A 4-hour Profile of 17-hydroxyprogesterone in Salt-wasting Congenital Adrenal Hyperplasia: Is the Serial Monitoring Strategy Worth the Effort?

Objective: Since there exists no gold standard laboratory variable for adjustment of treatment in congenital adrenal hyperplasia (CAH), we aimed to assess the use of a 4-hour profile of serum 17-OHP to determine the most appropriate time and level of 17-OHP in predicting the metabolic control and evaluate the role of sex hormone-binding globulin (SHBG) in hyperandrogenemia.
Methods: This study included 16 children (9 girls,7 boys; median age 7 years) with salt-wasting CAH. Measurements for 17-OHP and cortisol were made from samples obtained before and 1,2,4 hours after the morning dose of hydrocortisone. Patients were designated to have poor metabolic control when androstenedione levels according to age and sex-specific reference intervals were high and annual height SDS changes were ⩾0.5.
Results: Premedication 17-OHP levels were strongly correlated with 17-OHP levels 1, 2, 4 hours after the morning dose (rs=0.929, p<0.01; rs=0.943, p<0.01; rs=0.835, p<0.01, respectively). 17-OHP profiles (0,1,2,4 hours) of poor (n=6) and good (n=10) metabolically controlled cases were similar. Among the patients with poor metabolic control, two cases had 17-OHP levels <2 ng/mL at all times. Remaining patients with poor metabolic control had 17-OHP levels above 104 ng/mL, 82 ng/mL, 14 ng/mL, and 4 ng/mL, for baseline and 1, 2, and 4 hours, respectively. Differences between the poor and well-controlled group were androstenedione levels with respect to upper limit of normal [1.8(1.5) and 0.5(1.5) ng/mL, respectively p=0.03], annual change in height SDS [0.7(0.2) and -0.03(0.8) SDS, respectively, p=0.001], and daily hydrocortisone doses [7 (6) and 16 (8) mg/m2/day, respectively, p=0.02]. Androstenedione and SHBG levels were negatively correlated in the pubertal children (rs=-0.7, p=0.04).
Conclusion: We conclude that (i)a 4-hour 17-OHP profile is not useful in predicting hyperandrogenemia, (ii)suppressed levels of 17-OHP do not always indicate overtreatment, (iii)reference intervals of 17-OHP for different time periods might be of importance, (iv) low hydrocortisone doses should be avoided, (v)SHBG could be used in pubertal children as an indicator of hyperandrogenemia.

Eligibility, Utilization, and Effectiveness of 17-Alpha Hydroxyprogesterone Caproate (17OHPC) in a Statewide Population-Based Cohort of Medicaid Enrollees

Objectives: The primary objective was to estimate the initiation and adherence rates of 17 α-hydroxyprogesterone caproate (17OHPC) among eligible mothers in a statewide population-based cohort of Medicaid enrollees. The secondary objectives were to (1) determine the association of maternal sociodemographic and clinical characteristics with 17OHPC utilization and (2) assess the real-world effectiveness of 17OHPC on recurrent preterm birth prevention and admission to neonatal intensive care unit (NICU).
Study design: This is a retrospective cohort study using a linked, longitudinal administrative dataset of birth certificates and medical assistance claims. Medicaid-enrolled mothers in Pennsylvania were included in this study if they had at least one singleton live birth from 2014 to 2016 following at least one spontaneous preterm birth. Maternal Medicaid claims were used to ascertain the use of 17OHPC from various manufacturers, including compounded formulations. Propensity score matching was used to create a covariate balance between 17OHPC treatment and comparison groups.
Results: We identified 4,781 Medicaid-covered 17OHPC-eligible pregnancies from 2014 to 2016 in Pennsylvania, 3.4% of all Medicaid-covered singleton live births. The population-based initiation rate was 28.5% among eligible pregnancies. Among initiators, 50% received ≥16 doses as recommended, while 10% received a single dose only. The severity of previous spontaneous preterm birth was the strongest predictor for the initiation and adherence of 17OHPC. In the matched treatment (n = 1,210) and comparison groups (n = 1,210), we found no evidence of 17OHPC effectiveness. The risks of recurrent preterm birth (relative risk [RR] 1.10, 95% confidence interval [CI] 0.97-1.24) and births admitted to NICU (RR 1.00, 95% CI 0.84-1.18) were similar in treated and comparison mothers.
Conclusion: The 17OHPC-eligible population represented 3.4% of singleton live births. Less than one-third of eligible mothers initiated treatment. Among initiators, 50% were treatment adherent. We found no difference in the risk of recurrent preterm birth or admission to NICU between treatment and comparison groups.

A Possible Mechanism of Action of 17α-Hydroxyprogesterone Caproate: Enhanced IL-10 Production

Objective: The rate of recurrent spontaneous preterm birth (PTB) was reduced by 33% in the Maternal-Fetal Medicine Unit (MFMU) Network trial of 17α-hydroxyprogesterone caproate (17-OHPC), but the mechanism of action, 17 years later, remains elusive. The robustness of the interleukin-10 (IL-10) response to lipopolysaccharide (LPS) stimulation of leukocytes in pregnant women with a prior PTB correlates with gestational age at delivery. This study sought to determine if there is a relationship between the concentration of 17-OHPC and response to LPS stimulation.
Study design: We performed a secondary analysis of data from the Omega-3 MFMU trial which evaluated the effectiveness of omega-3 fatty acid supplementation in reducing recurrent PTB. We utilized previously characterized data from a subanalyses of the Omega-3 trial of IL-10 and tumor necrosis factor alpha (TNF-α) levels from peripheral blood mononuclear cells stimulated with LPS. Blood was obtained from enrolled women at 16 to 22 weeks’ gestation (baseline) and 25 to 28 weeks’ gestation (posttreatment). All women received 17-OHPC and plasma 17-OHPC concentrations were measured at 25 to 28 weeks’ gestation. We analyzed these data to determine if there was a relationship between 17-OHPC concentration and cytokine production. We then performed an in vitro study to determine if 17-OHPC could directly alter cytokine production by THP-1-derived macrophages.
Results: In the clinical samples, we found that 17-OHPC plasma concentrations were correlated with the quantity of the LPS-stimulated production of IL-10. TNF-α production after LPS stimulation was unrelated to 17-OHPC concentration. In the in vitro study, we demonstrate a 17-OHPC concentration dependent increase in IL-10 production.
Conclusion: In women receiving 17-OHPC for PTB prevention, we demonstrate a relationship between plasma 17-OHPC and LPS-stimulated IL-10 production by circulating leukocytes. We also demonstrate that, in vitro, 17-OHPC treatment affects IL-10 production by LPS-stimulated macrophages. Collectively, these findings support an immunomodulatory mechanism of action of 17-OHPC in the prevention of recurrent PTB.

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In utero exposure to 17α-hydroxyprogesterone caproate and risk of cancer in offspring

Background: 17α-hydroxyprogesterone caproate (17-OHPC) is a synthetic progestogen initially approved in the 1950s to treat gynecological and obstetrical conditions. Despite repeated concerns of safety and short-term efficacy regarding the use of 17-OHPC for the prevention of preterm birth in pregnant women, little is known about long-term effects of 17-OHPC on health of offspring.
Objective: To examine the association between in utero exposure to 17-OHPC and risk of cancer in offspring.
Study design: The Child Health and Development Studies is a population-based cohort of more than 18,000 mother-child dyads receiving prenatal care in the Kaiser Foundation Health Plan (Oakland, California) between 1959 and 1966. Clinical information was abstracted from mothers’ medical records beginning six months prior to pregnancy through delivery. We identified the number and timing of 17-OHPC injections during pregnancy. Incident cancers diagnosed in offspring were ascertained through 2019 by linkage to the California Cancer Registry. We used Cox proportional hazards models to estimate adjusted hazard ratios (aHR) and their 95% confidence intervals, with follow-up time accrued from date of birth through date of cancer diagnosis, death, or last contact.
Results: 1,008 offspring were diagnosed with cancer over 730,817 person-years of follow-up. About 1.0% of offspring (n=234) were exposed in utero to 17-OHPC. Exposure in the first trimester was associated with increased risk of any cancer (aHR 2.57, 95% CI 1.59, 4.15), and risk increased with number of injections (1-2 injections: aHR 1.80, 95% CI 1.12,2.90; ≥3 injections: aHR 3.07, 95% CI 1.34, 7.05). Exposure in the second or third trimester conferred an additional risk for male (aHR 2.59, 95% CI 1.07, 6.28) but not female (aHR 0.30, 0.04, 1.11) offspring. Risk of colorectal (aHR 5.51, 95% CI 1.73, 17.59), prostate (aHR 5.10, 95% CI 1.24, 21.00), and pediatric brain (aHR 34.72, 95% CI 7.29, 164.33) cancer was higher in offspring first exposed to 17-OHPC in the first trimester compared to offspring not exposed.

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