cushing's%20syndrome
CUSHING'S SYNDROME
Cushing’s syndrome is a condition which is due to prolonged exposure of the body tissue to excess cortisol (glucocorticoid hormone).
Laboratory tests and radiological findings confirm diagnosis and determine the actual cause of Cushing's syndrome.
Endogenous adrenocorticotropic hormone (ACTH)-independent Cushing's syndrome has adrenal hypersecretion due to adrenal adenoma, adrenal carcinoma, micronodular hyperplasia, and macronodular hyperplasia.
Exogenous ACTH-independent Cushing's syndrome has adrenal hypersecretion due to iatrogenic causes (eg drug-induced, corticosteroid use).

Pharmacotherapy

Replacement Therapy

  • To provide adequate glucocorticoid replacement following surgery until hypothalamic-pituitary-adrenal axis has recovered
  • To ensure life-long glucocorticoid & mineralocorticoid replacement following total bilateral adrenalectomy

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 w/ or without radiotherapy
    • Primary treatment in patients w/ 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 & 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 & 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 & adjuvant for tumors w/ 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

Glucocorticoid Antagonist

Mifepristone

  • Indicated for patients with Cushing’s syndrome & diabetes who are not surgical candidates & 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 & 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 & cell proliferation in cultured human corticotroph tumors

 

Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Endocrinology - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
Roshini Claire Anthony, 3 days ago

A subgroup of patients with HBeAg-negative chronic hepatitis B virus (HBV) infection who ceased their long-term nucleotide analogue treatment maintained virological suppression, pointing to a group of patients who may be suitable for treatment cessation, according to a recent study.

Rachel Soon, 5 days ago

Gels utilizing Stichopus horrens (golden sea cucumber/gamat) extract show a similar efficacy to standard-of-care hydrogels for promoting wound healing, according to a prospective study.

4 days ago
Higher cancer symptom burden in elderly adults is associated with functional impairment, reports a recent study.
2 days ago
The monoclonal antibody abrilumab is effective for treating moderate-to-severe ulcerative colitis, promoting remission, clinical response and mucosal healing, a recent study has found.