Secondary adrenocortical insufficiency: avoiding potentially fatal pitfalls in diagnosis and treatment.
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Adrenal Cortex Diseases↗
Biomedical subjects
R V Jackson
Publications and source records attributed to R V Jackson.
Diurnal effects of fluoxetine and naloxone on the human hypothalamic-pituitary-adrenal axis.
1. Central serotonergic pathways are hypothesized to be involved in the stimulation of hypothalamic adrenocorticotropic hormone (ACTH) secretagogue release by both circadian- and stress-induced mechanisms. We aimed to investigate this hypothesis by measuring the effect of the highly specific serotonin re-uptake inhibitor fluoxetine (FX) on ACTH and cortisol release in the morning and in the afternoon in humans, both by itself and in combination with the opioid antagonist naloxone (Nal). Naloxone causes ACTH release in humans by removing an endogenous inhibitory opioid tone on central noradrenergic pathways stimulatory to hypothalamic corticotropin-releasing hormone (CRH) secretion. Serotonergic agents may act directly or indirectly through these central noradrenergic pathways and, if so, would be expected to be additive to or synergistic with Nal in causing ACTH and cortisol release. 2. Oral FX (40 mg) was given at approximately 07.00 or 11.00 h, either alone or with intravenous Nal 3 h later, to normal human volunteers. Plasma ACTH and cortisol levels were measured for 5 h after FX dosing. 3. Fluoxetine produced a small but non-significant increase in Nal-stimulated ACTH and cortisol release in both morning and afternoon studies. Naloxone alone did not cause different ACTH and cortisol responses in the morning and afternoon. 4. These results suggest that serotonergic pathways are not major regulators of the hypothalamic-pituitary-adrenal axis in humans or that FX has counteracting acute inhibitory effects on the axis, such as inhibition of hypothalamic arginine vasopressin secretion, which has been demonstrated in chronic animal studies.
Administration, Oral↗
Aspirin inhibits vasopressin-induced hypothalamic-pituitary-adrenal activity in normal humans.
PGs influence ACTH secretion. However, their specific role in modulating the activity of the human hypothalamic-pituitary-adrenal (HPA) axis remains unclear. Acetylsalicylic acid (aspirin) inhibits the synthesis of PGs from arachidonic acid by blocking the cyclooxygenase pathway. In this study we administered a single, clinically relevant dose of aspirin before HPA axis stimulation by a bolus dose of iv arginine vasopressin (AVP) to seven normal males using a randomized, placebo-controlled, single blinded design. Aspirin significantly reduced the cortisol response to AVP [mean peak increase from basal, 221.1 +/- 20.1 vs. 165.4 +/- 22.5 nmol/L (P = 0.0456); mean integrated response, 11,199.3 +/- 1,560.0 vs. 6,162.3 +/- 1,398.6 nmol.min/L (P = 0.0116) for placebo aspirin/AVP and aspirin/ AVP, respectively]. The ACTH response was reduced, but did not reach statistical significance [mean peak increase from basal, 7.5 +/- 2.2 vs. 4.3 +/- 0.3 pmol/L (P = 0.0563); mean integrated response, 142.6 +/- 36.0 vs. 96.2 +/- 8.7 pmol.min/L (P = 0.12) for placebo aspirin/ AVP and aspirin/AVP, respectively]. PGs may influence ACTH secretion by being stimulatory or inhibitory to the HPA axis at different levels, such as hypothalamic or pituitary. Which effect predominates in vivo during dynamic activation of the axis may depend on the level at which the secretory stimulus acts. We showed that when normal male volunteers were treated with the PG synthesis inhibitor, aspirin, they had a blunted HPA axis response to the pituitary corticotroph stimulator, AVP.
Adolescent↗
Short synacthen test versus insulin stress test for the assessment of the hypothalamo-pituitary axis: controversy revisited again.
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Adrenal Insufficiency↗
Plasma corticotropin and cortisol responses to ovine corticotropin-releasing hormone (CRH), arginine vasopressin (AVP), CRH plus AVP, and CRH plus metyrapone in patients with Cushing's disease.
The CRH test may sometimes be useful in the differential diagnosis of Cushing's syndrome, because most patients with pituitary ACTH-dependent Cushing's syndrome (Cushing's disease) respond to CRH, but those with other causes of Cushing's syndrome usually do not. However, about 10% of Cushing's disease patients fail to respond to CRH. We wondered if we could eliminate these false negative results either by exploiting the potential additive or synergistic effects of another ACTH secretagogue or by reducing glucocorticoid inhibition of CRH's ACTH-releasing effect. We compared the effect on plasma ACTH and cortisol in 51 patients with Cushing's disease of administering ovine CRH (1 microgram/kg BW, i.v.) alone, arginine vasopressin (AVP; 10 U, i.m.) alone, the combination of CRH and AVP, and CRH after pretreatment with metyrapone (1 g, orally, every 4 h for three doses; CRH + MET). The rates of nonresponse (ACTH increment, < 35%; cortisol increment, < 20%) to AVP and CRH alone were 26% and 8%, respectively; all patients responded to CRH + AVP. The lack of response was not due to improper administration or rapid metabolism of the agonist, because plasma CRH and AVP concentrations were similar in responders and nonresponders. A synergistic ACTH response to CRH + AVP occurred in 65% of the patients. MET pretreatment increased basal plasma ACTH levels in most patients and induced the greatest mean peak ACTH response to CRH, but 8% of the patients did not respond to CRH + MET with an ACTH increment of 35% or more. Because all of the Cushing's disease patients tested in this study responded to the combination of CRH + AVP, whereas 8% failed to respond to CRH alone, we conclude that CRH + AVP administration may provide a more reliable test for the differential diagnosis of ACTH-dependent Cushing's syndrome than administration of CRH alone. Whether this improved sensitivity is accompanied by unaltered specificity for Cushing's disease must be tested in patients with chronic ectopic ACTH syndrome.
Adolescent↗
Corticosteroids.
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Administration, Inhalation↗
Naloxone-induced ACTH release: mechanism of action in humans.
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Adrenocorticotropic Hormone↗
A synergistic adrenocorticotropin response to naloxone and vasopressin in normal humans: evidence that naloxone stimulates endogenous corticotropin-releasing hormone.
Naloxone stimulates pituitary-adrenal function by blocking an endogenous inhibitory opioidergic tone which modulates pituitary adrenocorticotropin (ACTH) release. In animals, this action of naloxone is mediated by increased corticotropin-releasing hormone (CRH) secretion, but such a mechanism is disputed in humans. CRH and arginine vasopressin (AVP) are known to have a synergistic effect on ACTH secretion in both humans and animals. In vitro, this synergism is independent of L-type voltage-dependent Ca2+ channel function. The aims of this study were therefore: (i) to determine if the combined administration of naloxone and AVP is synergistic regarding ACTH release; (ii) to assess the effect of nifedipine, which blocks L-type Ca2+ channels, on the ACTH response to combined naloxone/AVP stimulation. Seven healthy volunteers were studied using a placebo-controlled, single-blind protocol. Naloxone (125 micrograms/kg) and/or AVP (10 units) were given in all four possible combinations, and oral nifedipine (20 mg) was also given with naloxone and AVP as an additional test. The mean AUC and the mean peak change in ACTH levels following combined naloxone/AVP administration were both significantly greater than the arithmetic sum of the ACTH responses to naloxone and AVP given on separate occasions (AUC: 1,576.4 +/- 417.9 vs. 567.1 +/- 106.1 pmol.min.l-1, p < 0.002; peak change: 37.9 +/- 14.0 vs. 11.8 +/- 2.0 pmol/l, p < 0.007). Nifedipine reduced the ACTH response to combined naloxone/AVP stimulation by 43% (AUC: 1,576.4 +/- 417.9 vs. 897.0 +/- 186.2; p < 0.05), but it remained greater than the sum of the individual responses (897.0 +/- 186.2 vs. 576.1 +/- 106.1, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Adrenocorticotropin hyperresponse to the corticotropin-releasing hormone-mediated stimulus of naloxone in patients with myotonic dystrophy.
We previously showed that CRH-mediated stimuli, including exogenous CRH, cause ACTH hypersecretion in many myotonic dystrophy (DM) patients. We confirmed this by giving naloxone, a stimulator of endogenous CRH release, to a large number of DM patients and controls. DM patients, first degree relatives, and normal controls received i.v. naloxone at 1400 h, and blood was taken for ACTH (RIA) and cortisol (high pressure liquid chromatography) measurements from 15 min before to 120 min after naloxone treatment. DM patients had basal ACTH levels approximately twice those of controls, and their ACTH responses were 4 times those of controls. In contrast, DM basal cortisol levels were not significantly different from those of relatives and were slightly higher than those of normal subjects. Cortisol responses were similar in the three groups, probably due to attenuation at high levels of adrenocortical stimulation, although some patients with inappropriately low cortisol responses for their level of ACTH stimulation warrant further investigation. Nineteen of the 36 patients whose ACTH responses were greater than 3 SD above the normal mean were classed as hyperresponders. Seven patients, who were tested more than once, had reproducible responses relative to those of the normal subjects. We conclude that ACTH hypersecretion after CRH-mediated stimuli, including naloxone, is an inherent, but variable, feature of DM, caused by expression of the genetic mutation at the anterior pituitary. The mechanism is probably a defect in the intracellular pathway initiated by CRH-receptor interaction as a result of abnormal levels of a cAMP-dependent kinase, DMPK, the product of the gene undergoing mutation in DM.
Adolescent↗
The effect of desipramine on basal and naloxone-stimulated cortisol secretion in humans: interaction of two drugs acting on noradrenergic control of adrenocorticotropin secretion.
Desipramine (DMI), a tricyclic antidepressant and norepinephrine (NE) reuptake blocker, is reported to induce ACTH and cortisol release acutely in humans, probably by facilitating central NE neurotransmission. Tricyclic antidepressant therapy, including DMI, normalizes the ACTH and cortisol hypersecretion that often accompanies depression. The mechanism of hypothalamic-pituitary-adrenal (HPA) axis inhibition by DMI in humans is unknown. In rats, DMI reduces the activity of the locus ceruleus, a major source of NE innervation of the hypothalamic paraventricular nucleus, the site of CRH neurons. Naloxone induces ACTH and cortisol release in humans through a noradrenergic-mediated mechanism and a probable consequent stimulation of hypothalamic CRH release. To study the interaction of these drugs on NE neurotransmission and, hence, HPA axis activity in humans, we administered DMI alone and with naloxone in a randomized, double blind, placebo-controlled protocol in eight healthy male volunteers. DMI (75 mg, orally) was given 180 min before naloxone (125 micrograms/kg BW, i.v.). Plasma ACTH and cortisol were measured at frequent intervals from 60 min before to 120 min after naloxone treatment. Plasma cortisol levels were 77% higher 180 min after DMI compared to those after placebo treatment (287 +/- 17 vs. 162 +/- 14 nmol/L; P = 0.000005). DMI reduced the naloxone-induced rise in cortisol (P = 0.02), but there was no change in the integrated cortisol response. The increase in basal plasma ACTH levels after DMI treatment did not reach statistical significance. DMI significantly increased systolic blood pressure and heart rate consistent with an effect on the noradrenergic control of the cardiovascular system. In summary, DMI increased basal cortisol levels consistent with facilitation of NE neurotransmission and, hence, hypothalamic CRH release. However, DMI had no enhancing effect on naloxone-induced cortisol release. This contrasts with the synergy observed when non-antidepressant agents that increase NE neurotransmission are given with naloxone to humans. DMI increases glucocorticoid feedback sensitivity in the rat HPA axis after several weeks through up-regulation of central corticosteroid receptors. However, this slowly developing effect is unlikely to occur during these acute studies. The effect of DMI on naloxone-induced cortisol release is consistent with an inhibitory effect on central noradrenergic control of ACTH release, perhaps at the locus ceruleus. This is the first human study to suggest an inhibitory effect of DMI on central noradrenergic control of ACTH release.
Adrenocorticotropic Hormone↗
Cell-mediated immunity in combat veterans with post-traumatic stress disorder.
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Humans↗
Effect of flumazenil on basal and naloxone-stimulated ACTH and cortisol release in humans.
1. Endogenous benzodiazepine receptor ligands are thought to influence the human hypothalamic-pituitary-adrenal (HPA) axis and naloxone, a known stimulator of adrenocorticotropic hormone (ACTH) release, is thought to act via release of hypothalamic corticotropin-releasing hormone. 2. The aim of the present study was to assess the influence of endogenous benzodiazepine-receptor ligands by administering flumazenil (Ro15-1788), a benzodiazepine antagonist, and measuring ACTH and cortisol release, both basal and during naloxone-stimulation. 3. Nine normal volunteers in a placebo-controlled double-blind design were studied. Flumazenil (0.5 mg, i.v. bolus) was given 2 min before naloxone (125 micrograms/kg bodyweight, i.v. bolus) immunoreactive-adrenocorticotropic hormone (IR-ACTH) and cortisol levels were measured at frequent intervals from 60 min before to 120 min after naloxone injection. 4. Flumazenil had no effect on ACTH and cortisol release when given alone; flumazenil area under the ACTH/time curve (pmol/L.min) = -36.5 +/- 63.5 compared with placebo = -53.5 +/- 31.8, flumazenil area under the cortisol/time curve (nmol/L.min x 10(-3)) = - 2.4 +/- 2.4 compared with placebo -0.56 +/- 1.4. Flumazenil did not change the ACTH and cortisol release achieved with naloxone; naloxone area under the ACTH/time curve (pmol/L.min) = 327.8 +/- 61.7 compared with flumazenil/naloxone = 366.3 +/- 88.1, naloxone area under the cortisol/time curve (nmol/L. min x 10(-3) = 12.2 +/- 3.4 compared with naloxone/flumazenil = 10.5 +/- 2.1. 5. The authors conclude that flumazenil dose not modify basal or stimulated ACTH and cortisol release in healthy humans. This would suggest that endogenous benzodiazepine-like ligands and the benzodiazepine/gamma-aminobutyric acid receptor complex do not tonically influence the hypothalamic-pituitary-adrenal axis.
Adrenocorticotropic Hormone↗
Sleep hypoxia in myotonic dystrophy and its correlation with awake respiratory function.
BACKGROUND: Tiredness and daytime respiratory failure occur frequently in myotonic dystrophy. Sleep hypoxaemia was studied in 12 patients with myotonic dystrophy and correlations were sought with their daytime lung and respiratory muscle function. METHODS: All patients underwent overnight sleep studies, clinical assessment, measurement of flow-volume loops and carbon monoxide transfer factor, arterial blood gas analysis, and physiological assessment of both thoracic muscle function and upper airways obstruction. RESULTS: The mean nadir of oxygen saturation during sleep was 75% (95% confidence interval 69% to 81%). A mean of 3.4% of total sleep duration was spent at an oxygen saturation level below 85%. Five of the 12 patients had an apnoea index of > 5, the group mean apnoea/hypopnoea index being 15.8 events/sleep hour. The mean awake arterial oxygen tension (PaO2) was 10.7 kPa. There was a trend to hypercapnoea with a mean awake arterial carbon dioxide tension of 6.1 kPa; carbon dioxide retention worsened during sleep. Respiratory muscle dysfunction was mainly evident as a low maximum expiratory mouth pressure. Upper airway obstruction assessed by physiological criteria was found in four of the 12 patients. The proportion of total sleep duration with oxygen saturation levels below 85% was directly related to body mass index (weight/height2) and inversely related to the awake PaO2. Body mass index was inversely related to the overnight nadir of oxygen saturation. CONCLUSIONS: Patients with myotonic dystrophy are often hypoxic during sleep and the subgroup that are obese, or have symptoms of sleep apnoea, or both, are particularly at risk. Sleep studies should be considered in this subgroup of patients with myotonic dystrophy.
Adult↗
Paradoxical inhibition by aspirin of naloxone-induced adrenocorticotropin secretion in myotonic dystrophy.
The ACTH response to endogenous or exogenous CRH is increased in patients with myotonic dystrophy (DM), possibly because of abnormal function of cAMP-dependent protein kinases in this condition. Arachidonic acid (AA) metabolites are believed to interact with the cAMP-dependent second messenger system activated by CRH; therefore, drugs that interfere with AA metabolism may alter ACTH secretion in DM. In this study, seven DM patients were given naloxone, which stimulates endogenous CRH release, and aspirin, which inhibits the synthesis of prostaglandins from AA via the cyclooxygenase metabolic pathway. Pretreatment with aspirin reduced the mean integrated ACTH response to naloxone by 33% (P < 0.05). However, the corresponding 18% reduction in cortisol levels was not statistically significant (P > 0.10). These findings are in contrast to those of a previous study using an identical protocol, in which aspirin increased the ACTH response to naloxone in six normal volunteers. This difference between DM and control subjects is consistent with the hypothesis that the interaction between AA metabolites and the cAMP-dependent protein kinase-A second messenger system is abnormal in the corticotrophs of persons with DM.
Adrenocorticotropic Hormone↗
Alprazolam attenuates vasopressin-stimulated adrenocorticotropin and cortisol release: evidence for synergy between vasopressin and corticotropin-releasing hormone in humans.
Alprazolam (APZ), a triazolobenzodiazepine with unique clinical utility, has potent inhibitory effects on the human hypothalamic-pituitary-adrenal axis. Because APZ inhibits CRH secretion from isolated rat hypothalami and inhibits the probable CRH-mediated effect of naloxone on ACTH release, it is likely APZ acts as an inhibitor of hypothalamic CRH release in humans. The two principal physiological ACTH secretagogues are CRH and arginine vasopressin (AVP). We studied the ACTH and cortisol responses to an ACTH-releasing dose of AVP with and without preadministration of APZ in humans. Our hypothesis was that acute CRH deprivation by APZ would attenuate the ACTH response to vasopressin, as CRH and AVP act synergistically to control ACTH release. This synergy may depend on activation of subpopulations of corticotropes, some of which require both CRH and AVP together to elicit an ACTH response and/or intracellular "cross-talk" between second messenger pathways stimulated by the secretagogues. APZ (2 mg, orally) was given to eight healthy volunteers 90 min before AVP (0.0143 IU/kg BW, iv) in a randomized, double blind, placebo-controlled design during afternoon studies. ACTH and cortisol levels were measured at frequent intervals from 60 min before to 120 min after AVP injection. APZ reduced the mean integrated ACTH and cortisol responses to AVP by 67% and 70% respectively [ACTH, 161.6 +/- 59.7 vs. 53.0 +/- 20.9 pmol/min.L (P = 0.022); cortisol, 9314 +/- 3310 vs. 2763 +/- 1472 nmol/min.L (P = 0.020, AVP vs. APZ/AVP, respectively)]. APZ reduced the mean peak ACTH and cortisol responses to AVP by 57% (P = 0.023) and 40% (P = 0.0012), respectively. AVP levels were not significantly different in those who received APZ or placebo. This study provides further evidence of the potent inhibitory effects of APZ on ACTH and cortisol release in humans and is the first to find that APZ inhibits AVP-stimulated ACTH and cortisol release. This study also suggests that CRH/AVP synergy is an important physiological mechanism for ACTH release in humans, as indicated by the blunted ACTH response to AVP after APZ-mediated acute CRH deprivation. Inhibition of the pituitary-adrenal axis by APZ may explain its unique efficacy in psychiatric disorders thought to be associated with dysregulation of hypothalamic CRH release.
Adrenocorticotropic Hormone↗
Naloxone stimulation of ACTH secretion during petrosal sinus sampling in Cushing's syndrome.
1. Petrosal sinus sampling has been used to establish the source of adrenocorticotropin (ACTH) in ACTH-dependent Cushing's syndrome. Naloxone, an opioid antagonist, stimulates ACTH secretion, probably via release of endogenous hypothalamic corticotropin releasing hormone (CRH). 2. Three patients with hypercortisolism were studied. Two showed suppressed (> 50%) urinary-free cortisol excretion with high-dose dexamethasone treatment (2 mg every 6 h for 2 days), one did not suppress. The patients were subjected to bilateral simultaneous inferior petrosal sinus sampling (BSIPSS) with simultaneous peripheral venous (forearm) samples. Basal (unstimulated) samples were taken and naloxone (125 micrograms/kg bodyweight) was given intravenously with subsequent simultaneous sampling. Plasma ACTH was measured by radio-immunoassay (RIA). 3. All cases exhibited a marked rise in immunoreactive (IR)-ACTH levels (pmol/L) after naloxone injection, basal to peak: case 1, left 11.5-22.1, right 9.8 with no rise, peripheral 9.1-9.5; case 2, left 456-863, right 125-501, peripheral 59-82; case 3, left 12.7-13.0, right 277-431, peripheral 12.1-11.7. All results indicate pituitary Cushing's syndrome, with a central to peripheral ratio > 2.3:1. Pituitary Cushing's syndrome was confirmed on the results of trans-sphenoidal pituitary surgery in cases 1 and 3. 4. It is suggested that naloxone injection during petrosal sinus sampling in Cushing's syndrome may assist in the diagnosis of ACTH source, by enhancing ACTH release from a pituitary micro-adenoma.
Adrenocorticotropic Hormone↗
Alprazolam blocks the naloxone-stimulated hypothalamo-pituitary-adrenal axis in man.
Alprazolam (APZ) is a benzodiazepine with unique antidepressant activity for a drug of its class. There is some evidence of inhibition of the unstimulated hypothalamo-pituitary-adrenal axis by APZ which may be important in its therapeutic action, and could be detrimental in APZ-treated subjects who encounter stressful stimuli. To assess the effect of APZ on stimulated ACTH and cortisol secretion, we studied 14 normal subjects in a randomized, double-blind, placebo-controlled design. APZ or placebo capsule was administered orally in doses of 0.5 mg and 2 mg, 90 min before either naloxone, 125 micrograms/kg body weight i.v. bolus dose, a known stimulator of ACTH and cortisol release, or placebo. After naloxone stimulation, the area under the plasma ACTH/time curves was significantly reduced by APZ, in both the 2 mg (P < 0.0005) and 0.5 mg (P < 0.005) doses, compared to their respective placebo studies; similar reductions in area under the plasma cortisol/time curves occurred after 2 mg (P < 0.00002) and 0.5 mg (P < 0.0005) APZ doses. We conclude that APZ is a potent inhibitor of naloxone-stimulated ACTH and cortisol release in humans. Since APZ has been shown to inhibit CRH release in vitro, and naloxone-induced ACTH secretion is likely to be caused through CRH release, this suggests that APZ inhibition of naloxone action is via the parvocellular CRH neurons of the paraventricular nucleus and/or central neurotransmitter pathways impinging directly or indirectly on these CRH neurons. Thus APZ may exert at least some of its clinical effects through inhibition of central CRH release. APZ treatment could lead to a relative hyporesponse of the pituitary-adrenal axis during stress. APZ may be an important tool for manipulation of hypothalamic CRH release in studies of pituitary-adrenal function.
Adrenal Glands↗
Altered hypothalamic-pituitary-adrenal axis responsiveness in myotonic dystrophy: in vivo evidence for abnormal dihydropyridine-insensitive calcium transport.
In persons with myotonic dystrophy (DM), the ACTH response to CRH is greater than normal, while it is delayed in response to arginine vasopressin. Since influx of extracellular Ca2+ ions is a common step in signal transduction by both of these secretagogues, an abnormality of cellular Ca2+ transport may underlie the disturbances of hypothalamic-pituitary-adrenal axis function in this condition. Seven myotonic patients were given naloxone, which stimulates endogenous CRH release, and nifedipine, which blocks L-type voltage-dependent Ca2+ channels. Each subject underwent three tests, using different drug combinations, in a single blind, placebo-controlled protocol. Pretreatment with nifedipine delayed the time of the peak plasma hormone responses after naloxone [ACTH, 32.1 +/- 2.1 vs. 51.4 +/- 4.5 min (P < 0.05); cortisol, 42.9 +/- 2.1 vs. 70.7 +/- 4.3 min (P < 0.02); for naloxone and nifedipine/naloxone, respectively]. Additionally, nifedipine significantly reduced the proportion of the mean integrated ACTH response that had occurred by 30 min after naloxone administration (32.0 +/- 4.0% for naloxone vs. 17.6 +/- 2.4% for nifedipine/naloxone; P < 0.02) and the proportion of the mean integrated cortisol response by 45 min after naloxone administration (34.7 +/- 3.5% for naloxone vs. 25.0 +/- 2.6% for nifedipine/naloxone; P < 0.02). However, the total integrated responses did not change [ACTH, 1182.6 +/- 548.9 vs. 905.5 +/- 157.0 pmol/min.L (P = NS); cortisol 17,353 +/- 2,984 vs. 18,469 +/- 3,561 nmol/min.L (P = NS); for naloxone and nifedipine/naloxone, respectively]. We conclude that nifedipine delays, but does not reduce, the ACTH and cortisol responses to naloxone in DM. Since nifedipine has a different effect on normal controls (reduced response with unchanged timing), these findings imply an abnormality of dihydropyridine-insensitive Ca2+ transport (such as T-type Ca2+ channels) in the corticotrophs of DM patients.
Adolescent↗