Cushing's%20syndrome Treatment

Replacement Therapy

• To provide adequate glucocorticoid replacement following surgery until hypothalamic-pituitary-adrenal axis has recovered
• To ensure life-long glucocorticoid and mineralocorticoid replacement following total bilateral adrenalectomy
  • Please see Adrenal Insufficiency disease management chart for further information

Glucocorticoid

• Hydrocortisone
  • Preferred agent as it is the true replacement of cortisol
  • Potent glucocorticoid with some mineralocorticoid activity

Mineralocorticoid

• Fludrocortisone is the preferred choice
  • Potent mineralocorticoid with some glucocorticoid activity

Steroid Biosynthesis Inhibitors

• Indicated in the following conditions:
  
  • 2nd-line treatment for patients who have undergone transsphenoidal surgery with or without radiotherapy
  • Primary treatment in patients with occult or metastatic ectopic ACTH secretion
  • Adjunctive treatment to reduce cortisol levels in adrenocortical carcinoma
• Actions: Most inhibit steroid biosynthesis by acting on cytochrome P450 enzymes
  
  • Action is nonspecific and extra-adrenal effects are likely

• Effects: Use in specific circumstances to decrease effects of hypercortisolism
  
  • In specific circumstances to decrease the effect of hypercortisolism, eg in preparation for surgery, surgical failure or when surgery cannot be performed, while awaiting the effects of radiotherapy and when patient’s psychiatric or physical state requires immediate control of cortisol levels

• Adrenocortical insufficiency may occur if not properly monitored

Ketoconazole

• Effective in hirsutism (in women) as it lowers circulating androgens
• Monitor liver function due to risk of liver injury

Metyrapone

• Fast onset; decreases serum cortisol within 2 hours of the 1st dose; advantage in controlling hypercortisolemia

Mitotane

• An adrenolytic agent used in metastatic adrenocortical carcinoma treatment and adjuvant for tumors with high risk of recurrence
• Also used for carcinomas not cured by surgery; for non-carcinomas, use lower doses to prepare patient for surgery; used extensively in all forms of hypercortisolism; slow onset; long-term control of cortisol secretion

• Approved for the use in patients who are non-surgical candidates or those who underwent surgery but experience persistence of the disease

Glucocorticoid Antagonist

Mifepristone

• Indicated for patients with Cushing’s syndrome and diabetes who are not surgical candidates and have failed surgery
• Actions: Blocks peripheral action of cortisol
• Effects: Used in specific circumstances to decrease effects of hypercortisolism
  • In specific circumstances to decrease the effect of hypercortisolism, eg in preparation for surgery, surgical failure or when surgery cannot be performed, while awaiting the effects of radiotherapy and when patient’s psychiatric or physical state requires immediate control of cortisol levels
  • Clinical improvement has been seen in patients without pituitary-dependent hypercortisolism

Others

• Some dopamine agonists, gamma-aminobutyric acid (GABA) agonists, serotonin antagonists, have been reported to be occasionally effective in treating Cushing’s disease
  
  • Cabergoline acts directly on corticotroph tumors to inhibit adrenocorticotropic hormone production

• Somatostatin analogues are used for unresectable tumors in ectopic adrenocorticotropic hormone (ACTH)/corticotropin-releasing hormone (CRH) syndrome
  
  • Pasireotide decrease adrenocorticotropic hormone secretion and cell proliferation in cultured human corticotroph tumors