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Lalonde R, Strazielle C. Neurochemical Anatomy of Cushing's Syndrome. Neurochem Res 2024; 49:1945-1964. [PMID: 38833089 DOI: 10.1007/s11064-024-04172-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/05/2024] [Accepted: 05/22/2024] [Indexed: 06/06/2024]
Abstract
The neurochemical anatomy underlying Cushing's syndrome is examined for regional brain metabolism as well as neurotransmitter levels and receptor binding of biogenic amines and amino acids. Preliminary studies generally indicate that glucose uptake, blood flow, and activation on fMRI scans decreased in neocortical areas and increased in subcortical areas of patients with Cushing's syndrome or disease. Glucocorticoid-mediated increases in hippocampal metabolism occurred despite in vitro evidence of glucocorticoid-induced decreases in glucose uptake or consumption, indicating that in vivo increases are the result of indirect, compensatory, or preliminary responses. In animal studies, glucocorticoid administration decreased 5HT levels and 5HT1A receptor binding in several brain regions while adrenalectomy increased such binding. Region-specific effects were also obtained in regard to the dopaminergic system, with predominant actions of glucocorticoid-induced potentiation of reuptake blockers and releasing agents. More in-depth neuroanatomical analyses are warranted of these and amino acid-related neurotransmission.
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Affiliation(s)
- Robert Lalonde
- Laboratory of Stress, Immunity, Pathogens (UR SIMPA), University of Lorraine, Campus Santé, Bât A/B 9, avenue de la Forêt de Haye, Vandoeuvre-les-Nancy, 54500, France.
| | - Catherine Strazielle
- Laboratory of Stress, Immunity, Pathogens (UR SIMPA), University of Lorraine, Campus Santé, Bât A/B 9, avenue de la Forêt de Haye, Vandoeuvre-les-Nancy, 54500, France
- CHRU Nancy, Vandoeuvre-les-Nancy, France
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Langlois F, Chu J, Fleseriu M. Pituitary-Directed Therapies for Cushing's Disease. Front Endocrinol (Lausanne) 2018; 9:164. [PMID: 29765354 PMCID: PMC5938400 DOI: 10.3389/fendo.2018.00164] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 03/27/2018] [Indexed: 12/30/2022] Open
Abstract
Cushing's disease (CD) is caused by a pituitary corticotroph neuroendocrine tumor inducing uncontrolled hypercortisolism. Transsphenoidal surgery is the first-line treatment in most cases. Nonetheless, some patients will not achieve cure even in expert hands, others may not be surgical candidates and a significant percentage will experience recurrence. Many patients will thus require medical therapy to achieve disease control. Pharmacologic options to treat CD have increased in recent years, with an explosion in knowledge related to pathophysiology at the molecular level. In this review, we focus on medications targeting specifically pituitary adrenocorticotropic hormone-secreting tumors. The only medication in this group approved for the treatment of CD is pasireotide, a somatostatin receptor ligand. Cabergoline and temozolomide may also be used in select cases. Previously studied and abandoned medical options are briefly discussed, and emphasis is made on upcoming medications. Mechanism of action and available data on efficacy and safety of cell cycle inhibitor roscovitine, epidermal growth factor receptor inhibitor gefitinib, retinoic acid, and silibinin, a heat shock protein 90 inhibitor are also presented.
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Affiliation(s)
- Fabienne Langlois
- Department of Endocrinology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jennifer Chu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, United States
| | - Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, United States
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
- *Correspondence: Maria Fleseriu,
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Abstract
Cushing's disease (CD) is characterized by an ACTH-producing anterior corticotrope pituitary adenoma. If hypothalamus-pituitary-adrenal (HPA) axis physiology is disrupted, ACTH secretion increases, which in turn stimulates adrenocortical steroidogenesis and cortisol production. Medical treatment plays an important role for patients with persistent disease after surgery, for those in whom surgery is not feasible, or while awaiting effects of radiation. Multiple drugs, with different mechanisms of action and variable efficacy and tolerability for controlling the deleterious effects of chronic glucocorticoid excess, are available. The molecular basis and clinical data for centrally acting drugs, adrenal steroidogenesis inhibitors, and glucocorticoid receptor antagonists are reviewed, as are potential novel molecules and future possible targets for CD treatment. Although progress has been made in the understanding of specific corticotrope adenoma receptor physiology and recent clinical studies have detected improved effects with a combined medical therapy approach, there is a clear need for a more efficacious and better-tolerated medical therapy for patients with CD. A better understanding of the molecular mechanisms in CD and of HPA axis physiology should advance the development of new drugs in the future.
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Affiliation(s)
- Daniel Cuevas-Ramos
- Department of MedicinePituitary Center, Cedars-Sinai Medical Center, Los Angeles, California, USANeuroendocrinology ClinicDepartment of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, MexicoDepartments of Medicine and Neurological Surgeryand Northwest Pituitary Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Road (BTE 472), Portland, Oregon 97239, USA Department of MedicinePituitary Center, Cedars-Sinai Medical Center, Los Angeles, California, USANeuroendocrinology ClinicDepartment of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, MexicoDepartments of Medicine and Neurological Surgeryand Northwest Pituitary Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Road (BTE 472), Portland, Oregon 97239, USA
| | - Maria Fleseriu
- Department of MedicinePituitary Center, Cedars-Sinai Medical Center, Los Angeles, California, USANeuroendocrinology ClinicDepartment of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, MexicoDepartments of Medicine and Neurological Surgeryand Northwest Pituitary Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Road (BTE 472), Portland, Oregon 97239, USA
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Ferone D, Pivonello C, Vitale G, Zatelli MC, Colao A, Pivonello R. Molecular basis of pharmacological therapy in Cushing's disease. Endocrine 2014; 46:181-98. [PMID: 24272603 DOI: 10.1007/s12020-013-0098-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/19/2013] [Indexed: 01/16/2023]
Abstract
Cushing's disease (CD) is a severe endocrine condition caused by an adrenocorticotropin (ACTH)-producing pituitary adenoma that chronically stimulates adrenocortical cortisol production and with potentially serious complications if not or inadequately treated. Active CD may produce a fourfold increase in mortality and is associated with significant morbidities. Moreover, excess mortality risk may persist even after CD treatment. Although predictors of risk in treated CD are not fully understood, the importance of early recognition and adequate treatment is well established. Surgery with resection of a pituitary adenoma is still the first line therapy, being successful in about 60-70 % of patients; however, recurrence within 2-4 years may often occur. When surgery fails, medical treatment can reduce cortisol production and ameliorate clinical manifestations while more definitive therapy becomes effective. Compounds that target hypothalamic-pituitary axis, glucocorticoid synthesis or adrenocortical function are currently used to control the deleterious effects of chronic glucocorticoid excess. In this review we describe and analyze the molecular basis of the drugs targeting the disease at central level, suppressing ACTH secretion, as well as at peripheral level, acting as adrenal inhibitors, or glucocorticoid receptor antagonists. Understanding of the underlying molecular mechanisms in CD and of glucocorticoid biology should promote the development of new targeted and more successful therapies in the future. Indeed, most of the drugs discussed have been tested in limited clinical trials, but there is potential therapeutic benefit in compounds with better specificity for the class of receptors expressed by ACTH-secreting tumors. However, long-term follow-up with management of persistent comorbidities is needed even after successful treatment of CD.
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Affiliation(s)
- Diego Ferone
- Endocrinology, Department of Internal Medicine and Medical Specialties & Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Viale Benedetto XV, 6, 16132, Genoa, Italy,
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5
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Abstract
Recent evidence supports the notion that the incidence of Cushing disease is higher than previously thought. Transphenoidal surgery, in the hands of experienced neurosurgeons, is currently considered the first-line treatment of choice. However, an examination of remission and recurrence rates in long-term follow-up studies reveals that potentially up to 40% to 50% of patients could require additional treatment. If left untreated, the resultant morbidity and mortality are high. Successful clinical management of patients with Cushing disease remains a challenge. The development of new therapeutic agents has been eagerly anticipated. This article discusses the results of currently available and promising new therapeutic agents used to treat this challenging disease.
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6
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The Pharmacologic Basis for the Treatment of Endocrinopathic Laminitis. Vet Clin North Am Equine Pract 2010; 26:303-14. [DOI: 10.1016/j.cveq.2010.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Alexandraki KI, Grossman AB. Pituitary-targeted medical therapy of Cushing's disease. Expert Opin Investig Drugs 2008; 17:669-77. [PMID: 18447593 DOI: 10.1517/13543784.17.5.669] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The goals of ideal medical therapy for Cushing's disease should be to target the aetiology of the disorder, as is the case for surgery, which is the current 'gold standard' treatment. However, no effective drug that directly and reliably targets the adrenocorticotropin-secreting pituitary adenoma has yet been found. OBJECTIVE To summarise pituitary-targeted medical treatment of Cushing's disease. METHODS Compounds with neuromodulatory properties and ligands of different nuclear hormone receptors involved in hypothalamo-pituitary regulation have been investigated. RESULTS The somatostatin analogue pasireotide and the dopamine agonist cabergoline, as well as their combination, show some therapeutic promise in the medical therapy of Cushing's disease. Other treatments such as retinoic acid analogues look promising and may be a possible option for further investigation. No other medical therapies seem to be reliably effective currently. CONCLUSION Since a percentage of patients treated with surgery are not cured, or improve and subsequently relapse, there is an urgent need for effective medical therapies for this disorder. At present, only cabergoline and pasireotide are under active investigation.
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Affiliation(s)
- Krystallenia I Alexandraki
- Professor of Neuroendocrinology St. Bartholomew's Hospital, Ashley Grossman FMedSci, London EC1A 7BE, UK
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Abstract
PURPOSE OF REVIEW To consider the current status and types of drug therapy aimed at restoring eucortisolaemia in patients with Cushing's syndrome. RECENT FINDINGS Advances such as laparoscopic adrenalectomy modify the exact placing of drug therapy among the wide variety of therapies available to treat patients with Cushing's syndrome because of different causes; nonetheless, it is now clear that hypercortisolism, per se, if present for any length of time, modifies the future prognosis of the patient, even after cure of the Cushing's syndrome. Thus, early diagnosis and restoration of eucortisolsm are critical. There are three main types of drug therapy: steroidogenesis inhibitors, glucocorticoid antagonists and neuromodulatory compounds. Currently, steroidogenesis inhibitors such as metyrapone and ketaconazole are most commonly the first choice if drug therapy is to be used, but at least for the most common form of Cushing's syndrome, Cushing's disease, the neuromodulatory compounds such as cabergoline show potential. SUMMARY Pharmacological therapy for Cushing's syndrome remains critically important for normalizing cortisol levels while awaiting the impact of more definitive treatment.
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Affiliation(s)
- Stephen Shalet
- Department of Endocrinology, Christie Hospital, Manchester, UK.
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Mullan KR, Atkinson AB. Endocrine clinical update: where are we in the therapeutic management of pituitary-dependent hypercortisolism? Clin Endocrinol (Oxf) 2008; 68:327-37. [PMID: 17854395 DOI: 10.1111/j.1365-2265.2007.03028.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Karen R Mullan
- Regional Centre for Endocrinology, Royal Victoria Hospital, Belfast, UK
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Dang CN, Trainer P. Pharmacological management of Cushing's syndrome: an update. ACTA ACUST UNITED AC 2007; 51:1339-48. [DOI: 10.1590/s0004-27302007000800020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Accepted: 10/08/2007] [Indexed: 01/09/2023]
Abstract
The treatment of choice for Cushing's syndrome remains surgical. The role for medical therapy is twofold. Firstly it is used to control hypercortisolaemia prior to surgery to optimize patient's preoperative state and secondly, it is used where surgery has failed and radiotherapy has not taken effect. The main drugs used inhibit steroidogenesis and include metyrapone, ketoconazole, and mitotane. Drugs targeting the hypothalamic-pituitary axis have been investigated but their roles in clinical practice remain limited although PPAR-gamma agonist and somatostatin analogue som-230 (pasireotide) need further investigation. The only drug acting at the periphery targeting the glucocorticoid receptor remains Mifepristone (RU486). The management of Cushing syndrome may well involve combination therapy acting at different pathways of hypercortisolaemia but monitoring of therapy will remain a challenge.
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Fleseriu M, Loriaux DL, Ludlam WH. Second-line treatment for Cushing's disease when initial pituitary surgery is unsuccessful. Curr Opin Endocrinol Diabetes Obes 2007; 14:323-8. [PMID: 17940460 DOI: 10.1097/med.0b013e328248b498] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Adenectomy via transsphenoidal surgery is considered the treatment of choice for Cushing's disease. It is successful in about 80% of patients in the hands of an experienced surgeon. When transsphenoidal surgery fails or is contraindicated, a second-line treatment must be chosen. The review focuses on second-line treatment options. RECENT FINDINGS Repeat pituitary surgery results in the cure of Cushing's disease in about 50% of cases. Bilateral adrenalectomy results in resolution of hypercortisolemia in almost all patients, but leaves the patient glucocorticoid and mineralocorticoid deficient. Nelson's syndrome, depending on the definition, occurs in up to 35% of these patients. Irradiation of the residual pituitary tumor typically takes several years before the full effect is realized; it can cause panhypopituitarism. Finally, pharmacologic treatment of persistent hypercortisolemia can be effective, but is often associated with untoward side effects. These side effects are a powerful deterrent to its use. Several new pharmacologic agents are being studied and show some promise. SUMMARY Each of the second-line treatments for Cushing's disease currently available can be effective at treating hypercortisolism, but each has significant limitations. New pharmacologic agents may soon offer some very exciting treatment options.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA.
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Levy A. Novel therapeutic directions in Cushing's syndrome. Expert Rev Endocrinol Metab 2006; 1:199-207. [PMID: 30754138 DOI: 10.1586/17446651.1.2.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cushing's disease is the most common cause of endogenous hypercortisolemia. It is a rare disease of unknown etiology that is prone to relapse and damaging to quality of life, even in remission. A significant proportion of patients are not cured by primary surgical treatment, and adjuvant radiotherapy has become an increasingly unattractive proposition for clinicians who wish to spare their patients hypopituitarism and other potential complications. The few effective pharmacological options that are available currently tend to have dose-limiting side effects and new alternatives that are safer and more effective than the adrenal cortical enzyme inhibitors and adrenolytic drugs would be most welcome. This article discusses preliminary efficacy data for several potential new groups of drugs.
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Affiliation(s)
- Andrew Levy
- a Henry Wellcome Labs for Integrative Neuroscience and Endocrinology, University of Bristol, Dorothy Hodgkin Building, Whitson St, Bristol BS1 3NY, UK.
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13
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Abstract
The successful treatment of Cushing syndrome depends on specific therapy directed against the etiology of hypercortisolism. In addition to surgical procedures, various drugs have been employed in the management of this difficult disease. Compounds with neuromodulatory properties have been effective in only a limited number of cases of hypothalamic-pituitary-dependent Cushing disease, the most common form of Cushing syndrome. These agents include serotonin antagonists (cyproheptadine, ketanserin, ritanserin), dopamine agonists (bromocriptine, cabergoline), GABA agonists (valproic acid [sodium valproate]), and somatostatin analogs (octreotide). Interesting new avenues at the pituitary level involve the potential use of thiazolidinedione compounds, such as rosiglitazone, and of retinoic acid, which are ligands of different nuclear hormone receptors involved in hypothalamic-pituitary regulation. The most exciting news, however, in the pharmacologic approach to Cushing syndrome refers to the adrenal corticotropin (adrenocorticotropic hormone; ACTH)-independent forms, in which aberrant adrenal receptors, through the binding of their respective ligands, could lead to chronic cortisol overproduction. They include receptors for gastric inhibitory peptide (GIP), beta-adrenergic agonists, luteinizing hormone (LH)/human chorionic gonadotropin, serotonin (5-HT(4) receptor), vasopressin (V(1) receptor), and angiotensin II (AT(1) receptor). In GIP-dependent Cushing syndrome, the most frequent subtype of ACTH-independent macronodular adrenal hyperplasia associated with the presence of aberrant adrenocortical hormone receptors described so far, octreotide administration before each meal showed clinical efficacy only in the first few months, probably because of somatostatin receptor downregulation in GIP-secreting cells. Long-term medical treatments with propranolol and the gonadotropin-releasing hormone analog leuprorelin (leuprolide acetate) were effective in patients with catecholamine-dependent and LH-dependent Cushing syndrome, respectively. The oral vasopressin V(1) receptor antagonist OPC-21268 and the angiotensin II (AT(1)) receptor antagonist candesartan cilexetil were also able to decrease cortisol levels during the few days of administration of the drugs in patients with specific receptor abnormalities. These adrenal forms of Cushing syndrome are rare, and clinical data are scarce. Moreover, the real clinical significance of aberrant hormone receptors is still under investigation, as is the possibility of avoiding surgery by pharmacologic manipulation. Patients in whom these intriguing syndromes are suspected require detailed investigation protocols, which should be carried out in specialized centers. While awaiting further developments, the use of traditional medical treatment at the adrenal level with adrenal steroid inhibitors is still valuable in several instances.
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Affiliation(s)
- Nicoletta Sonino
- Department of Statistical Sciences, University of Padova, Padova, Italy.
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Abstract
Cushing's syndrome results from prolonged exposure to excessive circulating glucocorticosteroids, and is associated with significant morbidity and mortality. While the treatment of choice in most patients is surgical, the metabolic consequences of the syndrome, including increased tissue fragility, poor wound healing, hypertension, and diabetes mellitus, increase the risks of such surgery. The hypercortisolemia and its sequelae can be efficiently reversed using medical therapy, either as a temporary measure prior to definitive treatment, or longer term in more difficult cases. Drug treatment has been targeted at the hypothalamic/pituitary level, the adrenal glands, and also at the glucocorticoid receptor level. In this review we discuss the pharmacotherapeutic agents that have been used in Cushing's syndrome, and their efficacy, the monitoring of treatment, and potential therapies that may prove useful in the future in this complex endocrinological disorder.
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Affiliation(s)
- Damian Morris
- Department of Endocrinology, St. Bartholomew's Hospital, London EC1A 7BE, England, United Kingdom
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Vilar L, Naves L, Freitas MDC, Oliveira Jr. S, Leite V, Canadas V. Tratamento medicamentoso dos tumores hipofisários. parte II: adenomas secretores de ACTH, TSH e adenomas clinicamente não-funcionantes. ACTA ACUST UNITED AC 2000. [DOI: 10.1590/s0004-27302000000600004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Este artigo revisa o potencial papel do tratamento medicamentoso para os adenomas hipofisários secretores de ACTH, TSH e aqueles clinicamente não-funcionantes (ACNF), Metirapona, mitotano e cetoconazol (preferível por causar menos efeitos colaterais) são as drogas mais eficazes no controle do hipercortisolismo, mas nenhuma delas supera a eficácia da cirurgia transesfenoidal (TSA). O tratamento medicamentoso da doença de Cushing está, portanto, melhor indicado para pacientes aguardando o efeito pleno da radioterapia ou, como alternativa para esta última, em casos de hipercortisolismo persistente após TSA, e para pacientes com rejeição ou limitações clínicas para a cirurgia. Outra indicação potencial seria em idosos com microadenomas ou pequenos macroadenomas, ou em casos associados a sela vazia. No que se refere aos adenomas secretores de TSH, os análogos somatostatínicos (SRIFa) proporcionam normalização dos hormônios tiroideanos em até 95% dos casos. Assim, eles podem se mostrar úteis em casos de insucesso da cirurgia ou como terapia primária de casos selecionados. Ocasionalmente, agonistas dopaminérgicos (DA), sobretudo a cabergolina, também podem ser eficazes. Em contraste, DA e SRIFa raramente induzem uma significante redução das dimensões dos ACNFs. Por isso, em pacientes com tais tumores, essas drogas devem ser principalmente consideradas diante de contra-indicações ou limitações clínicas para a cirurgia ou quando a cirurgia e a radioterapia tenham sido mal-sucedidas.
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Abstract
Various drugs have been employed in the management of pituitary-dependent Cushing's disease. The neuromodulatory compounds used thus far have demonstrated true clinical efficacy only occasionally when employed as sole treatment. Steroid synthesis inhibitors are effective in the majority of cases in a dose-dependent manner. By their ability to correct hypercortisolism and its severe complications quickly, they are suitable for critical cases and in preparation for surgery. The clinical experience with the only glucocorticoid receptor antagonist that can be administered to humans is still too limited to assess its therapeutic validity. No medical strategy can be standardized for this complex condition. Different therapeutic tools should be selected according to the form of disease to be treated (hypothalamic/pituitary) and the peculiar clinical situation of each patient. Combined treatments may achieve better therapeutic efficacy.
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Affiliation(s)
- N Sonino
- Division of Endocrinology, University of Padova, Italy
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