The role of combined low-dose dexamethasone suppression test and desmopressin stimulation test in the diagnosis of persistent Cushing's disease. Case report.

Cushing's disease is related to a significant increase in mortality due to chronic hypercortisolaemia complications. It is known that 50% of non-treated subjects die within 5 years. Transsphenoidal selective adenomectomy is the treatment of choice. The incidence of relapses, even following a successful surgical procedure, is high and reaches 20-25% during the 5-year follow-up period. The authors discuss the case of a patient, currently aged 60, after repeat pituitary surgery, with progressive cardiovascular complications, in whom persistent Cushing's disease was diagnosed. The diagnosis was determined despite normal plasma ACTH, serum cortisol levels, and 17-OHCS concentrations in daily urine. There was also a lack of obvious pituitary adenoma features in the magnetic resonance imaging (MRI). Persistent Cushing's disease was diagnosed based on the combined dexamethasone desmopressin test. The presented case points to the role of provocative testing, including the desmopressin test following 1 mg of dexamethasone, for diagnostically difficult cases of Cushing's disease.

The influence of lithium on the antidiuretic effect of desmopressin.

The objective of this study was to investigate the graded influence from lithium on the antidiuretic effects of desmopressin. Eight healthy male subjects participated in this open, randomised cross-over study with two periods comprising 6 days each. For each subject, one of the study days (6th day) was preceded by a period of lithium treatment. On the study days the subjects were orally water loaded to achieve a state of overhydration with a high urine flow rate. When a steady-state diuresis was achieved after approximately 2 h, 0.396 microg of desmopressin was administered intravenously as a bolus injection. An indirect-response model, where desmopressin was assumed to inhibit the elimination of response, was fitted to the urine osmolarity data. The effects of the independent variables, Uflow(baseline) (baseline urine flow rate), R0 (baseline osmolarity) and serum lithium concentration, on IC50 (concentration producing 50% of the maximum inhibition) could be expressed by multiple linear regression. In conclusion, we found that an indirect-response model can be a useful tool in investigating and describing the pharmacodynamic interaction between drugs, in this particular case, between lithium and desmopressin.

Epidermal growth factor antagonizes vasopressin in vivo and in vitro.

Since EGF causes diuresis through a renal action and may antagonize the hydroosmotic effect of AVP in vitro we investigated the antagonistic action of EGF with AVP in vivo and the mechanism of the antagonism in vitro. Conscious ewes received i.m. injections of a selective AVP V2-receptor agonist (1-desamino, D-Arg8 vasopressin acetate, DDAVP) every 12 hours for days 5 to 16. All ewes received an i.v. isotonic saline infusion (100 ml/day) for days 1 to 8 and days 13 to 16, and i.v. EGF in 100 ml saline/day at doses of 0 (N = 8) or 10 (N = 8) micrograms/hr for days 9 to 12. DDAVP reduced both urine volume and water intake, and increased urine osmolality. In contrast, simultaneous infusion of EGF reversed the DDAVP-induced responses, resulting in a transient negative fluid balance, kaliuresis and a transient natriuresis (all P < 0.05). When EGF treatment ceased, the effects of DDAVP treatment alone gradually became apparent. From the in vitro studies, the AVP-related peptides displaced specific AVP V1- and V2-receptor antagonist radioligands from rat renal inner medullary membranes, whereas EGF had no effect. However, EGF antagonized AVP V2-stimulated cAMP production in a dose-dependent way (IC50 = 2 x 10(-7) M). Therefore, the diuretic effect of EGF is not via direct antagonism of the antidiuretic AVP V2-receptor but seems mediated by inhibition of the antidiuretic AVP V2-receptor second messenger system.

The release of factor VIII and tissue plasminogen activator can not be blocked by specific antagonists to vasopressin.

Vasopressin and in particular 1-deamino-8-D-arginine vasopressin (DDAVP) can release factor VIII (FVIII) and tissue plasminogen activator (tPA) to the blood. In the present study DDAVP was injected in conscious dogs which had been preloaded with specific antagonists either against vasopressin's vasopressor response (V1-receptors) or its antidiuretic response (V2-receptors). The presence in the blood of either of the antagonists had no effect on the increase of FVIII or tPA following stimulation with DDAVP. It is therefore concluded that the effect of DDAVP on coagulation and fibrinolysis is elicited via a new class of receptors different from the known V1- and V2-receptors.

Tonic inhibition of renal response to vasopressin by a pertussis toxin substrate.

The putative role of the inhibitory guanine nucleotide binding protein (Gi) in modulating the renal response to vasopressin was investigated using islet activating protein (IAP). IAP treatment in rats in vivo abolished the capacity of alpha 2-adrenoceptors to reverse vasopressin-induced adenosine 3',5'-cyclic monophosphate (cAMP) accumulation in microdissected cortical collecting tubule (CCT) segments. IAP pretreatment also caused a marked upward shift in the dose-response curve of vasopressin (10(-10) to 10(-4) M)-induced cAMP accumulation. Augmentation of the response to vasopressin in rat CCT was dependent on the in vivo dose of IAP and paralleled the loss in alpha 2-adrenoceptor responsiveness. In the isolated perfused kidney the antinatriuretic and antidiuretic effects of the V2-receptor agonist desamino-8-D-arginine vasopressin (DDAVP) (1 pM) were enhanced following IAP pretreatment. alpha 2-Adrenoceptor stimulation (30 nM epinephrine) inhibited the renal effects of DDAVP (1 pM) in kidneys from control but not IAP-pretreated rats. Interestingly, IAP pretreatment alone caused increased urine flow rate and enhanced excretion of sodium and chloride without affecting potassium excretion or renal hemodynamics in vitro. Our results suggest that an IAP substrate, probably Gi, 1) is required for signal transduction by renal alpha 2-adrenoceptors, 2) may tonically modulate the response to vasopressin in the CCT but not of parathyroid hormone in the proximal convoluted tubule, and 3) participates in renal water and electrolyte reabsorption independent of exogenous adenylate cyclase stimulation.

Effect of intranasal histamine on nasal mucosal blood flow and the antidiuretic activity of desmopressin.

The effects of exogenous histamine on nasal mucosal blood flow and the systemic activity of intranasally administered desmopressin, a vasopressin analogue, were studied in normal volunteers. Ten subjects received either saline or histamine (1, 20, 100, and 500 micrograms) by intranasal spray. Maximal nasal mucosal blood flow response, determined by laser doppler velocimetry, demonstrated a significant (P less than 0.05) linear relationship to histamine dose. Eight additional subjects received each of the following intranasal treatments: 20 micrograms histamine followed by 10 micrograms desmopressin; normal saline followed by 10 micrograms desmopressin; 20 micrograms histamine followed by vehicle; or normal saline and vehicle. Nasal blood flow was determined before and after each treatment. Desmopressin activity was assessed by measuring urine osmolality, flow rate, electrolyte, and creatinine concentration for 24 h after each treatment. The effect of histamine and desmopressin was greater than desmopressin alone, with respect to nasal blood flow response (103 +/- 24 vs. 4 +/- 17%, mean +/- SEM, P less than 0.02), initial urine osmolality (520 +/- 123 vs. 333 +/- 75 mosM, P less than 0.03), urine electrolyte (potassium, 45 +/- 11 vs. 28 +/- 7 meq/liter; sodium, 68 +/- 21 vs. 36 +/- 8 meq/liter, P less than 0.03) and creatinine concentrations (95 +/- 23 vs. 60 +/- 13 mg/dl, P less than 0.03), and the duration of decrease in urine flow rate compared with saline and vehicle. These results suggest that the systemic activity of intranasal desmopressin is enhanced by increasing local nasal blood flow and are consistent with increased transnasal absorption of the peptide.

Inhibition of the antidiuretic effect of 1-deamino-8d-arginine vasopressin (DDAVP) by glibenclamide in water-loaded healthy subjects.

The diuretic effect of a three-day glibenclamide treatment was studied in 8 healthy subjects during maximal sustained water diuresis before and after administration of 0.04 mug l-deamino-8d-arginine vasopression (DDAVP). The antidiuretic response (decrease in free water clearance per 100 ml GFR and increase in urine osmolality) induced by DDAVP was significantly reduced by glibenclamide. In addition, changes in urine osmolality indicated a shorter duration of DDAVP -antidiuresis. These findings are consistent with the hypothesis that glibenclamide competitively inhibits the peripheral action of vasopressin.