Clinical Study on Circadian Genes Dysregulation in Patients With Glucocorticoid Disorders (CHROnOS)

This is a multicentric, prospective, intervention study on circadian genes expression in peripheral blood mononuclear cells as biomarkers of circadian rhythm derangement in patients affected by alterations of endogenous glucocorticoids secretion (Cushing's Syndrome during active phase, treatment and under remission and newly or on established glucocorticoid replacement therapy adrenal insufficiency)

Study Overview

• Status: Recruiting
• Conditions: Cushing Syndrome; Adrenal Insufficiency; Cushing Disease; Addison Disease
• Intervention / Treatment: Diagnostic test: circadian gene expression evaluation

Detailed Description

This is an intervention, prospective, multicentric study.

Enrolled patients will undergo 4 visits:

• Adrenal insufficiency (AI) patients: patients affected by primary or secondary adrenal insufficiency, whether newly diagnosed or on established glucocorticoid therapy, will be evaluated at baseline and after one, three and six months.
• Cushing's Syndrome (CS) patients: patients affected by Cushing's Syndrome will be evaluated at baseline during active phase of the disease and one, three and six months after treatment or remission. Patients affected by Cushing's Syndrome who will require glucocorticoid replacement therapy after remission will be evaluated three and six months after remission and then three and six months after the eventual glucocorticoid replacement therapy withdrawal. CS treatment will be surgery or medical therapy according to guidelines. Timing of medical therapy administration will change during protocol according to circadian rhythms.

Age-, sex- and BMI- matched healthy controls will be enrolled. Patients and controls will undergo the same procedures at baseline and after 1, 3 and 6 months.

The primary outcome measure will be the evaluation of circadian genes CLOCK and Aryl Hydrocarbon Receptor Nuclear Translocator Like (ARNTL) expression in peripheral blood mononuclear cells (PBMC) compared to healthy controls.

Secondary Outcomes measures will be:

• Circadian genes expression assessment compared to healthy controls at 7:00-8:00 Ante Meridiem (AM) (before breakfast), 12:00 AM (before lunch), 3:00-4:00 Post Meridiem (PM) (after lunch), 7:00 PM (before dinner), 12:00 PM;
• Immune profiling compared to healthy controls by the quantification of peripheral blood mononuclear cells (PBMC) subpopulations assessed by flow cytometry at 7:00-8:00 AM (before breakfast), 12:00 AM (before lunch), 3:00-4:00 PM (after lunch), 7:00 PM (before dinner), 12:00 PM;
• Evaluation of inflammatory cytokines and adipokines production compared to healthy controls at 7:00-8:00 AM (before breakfast), 12:00 AM (before lunch), 3:00-4:00 PM (after lunch), 7:00 PM (before dinner), 12:00 PM;
• Circadian cortisol rhythm by serum and salivary dosage at 7:00-8:00 AM (before breakfast), 12:00 AM (before lunch), 3:00-4:00 PM (after lunch), 7:00 PM (before dinner), 12:00 PM;
• Sleep disturbances evaluation by The Pittsburgh Sleep Quality Index (PSQI) self reported questionnaire
• Evaluation of infectious diseases frequencies and severity compared to healthy controls. Infectious diseases will be evaluated by an adaptation of Infectious Diseases Questionnaire (GNC)
• Circadian blood pressure using ambulatory blood pressure monitoring blood pressure waves for a noninvasive estimation
• Quality of life using SF-36-Item Health Survey questionnaire
• Psychometric Evaluation using Beck Depression Inventory questionnaire
• Evaluation of sexual dysfunction using FSFI questionnaire in woman and IIEF questionnaire in man
• Evaluation of insuline resistance calculated with HOMA index
• Evaluation of body weight (kg)
• Evaluation of blood lipid profile

• Study Type: Interventional
• Enrollment (Anticipated): 44
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Andrea Isidori, MD,PhD; Phone Number: 0039649970711; Email: andrea.isidori@uniroma1.it

Study Locations

• Italy
  • Roma, Italy, 00161
    • Recruiting
    • Department of Experimental Medicine, "Sapienza" University of Rome
    • Contact: Andrea M Isidori, MD,PhD; Phone Number: 0039649970711; Email: andrea.isidori@uniroma1.it

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 80 years (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Primary or secondary chronic adrenal insufficiency, previously or newly diagnosed.

• ACTH-dependent or ACTH-independent Cushing's Syndrome diagnosis during active disease (new diagnosis or recidivating).

  • Signed informed consent to participate in the study.

Exclusion Criteria:

- acute adrenal insufficiency;

• clinical or laboratory signs of significant respiratory, hepatobiliary, or pancreatic disease;
• pregnancy;
• severe infections, surgery, trauma requiring hospitalization within 3 months before study entry;
• any active blood or rheumatic disorders, and active liver disease in the previous 5 years;
• clinically significant chronic kidney disease;
• severe psychiatric diseases;
• history of neoplasms in the last 5 years (except for adrenal or pituitary adenoma in Cushing Syndrome, pituitary adenoma or related neolpasms in secondary adrenal insufficiency);
• heart disease with a class III or class IV functional capacity;
• BMI greater than 40 kg/m²;
• use of medication that interferes with cortisol metabolism within 1 month before study entry;
• treatment with systemic Glucocorticoid (GC) therapy other than hydrocortisone (HC), or cortisone acetate (CA);
• alcoholism and/or drug addictions;
• night-shift workers;
• use of melatonin, antipsychotic medications, estroprogestinic preparations

Study Plan

How is the study designed?

Design Details

• Primary Purpose: OTHER
• Allocation: NON_RANDOMIZED
• Interventional Model: PARALLEL
• Masking: NONE

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: Patients with Adrenal Insufficiency; Patients with Adrenal Insufficiency established or newly diagnosed, under glucocorticoid replacement therapy.	Diagnostic test: circadian gene expression evaluation; patients and controls will undergo circadian gene expression (CLOCK, ARNTL) evaluation at baseline and after 1, 3 and 6 months
EXPERIMENTAL: Patients with Cushing's Syndrome; patients with adrenocorticotropic hormone (ACTH)-dependent or ACTH-independent Cushing's Syndrome diagnosis during active disease (new diagnosis or recidivating) at enrollment.	Diagnostic test: circadian gene expression evaluation; patients and controls will undergo circadian gene expression (CLOCK, ARNTL) evaluation at baseline and after 1, 3 and 6 months
EXPERIMENTAL: Healthy Controls; Age-, sex- and BMI- matched patients referring to our center for diagnostic procedures not affected by Adrenal Insufficiency or Cushing's Syndrome.	Diagnostic test: circadian gene expression evaluation; patients and controls will undergo circadian gene expression (CLOCK, ARNTL) evaluation at baseline and after 1, 3 and 6 months

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Circadian genes CLOCK and ARNTL expression evaluation	Change in relative expression circadian genes of CLOCK and ARNLT from baseline compared to healthy controls. After PBMC isolation by Ficoll-Plaque gradient, complementary DNA (cDNA) pool will be extracted and used as the template for subsequent Polymerase Chain Reaction (PCR) amplification in Real time PCR; Gene expression will be quantified as relative expression compared to housekeeping genes.	baseline, +1 month, +3 months, +6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Circadian gene expression profile	Change from baseline in relative expression and variations throughout the day of circadian genes (CLOCK and ARNTL) compared to healthy controls at 7:00-8:00 AM (before breakfast), 12:00 AM (before lunch), 3:00-4:00 PM (after lunch), 7:00 PM (before dinner), 12:00 PM. After PBMC isolation by Ficoll-Plaque gradient, cDNA pool will be extracted and used as the template for subsequent Polymerase Chain Reaction (PCR) amplification in Real time PCR; Gene expression will be quantified as relative expression compared to housekeeping genes.	baseline, +1 month, +3 months, +6 months
Peripheral Blood Mononuclear Cells circadian profiling	Number of cells (number per mm3) of peripheral blood mononuclear cell subpopulations at 7:00-8:00 AM (before breakfast), 12:00 AM (before lunch), 3:00-4:00 PM (after lunch), 7:00 PM (before dinner), 12:00 PM	baseline, +1 month, +3 months, +6 months
Circadian cortisol rhythm	Circadian cortisol rhythm by serum and salivary dosage at 7:00-8:00 AM (before breakfast), 12:00 AM (before lunch), 3:00-4:00 PM (after lunch), 7:00 PM (before dinner), 12:00 PM.	baseline, +1 month, +3 months, +6 months
Sleep Disturbances	Sleep disturbances will be evaluated by The Pittsburgh Sleep Quality Index (PSQI). This questionnaire contains 19 self-related questions which are combined to create 7 component scores with a range of 0-3 points (0:no difficulty, 3: severe difficulty). Global score is the result to the addition of all component scores with a range of 0-21 points (0:no difficulty, 21: severe difficulty).	baseline, +1 month, +3 months, +6 months
Infectious Diseases Frequency and Severity	Frequencies and severity of infectious diseases will be evaluated by modified Infectious Diseases Questionnaire (GNC). This questionnaire includes questions on infectious diseases of upper and lower respiratory tract, gastrointestinal tract, skin and urogenital tract contracted during the previous 12 months. Questions investigate on the number and duration of infections, necessity of antibiotic or antifungal therapy, hospital stay and days of absence from work. Final score represents the frequency of infections. Moreover, some questions investigate possible susceptible or protective factors for infectious diseases: vaccinations, use of corticosteroids, concomitant diseases, previous appendectomy, tonsillectomy, adenoidectomy, splenectomy or thymectomy.	baseline, +1 month, +3 months, +6 months
Circadian blood pressure	Circadian blood pressure will be evaluated using ambulatory blood pressure monitoring blood pressure waves for a noninvasive estimation	baseline, +1 month, +3 months, +6 months
Quality of life evaluation	Quality of life will be evaluated by the Physical Component score and the Mental Component score of the self-administered questionnaire SF-36-Item Health Survey questionnaire. This questionnaire measures eight scales: physical functioning, role physical, bodily pain, general health (physical component) and vitality, social functioning, role emotional, mental health (mental component). Interpretation of the score will be the following: at each item of the questionnaire corresponds a percentage value (from 0% to 100%). The average of the single items constitutes the scale total percentage (from 0% to 100%); missing data are not considered during calculation. High score defines a more favorable health state.	baseline, +1 month, +3 months, +6 months
Psychometric Evaluation	Psychometric Evaluation will be evaluated using Beck Depression Inventory questionnaire. : a 21-item measure of depressive symptoms. Each answer is scored on a scale value (from 0 to 3 points). The global score is obtained adding all single scores, with a range of 0-63. Higher score constitutes worse burden of symptoms (0-13: minimal depression, 14-19: mild depression, 20-28: moderate depression, 29-63: severe depression).	baseline, +1 month, +3 months, +6 months
Sexual dysfunction in women	Evaluation of sexual dysfunction will be evaluated in women using FSFI questionnaire. This is a 19-item questionnaire that covers six domains: desire, arousal, lubrication, and orgasm, satisfaction, and pain. The ranges of the domain scores are as follows: for desire 1.2 - 6.0, for arousal, lubrication, orgasm and pain 0 - 6.0 and for satisfaction 0.8 - 6.0. The higher scores of the six domains indicate better sexual functioning about that domain. The overall FSFI score is obtained by summing the six domain scores. The overall FSFI scores range from 2.0 to 36.0, with higher scores indicating better sexual functioning.	baseline, +1 month, +3 months, +6 months
Sexual dysfunction in men	Evaluation of sexual dysfunction will be evaluated in men using IIEF questionnaire. The IIEF is an internationally validated test. It is used to assign a score of erectile dysfunction: severe score 1 to 10; moderate score 11 to 16; low to moderate score 17 to 21; Low score 22 to 25; no erectile dysfunction score 26 to 30	baseline, +1 month, +3 months, +6 months
insuline resistance	Measurement of HOMA index calculated according to the formula: fasting insulin (microU/L) x fasting glucose (nmol/L)/22.5.	baseline, +1 month, +3 months, +6 months
blood lipid profile	Measurement of Total Cholesterol, LDL cholesterol, HDL cholesterol, Triglyceredes	baseline, +1 month, +3 months, +6 months
Inflammatory cytokines levels	Evaluation of Tumor Necrosis Factor alpha (TNFα), Transforming Growth Factor beta (TGF-β), Interferon gamma (IFN-γ), Leptin, Resistin, Adiponectin, Adipsin, Monocyte Chemoattractant Protein-1 (MCP-1), Serpin, C Reactive Protein (CRP), Interleukin 6 (IL-6), Interleukin 10 (IL-10) serum concentrations at 7:00-8:00 AM (before breakfast), 12:00 AM (before lunch), 3:00-4:00 PM (after lunch), 7:00 PM (before dinner), 12:00 PM	baseline, +1 month, +3 months, +6 months

Collaborators and Investigators

• Sponsor: University of Roma La Sapienza

Study record dates

Study Major Dates

• Study Start (ACTUAL): July 4, 2018
• Primary Completion (ANTICIPATED): June 1, 2023
• Study Completion (ANTICIPATED): December 1, 2023

Study Registration Dates

• First Submitted: April 23, 2020
• First Submitted That Met QC Criteria: April 30, 2020
• First Posted (ACTUAL): May 5, 2020

Study Record Updates

• Last Update Posted (ACTUAL): November 30, 2022
• Last Update Submitted That Met QC Criteria: November 22, 2022
• Last Verified: November 1, 2022

More Information

Terms related to this study

• Keywords: cortisol; circadian clock; circadian rhythm; glucocorticoids; circadian genes
• Additional Relevant MeSH Terms: Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Immune System Diseases; Neoplasms by Histologic Type; Neoplasms; Autoimmune Diseases; Neoplasms by Site; Neoplasms, Glandular and Epithelial; Endocrine System Diseases; Endocrine Gland Neoplasms; Hypothalamic Diseases; Hyperpituitarism; Pituitary Diseases; Adenoma; Adrenocortical Hyperfunction; Adrenal Gland Diseases; Pituitary Neoplasms; Cushing Syndrome; ACTH-Secreting Pituitary Adenoma; Pituitary ACTH Hypersecretion; Adrenal Insufficiency; Addison Disease
• Other Study ID Numbers: CHROnOS

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No