Riassunto
L’anoressia nervosa è una patologia psichiatrica che ha avuto un notevole aumento di incidenza nel corso delle ultime decadi, caratterizzata dall’insorgenza tipicamente in età puberale. Prevalente nel sesso femminile e nelle società industrializzate, è gravata dalla più alta mortalità fra le malattie psichiatriche: a ciò contribuiscono le complicanze organiche del grave stato di denutrizione e l’elevata frequenza di suicidi. Sul versante endocrino, sono descritte anomalie più o meno rilevanti a carico di tutti gli assi funzionali. Tali alterazioni, reversibili con il recupero ponderale o la guarigione, costituiscono epifenomeni della malattia di base. L’ipogonadismo ipogonadotropo di origine ipotalamica dà luogo nei soggetti di sesso femminile all’amenorrea, che costituisce uno dei criteri diagnostici della malattia. La secrezione spontanea e stimolata delle gonadotropine riacquista caratteristiche tipiche della fase prepuberale, mentre appaiono ridotte le concentrazioni sieriche degli steroidi gonadici. L’asse ipotalamo-ipofisi-surrene risulta attivato, come in altre patologie psichiatriche (ad esempio, la depressione). Si segnalano elevati livelli liquorali di CRH, aumentata escrezione urinaria di cortisolo libero, abolizione del ritmo circadiano del cortisolo plasmatico e mancata soppressione della cortisolemia dopo test di inibizione rapida con desametasone a basse dosi. La low T 3 syndrome, comune ad altri stati di defedamento, deriva da una conversione preferenziale di T4 a reverse T3 piuttosto che a T3 nei tessuti periferici. Questo meccanismo, finalizzato al risparmio energetico, pur contribuendo alla bradicardia e all’intolleranza al freddo delle pazienti anoressiche, non necessita di terapia sostitutiva. Le anomalie dell’asse somatotropo configurano un quadro di resistenza all’azione del GH. A fronte infatti di un’esaltata secrezione somatotropinica, i livelli circolanti di IGF-I risultano francamente ridotti a causa della malnutrizione cronica. La secrezione spontanea del GH è amplificata per un aumento sia della componente pulsatile che di quella tonica, mentre la responsività dell’ormone ai vari stimoli farmacologici è estremamente variabile. A tali anomalie contribuiscono verosimilmente sia il mancato feedback negativo da parte dell’IGF-I sia alterazioni della secrezione ipotalamica di GHRH e somatostatina. Insieme alla carenza di sostanze nutritive e al basso peso corporeo, ipogonadismo, ipercortisolismo e deficit somatomedinico contribuiscono allo sviluppo di una osteopenia di entità tale da aumentare il rischio di fratture nel lungo termine. Tale osteoporosi sembra poco responsiva al trattamento con estroprogestinici, mentre risulterebbe più efficace la somministrazione di IGF-I biosintetico (terapia peraltro non proponibile al momento attuale data la scarsa reperibilità del farmaco, che viene interamente riservato al trattamento del nanismo di Laron) e di bisfosfonati.
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Scacchi, M., Fedeli, C., Ascoli, P. et al. Aspetti endocrini dell’anoressia nervosa. L’Endocrinologo 6, 155–167 (2005). https://doi.org/10.1007/BF03344526
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DOI: https://doi.org/10.1007/BF03344526