Glucocorticoid generation in the adrenals and

adipose tissue in obesity

Brian Walker Endocrinology UnitUniversity of Edinburgh

Cushing’s or Metabolic Syndrome?

• Similarities

• The clinical problem – telling them apart

• Does cortisol contribute to Metabolic Syndrome?

• Can manipulating cortisol treat Metabolic Syndrome?

?�Cardiovascular Disease

��+ other features

��Glucose

intolerance

��Hypertension

��Dyslipidaemia

+ Two from:

��Central obesity

Cushing’s

Syndrome

Metabolic

Syndrome (IDF)

RR (95%CI)

106421.6.4.2.1

1.52 (1.47-1.58)

1.78 (1.69-1.87)

4.83 (4.24-5.51)

1.00

Low topical

Medium <7.5

High >7.5

NoneCrude

MEMO

Dose of glucocorticoids and all cardiovascular events

0.99 (0.95-1.03)

1.03 (0.96-1.10)

2.70 (2.33-3.13)

1.00Low

Medium

High

NoneAdjusted*

*Age, gender, social deprivation, cardiovascular drug use, HRT & OCP, NSAIDs, DMARDs, bronchodilators, non-cardiovascular hospitalisation in the 6 months prior to study entry, diabetes mellitus, cancer, renal disease, interaction between exposure and cardiovascular drug use, propensity score

Wei et al Ann Int Med 2004

Cushing’s or Metabolic Syndrome?

• Similarities

• The clinical problem – telling them apart

• Does cortisol contribute to Metabolic Syndrome?

• Can manipulating cortisol treat Metabolic Syndrome?

HPA axis abnormalities in Metabolic Syndrome

• + Increased urinary free cortisol excretion› Marin Metabolism 1992; Pasquali JCEM 1993

• + Loss of diurnal cortisol variation› Rosmond JCEM 1998

• (Increased responses to CRH/AVP and ACTH)› Pasquali Horm Metab Res 2000

• Normal response to dexamethasone at conventional doses

› Chalew Obes Res 1995; Pasquali JCEM 2002

Conclusion – how do you tell?

• Use dexamethasone suppression at conventional doses

Pasquali, R. et al. J Clin Endocrinol Metab 2002;87:166-175

n=13 n=21n=36 n=51

Variation in cortisol suppression explained by:

• Gender• [dexamethasone]• not BMI

Cushing’s or Metabolic Syndrome?

• Similarities

• The clinical problem – telling them apart

• Does cortisol contribute to Metabolic Syndrome?

• Can manipulating cortisol treat Metabolic Syndrome?

Blood cortisol and cardiovascular risk

Umea

Edinburgh

Sheffield

London

Hertfordshire

Preston

Uppsala

Phoenix

Plasma [cortisol] and cardiovascular risk factors

1.8

2

2.2

2.4

<250 -300 -350 -400 >400 All

120

140

160

180

200

Fasting120 min in OGTT

5

5.5

6

6.5

7

7.5

0.95

1.05

1.15

1.25

1.35

1.45

1.55

1.65

<250 -300 -350 -400 >400 All

Systolic blood pressure

(mmHg)

Plasma glucose

se Triglyceride Insulin resistance

(HOMA index)

p<0.03 p<0.001

p<0.04

p<0.05 p<0.03

<250 -300 -350 -400 >400 All <250 -300 -350-400 >400 All

Fasting 0900 h plasma [cortisol] (nM)

84 6662

6395

370

Phillips et al JCEM 1998

Cortisol metabolites & familial BP

5ß-THF

5α-THF

THE

0

1

2

3

4

5U

rinary

excre

tion (

mg/d

ay) NS *

*

C Low Low

D Low High

AHigh Low

B High High

Offspring Parents

O A BC D

P

F E

5βTHF 5αTHF THE

Walker et al Hypertension 1998

HPA axis in leaninsulin resistance syndrome

ACTH

Cortisol

CRH

Central drive

Negative

Feedback

(dexamethasone)

NORMAL

Habituation

IMPAIRED

• Stress?

• Programming?

SynACTHen response

ENHANCED

Reynolds JCEM 2001a, 2001b

Brunner Circulation 2002

Phillips Hypertension 2000Amplified by obesity?

Cortisol in obesity in men

N Sweden (28-65 y) n=33 p<0.01

Preston (47-56 y) n=31 p=0.30

Sheffield (69-74y) n=87 p<0.02

Hertfordshire (60-65y) n=140 p=0.06

Overall r=+0.19, 217µg/cm, p<0.001

Waist circumference (cm)

Total cortisol metabolites (mg/d)

0

10

20

30

40

50

70 80 90 100 110 120 130

0900 h plasma [cortisol] (nM)

0

200

400

600

800

1000

60 70 80 90 100 110 120 130 140

Waist circumference (cm)

N Sweden (25-65 y) n=147 p=0.67

Preston (45-55 y) n=133 p<0.01

Hertfordshire (60-65 y) n=203 p=0.06

Overall r=-0.17, 2nM/cm, p<0.001

5α-Reductase 1 is increased in obesity

0

0.5

1

1.5

2

Lean Obese

mRNA

0.0

0.2

0.4

0.6

0.8

1.0

Lean Obese

protein

* *

0

0.05

0.10

0.15**

5alpha-D4-Cortisol

Excretion

Human Zucker obese rat

Lean Obese

Consequences of enhanced cortisol clearancein obesity

ACTH

Cortisol

CRH

Central drive

Negative

Feedback

Clearance5α-Reductase 1

Adrenal Androgens

GR activation?

Cushing’s or Metabolic Syndrome?

• Similarities

• The clinical problem – telling them apart

• Does cortisol contribute to Metabolic Syndrome?

• Can manipulating cortisol treat Metabolic Syndrome?

Hypothalamic-pituitary-adrenal-tissue axis

ACTH

Cortisol

CRH

Central drive

Negative

Feedback

Tissue responses

Steroid hormone action

11β-HSD2 in kidneyStewart, Edwards et al.

Cortisol (F)

Cortisone (E)

MR

F

E

11HSD2

Na retentionHypertension

Congenitaldeficiency

Inhibitionwith liquorice

Impaired in 1/3

of patients

with hypertension

F

E

11HSD1

LiverAdipose

CNS

GR

Cortisol (F)

Cortisone (E)

MR

F

E

11HSD2

Kidney

Lessons from 11HSD1 transgenic mice

non-Tg Tg

AP2-11HSD1 TGMasuzaki Science 2001

• Obese

• Hypertensive

• Diabetic

wild type

11ß-HSD1-/-

1412108642025

30

35

40

45

weeks on high fat diet

weig

ht

(g)

** *

*

11HSD1 ‘knockouts’Kotelevtsev PNAS 1997

Morton Diabetes 2004

Protected from:

• Obesity

• Diabetes

• dyslipidaemia80

100

120

140

160

180

12:00 pm12:00 am12:00 pm12:00 am12:00 pm12:00 am

• hypertensive• Fatty liver• hyperinsulinaemic• dyslipidaemia• not obese• not diabetic

ApoE-11HSD1 TGPaterson PNAS 2004

Quantifying cortisol regeneration in humans

O

HO OHCO

CH2OH

O

OHCO

CH2OH

D

CH2OH

O

OHCO

O

CH2OH

O

OHCO

O

OH

O

HOCO

CH2OH

O

CO

CH2OH

D4 cortisol

D3 cortisone

D3 cortisol

D

D2

D

D2

D

D2

Andrew et al JCEM 2002

0

2

4

6

8

10

Placebo CBX

D3-cortisol production

nmol/min

Regional cortisol production in humans

Cortisol

Cortisone

D4-Cortisol

D4-Cortisol

D3-Cortisone

D3-Cortisol

Visceralfat

other

Fat

etc

Liver

Kidney

Adrenals

~38 nmol/min

~11 nmol/min

Basu et al

Diabetes 2004

Cortisone

~15 nmol/min

~30 nmol/min

[Cortisol] 118nM

[Cortisol]

155nM

45 nmol/min

Andrew et al

Diabetes 2005

~2nmol/

min/kg

Andersson et al

unpublished

Highest

100

300

500

700

0 60 120 180 240

Time after oral cortisone (min)

Plasma cortisol (nmol/L)

LowestMiddle34 (16) men in

tertiles of BMI:

Tissue-specific dysregulationof 11-HSD1 in obese men

Liver

0

5

10

15

20

25

30

35

40

0 3 6 20 30

Incubation time (h)

%11-HSD1 activity

sc adipose tissue

Rask et al. JCE&M 2001

SC adipose 11HSD1 in obesity - microdialysis

Skin

Adiposeinterstitial

fluid

Tracer3Hcortisone Analysis

3Hcortisol

Dialysismembrane

3H4-cortisone

to 3H4-cortisol

0

10

20

30

40

Lean Obese

*

Sandeep et al Diabetes 2005

11HSD1 in human obesity

cortisol

cortisone

11HSD1

Carbenoxolone

2

2

C O H

C H

C H

C O

O

2

H

CO H

O

2

Drug discovery

Potent selective inhibitors of 11HSD1 in mice

eg Biovitrum/Amgen, Merck, Johnson & Johnson, Wyeth, Abbott ….

• Lower blood glucose in KKAy, ob/ob, db/db, DIO

• Lower body weight

• Atheroprotective eg in ApoE -/- mice

Alberts et al Diabetologia 2002; Endocrinology 2003;

Vosatka J Exp Med 2005

Clinical

DevelopmentTarget Biology

Lead

Finding

In vitro

& In Vivo

Models

Drug

Candidate

Lead

Optimisation

Key points

• Glucocorticoids cause cardiovascular disease

• Dexamethasone discriminates Cushing’s vs Metabolic Syndrome

• Plasma cortisol:

› elevated in Metabolic Syndrome

› lower in obesity

• Liver glucocorticoid action depends on:

› 11HSD1 in visceral adipose

› 5α-reductase 1 in liver?

• 11HSD1 generates more cortisol within adipose tissue in obesity

• 11HSD1 inhibitors may be useful in Metabolic Syndrome

Thanks!Edinburgh

Jonathan Seckl

Nik Morton

John Mullins

Ruth Andrew

Dawn Livingstone

Paddy Hadoke

Natalie Homer

Ken Smith

Rob Andrews

Greg Jones

Rebecca Reynolds

Thekkepat Sandeep

Gary Small

Debbie Wake

Alison Ayres

Wendy Barron

Jill Campbell

Scott Denham

UmeaTommy Olsson

Stefan Soderberg

et al

PhoenixAntonio Tataranni

Paska PermanaRobbie Lindsay

SouthamptonDavid Phillips

Cyrus Cooper

Utrecht

Tjeerd van StaaPatrick Souverein

HelsinkiHannele Yki-Jarvinen

Jukka WesterbackaJussi Sutinen

StockholmJohn Wahren

Dundee

Tom MacDonald

Li Wei

LondonEric Brunner

Michael Marmot