The Current Treatment Landscape for Congenital Adrenal Hyperplasia

Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive endocrine disorders caused by impaired steroidogenesis and insufficient cortisol production from the adrenal cortex. The most common form of CAH is 21-hydroxylase deficiency, caused by mutations in the CYP21A2 gene. This enzyme deficiency causes failure to progress through the steroidogenic pathways, consequently there is an increased synthesis of steroid hormone precursors that result in adrenal androgens excess, leading to virilisation in female patients. Over the past two decades, significant progress has been made in optimising corticosteroid replacement strategies, with a focus on reducing androgen excess while minimising glucocorticoid exposure. Modified-release hydrocortisone formulations, such as Efmody^® and Plenadren^®, as well as continuous subcutaneous infusion therapies, have been developed to help better mimic physiological cortisol rhythms. In addition, corticotropin-releasing hormone-1 (CRH1) receptor antagonists have been investigated and have now been approved as a novel approach to reducing adrenocorticotropic hormone (ACTH)-driven adrenal hyperplasia and androgen excess. More recently, promising novel approaches have been developed to control androgen excess and reduce glucocorticoid exposure. This review provides an overview of current standard-of-care treatments for CAH and highlights recent advancements in therapeutic strategies. By addressing the limitations of traditional glucocorticoid replacement, these innovations have the potential to improve long-term outcomes and quality of life for patients with CAH.