein and apolipoprotein A1 levels declined. Patients appeared to tolerate 6 months of DHEA therapy well. Given the small study size, no statistically significant differences in morphometric indices, immune indices, or insulin-sensitizing properties were observed, but significant attenuation of bioavailability occurred. Supplementation with DHEA increased IGF-I/IGFBP-3 levels at 3 months and decreased high-density lipoprotein and apolipoprotein A1 levels at 6 months.
Article
The menopause transition is associated with several physiological changes that may impact women's health outcome. Among the changes associated with the loss of ovarian function is an increased risk of metabolic and cardiovascular disease. The present review focuses on changes in energy expenditure, body composition and body fat distribution during the postmenopausal transition. Previous work indicates that the most important component of total daily expenditure, resting metabolic rate, may be reduced by the menopause, independently of the effects of the normal aging process. This effect is mainly attributable to a decrease in fat-free mass. The energy expenditure associated with physical activity is the most variable component of total daily energy expenditure. However, small changes in this component may have a substantial impact on body composition. Longitudinal data from our laboratory indicate that the menopause transition also leads to significant decreases in physical activity energy expenditure. The changes in body composition that accompany the menopause transition have been studied by several groups and, although some studies suggested increases in body mass index or total body fat mass with the menopause, currently available cross-sectional data preclude a firm conclusion. Nevertheless, results from our longitudinal study showed significant increases in fat mass with the menopause. The accumulation of abdominal fat, which may be a better correlate of the comorbidities associated with obesity, has also been shown to be accelerated by the menopause transition. In this regard, it has been shown that treatment with hormone replacement therapy prevents the increase in the rate of abdominal adipose tissue accumulation that was noted with the menopause. Thus, it appears that the loss of ovarian function induces a reduction in resting metabolic rate, physical activity energy expenditure, fat-free mass, and an increase in fat mass and abdominal adipose tissue accumulation. These modifications probably contribute to the increased risk of cardiovascular disease of postmenopausal women.
Article
Dehydroepiandrosterone (DHEA) is abundantly found in brain tissues of several species, including human. However, the cellular origin and pathway by which DHEA is synthesized in brain are not yet known. We have, therefore, initiated pilot experiments to explore gene expression of cytochrome P450 17alpha-hydroxylase (P450c17), the key steroidogenic enzyme for androgen synthesis, and evaluate DHEA production by highly purified astrocytes, oligodendrocytes, and neurons. Using RT-PCR, we have demonstrated for the first time that astrocytes and neurons in the cerebral cortex of neonatal rat brain express P450c17. The presence of P450c17 in astrocytes and neurons was supported by the ability of these cells to metabolize pregnenolone to DHEA in a dose-dependent manner as determined by RIA. These data were further confirmed by production of androstenedione by astrocytes using progesterone as a substrate. However, cortical neurons express a low transcript of P450c17 messenger RNA and produce low levels of DHEA and androstenedione compared with astrocytes. Oligodendrocytes neither express the messenger RNA nor produce DHEA. The production of DHEA by astrocytes is not limited to cerebral cortex, as hypothalamic astrocytes produce DHEA at a level 3 times higher than that produced by cortical astrocytes. Cortical and hypothalamic astrocytes also have the capacity to metabolize DHEA to testosterone and estradiol in a dose-dependent manner. However, hypothalamic astrocytes were 3 times more active than cortical astrocytes in the metabolism of DHEA to estradiol. In conclusion, our data presented evidence that astrocytes and neurons express P450c17 and synthesize DHEA from pregnenolone. Astrocytes also have the capacity to metabolize DHEA into sex steroid hormones. These data suggest that as in gonads and adrenal, DHEA is biosynthesized in the brain by a P450c17-dependent mechanism.
Article
To determine if dehydroepiandrosterone (DHEA) is beneficial in severe systemic lupus erythematosus (SLE). A double-blinded, placebo-controlled, randomized clinical trial in 21 patients with severe and active SLE, manifestated primarily by nephritis, serositis or hematological abnormalities. In addition to conventional treatment with corticosteroids +/- immunosuppressives, patients received DHEA 200 mg/d vs. placebo for 6 months, followed by a 6-month open label period. The primary outcome was a prospectively defined responder analysis, based on a quantitatively specified improvement of the principal severe lupus manifestation at 6 months. Nineteen patients were available for evaluation at 6 months. Baseline imbalance between the groups was noted, with the DHEA group having greater disease activity at baseline (P<0.05 by physician's global assessment). Eleven patients were responders: 7/9 patients on DHEA vs. 4/10 patients on placebo (P<0.10). Of the secondary outcomes, mean improvement in SLE disease activity index (SLE-DAI) score was greater in the DHEA group (-10.3+/-3.1 vs. -3.9+/-1.4. P<0.07). Bone mineral density at the lumbo-sacral spine showed significant reduction in the placebo group, but was maintained in the DHEA group. DHEA therapy, when added to conventional treatment for severe SLE, may at most have a small added benefit with respect to lupus outcomes, but baseline imbalances in the study population limit the generalizability of the results. DHEA appears to have a protective effect with respect to corticosteroid-induced osteopenia in such patients.
Article
Serum testosterone levels decline slowly with normal ageing in men and, although all men are not destined to become hypogonadal as they age, the prevalence of androgen deficiency in the older male is not insignificant. Over the past several decades, there has been an increasing interest in evaluating whether testosterone therapy (male HRT) might be beneficial for certain older men in preventing or reversing some aspects of ageing. The major androgen target organs of interest with regard to beneficial effects of male HRT include bone, muscle, adipose tissue, the cardiovascular system and the central nervous system (libido and aspects of mood). At the same time, potential adverse effects of male HRT on target organs such as the prostate continue to be evaluated. It is the purpose of this review to summarize the information to date with regard to testosterone replacement therapy in the older man and to discuss areas where more research and clinical information need to be forthcoming. Hormonal replacement therapy (HRT) for post-menopausal women has been studied and discussed for many years. The idea of male HRT, however, is a relatively recent development, with increasing interest in this area occurring only over the past two decades. Reasons for this nascent enthusiasm include burgeoning evidence that testosterone levels decline with normal male ageing (and with age-associated diseases) and an interest in preventing age-related dysfunction and prolonging quality life among an ever increasing population of older adults. The decline in testosterone with age often parallels unfavourable changes in organs upon which androgens act and the goal of male HRT would be to prevent, stabilize or even reverse some of these detrimental target-organ changes.
Article
Overt hypothyroidism has been found to be associated with cardiovascular disease. Whether subclinical hypothyroidism and thyroid autoimmunity are also risk factors for cardiovascular disease is controversial. To investigate whether subclinical hypothyroidism and thyroid autoimmunity are associated with aortic atherosclerosis and myocardial infarction in postmenopausal women. Population-based cross-sectional study. A district of Rotterdam, The Netherlands. Random sample of 1149 women (mean age +/- SD, 69.0 +/- 7.5 years) participating in the Rotterdam Study. Data on thyroid status, aortic atherosclerosis, and history of myocardial infarction were obtained at baseline. Subclinical hypothyroidism was defined as an elevated thyroid-stimulating hormone level (>4.0 mU/L) and a normal serum free thyroxine level (11 to 25 pmol/L [0.9 to 1.9 ng/dL]). In tests for antibodies to thyroid peroxidase, a serum level greater than 10 IU/mL was considered a positive result. Subclinical hypothyroidism was present in 10.8% of participants and was associated with a greater age-adjusted prevalence of aortic atherosclerosis (odds ratio, 1.7 [95% CI, 1.1 to 2.6]) and myocardial infarction (odds ratio, 2.3 [CI, 1.3 to 4.0]). Additional adjustment for body mass index, total and high-density lipoprotein cholesterol level, blood pressure, and smoking status, as well as exclusion of women who took beta-blockers, did not affect these estimates. Associations were slightly stronger in women who had subclinical hypothyroidism and antibodies to thyroid peroxidase (odds ratio for aortic atherosclerosis, 1.9 [CI, 1.1 to 3.6]; odds ratio for myocardial infarction, 3.1 [CI, 1.5 to 6.3]). No association was found between thyroid autoimmunity itself and cardiovascular disease. The population attributable risk percentage for subclinical hypothyroidism associated with myocardial infarction was within the range of that for known major risk factors for cardiovascular disease. Subclinical hypothyroidism is a strong indicator of risk for atherosclerosis and myocardial infarction in elderly women.
Article
In recent years, adrenal function and aging has been the subject of intense interest. This cross-sectional study examines age and gender differences in plasma levels of cortisol, dehydroepiandrosterone (DHEA), DHEA-sulfate (DHEAS), and the molar ratio of cortisol/DHEAS in 50-89-yr-old community-dwelling adults. Plasma hormone levels were assayed in samples obtained between 0730 h and 1100 h from 857 men and 735 nonestrogen-using, postmenopausal women. Hormone levels were stratified by 10-yr age groups and compared by two-factor (gender and age) ANOVA. Overall, age and BMI-adjusted DHEA and DHEAS [collectively DHEA(S)] levels were 40% lower and cortisol levels 10% higher in women than men, resulting in a 1.7-fold higher cortisol/DHEAS molar ratio for women (both, P < 0.001). Cortisol levels increased progressively (20% overall) with age in both men and women (both, P < 0.01). Although DHEA(S) levels declined 60% and the cortisol/DHEAS ratio increased 3-fold across the 40-yr age range for both men and women (all P < 0.001), the pattern of the change differed (all P < 0.01 for interaction). For men, DHEA(S) fell in a curvilinear fashion, with the degree of change decreasing with each decade. In contrast, DHEA(S) levels in women fell 40% from the 50s to 60s, were unvarying from 60-80 yr of age, and declined an additional 18% in the 80s. The cortisol/DHEAS ratio increased in a linear fashion for men, but was flat during the 60-80-yr age range for women. Despite these differences in the effect of aging, levels of DHEA(S) remained lower and cortisol and the cortisol/DHEAS ratio higher, in women than men throughout the 50-89-yr age range. These results were independent of adiposity, smoking, and alcohol consumption. In summary, among older, healthy adults DHEA(S) levels are lower and cortisol levels higher in women than men. The age-related decline in adrenal androgens persists into advanced age for both men and women, but exhibits a sexually dimorphic pattern. In contrast, cortisol levels in men and women show a parallel, linear increase with aging. These findings may have important implications for a host of age-related processes that exhibit gender differences, including brain function, bone metabolism, and cardiovascular disease.
Article
Dehydroepiandrosterone (DHEA) is a precursor for both oestrogens and androgens. Its marked decline with ageing may influence age-related changes in tissues influenced by sex hormones. The aim of this study was to determine the effects of DHEA replacement on bone mineral density (BMD) and body composition in elderly women and men with low serum DHEA sulphate (DHEAS) levels. Prospective 6 month trial of oral DHEA replacement, 50 mg/day. Experimental subjects were 10 women and eight men, aged 73 +/- 1 years. Control subjects were 10 women and eight men, aged 74 +/- 1 years. BMD, body composition, serum markers of bone turnover, serum lipids and lipoproteins, oral glucose tolerance, serum IGF-I, total serum oestrogens and testosterone. BMD of the total body and lumbar spine increased (mean +/- SEM; 1.6 +/- 0.6% and 2.5 +/- 0.8%, respectively; both P < or = 0.05), fat mass decreased (- 1.3 +/- 0.4 kg; P < 0.01) and fat-free mass increased (0.9 +/- 0.4 kg; P < or = 0. 05) in response to DHEA replacement. DHEA replacement also resulted in increases in serum IGF-I (from 108 +/- 8 to 143 +/- 7 microg/l; P < 0.01) and total serum testosterone concentrations (from 10.7 +/- 1.2 to 15.6 +/- 1.8 nmol/l in the men and from 2.1 +/- 0.2 to 4.5 +/- 0.4 nmol/l in the women; both P < or = 0.05). The results provide preliminary evidence that DHEA replacement in those elderly women and men who have very low serum DHEAS levels can partially reverse age-related changes in fat mass, fat-free mass, and BMD, and raise the possibility that increases in IGF-I and/or testosterone play a role in mediating these effects of DHEA.
Article
In order to gain further insight into the potential immunological benefits of oral administration of DHEA we have examined its effects on the constitutive and PHA-inducible expression by human spleen cell suspensions in vitro of IL-6 and IL-2. This was studied at both the mRNA and protein levels. The quantification of specific mRNA was undertaken using commercially available quantitative polymerase chain reaction kits. These studies, which were performed on suspensions from six individual spleens, revealed that 10(-5) M DHEA did not impair the expression of IL-6 at either the mRNA or protein level, but may have slightly enhanced the latter. In contrast, IL-2 mRNA levels were increased on most occasions, whilst IL-2 secretion was decreased, albeit slightly. Additional studies revealed that cyclosporin (approx. 10(-5) M) and dexamethasone (10(-7) M) readily inhibited these responses and the production of other cytokines, including interferon-gamma and tumour necrosis factor-alpha. These preliminary studies suggest that high doses of DHEA do not readily inhibit the production of IL-6, and indeed other cytokines, by PHA-stimulated secondary human lymphoid tissue suspensions in vitro. They may also partially explain the meagre immunomodulatory effects noted in some DHEA replacement studies in humans.
Article
Addison's disease is a rare endocrine disorder which can be life-threatening. It can also interfere with the normal development of adrenarche, resulting in the absence of pubic and axillary hair growth. We report a case of satisfactory restoration of adrenarche through DHEA administered in conjunction with the standard glucocortisone and fluorocortisone replacement.
Article
Dehydroepiandrosterone sulfate levels have been inversely related with cardiovascular mortality in men, but findings have been inconsistent, and there are few data in women. We examined the relationship between baseline circulating dehydroepiandrosterone sulfate levels and subsequent all-cause and cardiovascular mortality in 963 men and 1171 women, 65-76 yr old, surveyed in 1991-1995, and followed up until August 2000 (when 296 deaths had occurred). All-cause and cardiovascular disease mortality rates were highest in the lowest dehydroepiandrosterone sulfate quartile in men; and thereafter, rates did not differ significantly in the upper three quartiles. This pattern remained after excluding those with previous history of cardiovascular disease and, in multivariate analyses, was independent of age, cigarette smoking habit, systolic blood pressure, body mass index, blood cholesterol, and steroid use. There was no significant association of dehydroepiandrosterone sulfate and mortality in women. The multivariate adjusted relative risks for all-cause mortality by sex-specific increasing quartile of dehydroepiandrosterone sulfate were 1.00, 0.66 (95% confidence interval, 0.44-1.01), 0.70 (0.46-1.07), 0.73 (0.48-1.10), respectively, for men and 1.00, 0.71 (95% confidence interval, 0.41-1.24), 0.97 (0.58-1.62), and 1.14 (0.69-1.88), respectively, for women. In older men and women, there is no consistent relationship between dehydroepiandrosterone sulfate and all-cause or cardiovascular mortality. The highest mortality rates were observed in the lowest quartile in men, but the highest rates were in the highest quartile in women.