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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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2
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Divaris E, Kostopoulos G, Efstathiadou ZA. Current and Emerging Pharmacological Therapies for Cushing's Disease. Curr Pharm Des 2024; 30:757-777. [PMID: 38424426 DOI: 10.2174/0113816128290025240216110928] [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: 10/29/2023] [Revised: 01/09/2024] [Accepted: 01/31/2024] [Indexed: 03/02/2024]
Abstract
Cushing's Disease (CD), hypercortisolism due to pituitary ACTH secreting neuroendocrine neoplasm, is associated with increased morbidity and, if untreated, mortality in about half of the affected individuals. Consequently, the timely initiation of effective treatment is mandatory. Neurosurgery is the first line and the only potentially curative treatment; however, 30% of patients will have persistent disease post-surgery. Furthermore, a small percentage of those initially controlled will develop hypercortisolism during long-term follow- up. Therefore, patients with persistent or recurrent disease, as well as those considered non-eligible for surgery, will need a second-line therapeutic approach, i.e., pharmacotherapy. Radiation therapy is reserved as a third-line therapeutic option due to its slower onset of action and its unfavorable profile regarding complications. During the past few years, the understanding of molecular mechanisms implicated in the physiology of the hypothalamus-pituitary-adrenal axis has evolved, and new therapeutic targets for CD have emerged. In the present review, currently available treatments, compounds currently tested in ongoing clinical trials, and interesting, potentially new targets emerging from unraveling molecular mechanisms involved in the pathophysiology of Cushing's disease are discussed.
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Affiliation(s)
- Efstathios Divaris
- Department of Endocrinology, "Hippokration" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Georgios Kostopoulos
- Department of Endocrinology, "Hippokration" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Zoe A Efstathiadou
- Department of Endocrinology, "Hippokration" General Hospital of Thessaloniki, Thessaloniki, Greece
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3
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Feelders RA, Fleseriu M, Kadioglu P, Bex M, González-Devia D, Boguszewski CL, Yavuz DG, Patino H, Pedroncelli AM, Maamari R, Chattopadhyay A, Biller BMK, Pivonello R. Long-term efficacy and safety of subcutaneous pasireotide alone or in combination with cabergoline in Cushing's disease. Front Endocrinol (Lausanne) 2023; 14:1165681. [PMID: 37876540 PMCID: PMC10593462 DOI: 10.3389/fendo.2023.1165681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 08/11/2023] [Indexed: 10/26/2023] Open
Abstract
Objective This study evaluated short- and long-term efficacy and safety of the second-generation somatostatin receptor ligand pasireotide alone or in combination with dopamine agonist cabergoline in patients with Cushing's disease (CD). Study design This is an open-label, multicenter, non-comparative, Phase II study comprising 35-week core phase and an optional extension phase. All patients started with pasireotide, and cabergoline was added if cortisol remained elevated. Eligible patients had active CD, with or without prior surgery, were pasireotide naïve at screening or had discontinued pasireotide for reasons other than safety. Primary endpoint was proportion of patients with a mean urinary free cortisol (mUFC) level not exceeding the upper limit of normal (ULN) at week 35 with missing data imputed using last available post-baseline assessments. Results Of 68 patients enrolled, 26 (38.2%) received pasireotide monotherapy and 42 (61.8%) received pasireotide plus cabergoline during the core phase. Thirty-four patients (50.0%; 95% CI 37.6-62.4) achieved the primary endpoint, of whom 17 (50.0%) received pasireotide monotherapy and 17 (50.0%) received combination therapy. Proportion of patients with mUFC control remained stable during the extension phase up to week 99. Treatment with either mono or combination therapy provided sustained improvements in clinical symptoms of hypercortisolism up to week 99. Hyperglycemia and nausea (51.5% each), diarrhea (44.1%) and cholelithiasis (33.8%) were the most frequent adverse events. Conclusion Addition of cabergoline in patients with persistently elevated mUFC on maximum tolerated doses of pasireotide is an effective and well-tolerated long-term strategy for enhancing control of hypercortisolism in some CD patients. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT01915303, identifier NCT01915303.
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Affiliation(s)
- Richard A. Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Maria Fleseriu
- Pituitary Center, Departments of Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
| | - Pinar Kadioglu
- Division of Endocrinology, Metabolism and Diabetes, Cerrahpasa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Türkiye
| | - Marie Bex
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Deyanira González-Devia
- Departamento de Medicina Interna, Sección de Endocrinologia, Hospital Universitario Fundación Santa Fé de Bogotá, Bogota, Colombia
| | - Cesar Luiz Boguszewski
- Department of Internal Medicine, Endocrine Division (SEMPR), Federal University of Paraná, Curitiba, Parana, Brazil
| | - Dilek Gogas Yavuz
- Section of Endocrinology and Metabolism, Marmara University School of Medicine, Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul, Türkiye
| | - Heather Patino
- Global Medical Affairs, Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | - Alberto M. Pedroncelli
- Recordati AG, Basel, Switzerland
- Global Medical Affairs, Novartis Pharma AG, Basel, Switzerland
| | - Ricardo Maamari
- Global Medical Affairs, Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | - Arghya Chattopadhyay
- Global Medical Affairs, Novartis Healthcare Private Limited, Hyderabad, Telangana, India
| | - Beverly M. K. Biller
- Neuroendocrine & Pituitary Tumor Clinical Center, Massachusetts General Hospital, Boston, MA, United States
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
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4
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Fleseriu M, Varlamov EV, Hinojosa-Amaya JM, Langlois F, Melmed S. An individualized approach to the management of Cushing disease. Nat Rev Endocrinol 2023; 19:581-599. [PMID: 37537306 DOI: 10.1038/s41574-023-00868-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 08/05/2023]
Abstract
Cushing disease caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary corticotroph adenoma leads to hypercortisolaemia with high mortality due to metabolic, cardiovascular, immunological, neurocognitive, haematological and infectious conditions. The disorder is challenging to diagnose because of its common and heterogenous presenting features and the biochemical pitfalls of testing levels of hormones in the hypothalamic-pituitary-adrenal axis. Several late-night salivary cortisol and 24-h urinary free cortisol tests are usually required as well as serum levels of cortisol after a dexamethasone suppression test. MRI might only identify an adenoma in 60-75% of patients and many adenomas are small. Therefore, inferior petrosal sinus sampling remains the gold standard for confirmation of ACTH secretion from a pituitary source. Initial treatment is usually transsphenoidal adenoma resection, but preoperative medical therapy is increasingly being used in some countries and regions. Other management approaches are required if Cushing disease persists or recurs following surgery, including medications to modulate ACTH or block cortisol secretion or actions, pituitary radiation, and/or bilateral adrenalectomy. All patients require lifelong surveillance for persistent comorbidities, clinical and biochemical recurrence, and treatment-related adverse effects (including development of treatment-associated hypopituitarism). In this Review, we discuss challenges in the management of Cushing disease in adults and provide information to guide clinicians when planning an integrated and individualized approach for each patient.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA.
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
| | - Elena V Varlamov
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
| | - Jose M Hinojosa-Amaya
- Division of Endocrinology, Department of Medicine, Hospital Universitario "Dr. José E. González", Autonomous University of Nuevo León, Monterrey, Mexico
| | - Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Shlomo Melmed
- Department of Medicine and Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Sulu C, Gul N, Tanrikulu S, Ciftci S, Yener Ozturk F, Sarac B, Ersungur EB, Tanriover E, Sahin S, Ozkaya HM, Poyraz BC, Kadioglu P. Risk of impulse control disorders in patients with Cushing's disease: do not blame cabergoline but do not give up caution. Pituitary 2023:10.1007/s11102-023-01342-3. [PMID: 37474846 DOI: 10.1007/s11102-023-01342-3] [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] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE To asses risk of new-onset impulse control disorders (ICDs) in patients with Cushing's disease (CD) who initiated cabergoline (CBG) and to determine frequency of ICDs in CBG-treated patients with CD. METHODS This naturalistic observational study had prospective and cross-sectional arms which included patients at five referral centers based in Istanbul. Patients who were scheduled for CBG were assigned to prospective arm. These patients underwent neuropsychological tests (Barratt Impulsiveness Scale, Minnesota Impulsive Disorders Interview, Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease-Rating Scale, Go/No-Go Task, Iowa Gambling Task, and Short Penn Continuous Performance Test) for assessment of impulsivity and psychiatric evaluations at baseline, 3, 6, and 12 months of CBG treatment. Impulsivity and new-onset ICDs were prospectively assessed. Patients with CD with current CBG treatment for ≥ 3 months and matched CBG-naïve patients with CD were included in cross-sectional arm. These patients underwent the same neuropsychological and psychiatric assessments. The impulsivity and frequency of ICDs were compared between CBG-treated and CBG-naïve patients with CD. RESULTS The follow-up duration of prospective cohort (n = 14) was 7.3 ± 2.3 months. One patient developed major depressive episode and another patient developed compulsive gambling after CBG. We observed no significant changes in impulsivity scores during follow-up. In cross-sectional arm, CBG-treated (n = 34) and CBG-naïve patients (n = 34) were similar in impulsivity scores and frequency of ICDs [3 patients (8.8%) vs. 2 patients (5.9%) respectively, p = 1.0]. CONCLUSION CBG-treated patients with CD appeared to have a low risk of ICDs, suggesting that CBG still holds promise as a safe agent in CD.
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Affiliation(s)
- Cem Sulu
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street No:53, Fatih, 34098, Istanbul, Turkey
| | - Nurdan Gul
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Seher Tanrikulu
- Division of Endocrinology, Department of Internal Medicine, Acibadem Hospital, Istanbul, Turkey
| | - Sema Ciftci
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Feyza Yener Ozturk
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Betul Sarac
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Elif Burcu Ersungur
- Department of Psychiatry, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | - Serdar Sahin
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street No:53, Fatih, 34098, Istanbul, Turkey
| | - Hande Mefkure Ozkaya
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street No:53, Fatih, 34098, Istanbul, Turkey
| | - Burc Cagri Poyraz
- Department of Psychiatry, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Pinar Kadioglu
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street No:53, Fatih, 34098, Istanbul, Turkey.
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Ashrafzadeh S, Mariano MT, Syed S. Cushing's Disease Presenting with Functional Neurological (Conversion) Disorder. Case Rep Psychiatry 2023; 2023:1662271. [PMID: 36938346 PMCID: PMC10017209 DOI: 10.1155/2023/1662271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 01/06/2023] [Accepted: 01/25/2023] [Indexed: 03/10/2023] Open
Abstract
While psychiatric manifestations are common in patients with Cushing's syndrome (CS), to our knowledge, there are no reported cases of CS presenting with functional neurological disorder (FND), a neuropsychiatric condition in which patients experience neurological symptoms, such as motor dysfunctions, sensory symptoms, speech disorders, or nonepileptic seizures, in the absence of neurological disease. Here, we report a case of a complex patient with Cushing's disease who presented with multiple FND symptoms including nonepileptic seizures, bilateral lower extremity paralysis, decreased finger flexion resulting in limited hand function, and stuttering. This case illustrates a rare psychiatric manifestation of CS presenting as multiple neurological complaints. Furthermore, we elucidate how a multidisciplinary treatment approach improved our patient's FND symptoms.
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Affiliation(s)
- Sahar Ashrafzadeh
- 1David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Maria Theresa Mariano
- 1David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- 2Department of Psychiatry and Biobehavioral Sciences, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Saba Syed
- 1David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- 2Department of Psychiatry and Biobehavioral Sciences, Olive View-UCLA Medical Center, Sylmar, CA, USA
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7
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Mehlich A, Bolanowski M, Mehlich D, Witek P. Medical treatment of Cushing's disease with concurrent diabetes mellitus. Front Endocrinol (Lausanne) 2023; 14:1174119. [PMID: 37139336 PMCID: PMC10150952 DOI: 10.3389/fendo.2023.1174119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/03/2023] [Indexed: 05/05/2023] Open
Abstract
Cushing's disease (CD) is a severe endocrine disorder characterized by chronic hypercortisolaemia secondary to an overproduction of adrenocorticotropic hormone (ACTH) by a pituitary adenoma. Cortisol excess impairs normal glucose homeostasis through many pathophysiological mechanisms. The varying degrees of glucose intolerance, including impaired fasting glucose, impaired glucose tolerance, and Diabetes Mellitus (DM) are commonly observed in patients with CD and contribute to significant morbidity and mortality. Although definitive surgical treatment of ACTH-secreting tumors remains the most effective therapy to control both cortisol levels and glucose metabolism, nearly one-third of patients present with persistent or recurrent disease and require additional treatments. In recent years, several medical therapies demonstrated prominent clinical efficacy in the management of patients with CD for whom surgery was non-curative or for those who are ineligible to undergo surgical treatment. Cortisol-lowering medications may have different effects on glucose metabolism, partially independent of their role in normalizing hypercortisolaemia. The expanding therapeutic landscape offers new opportunities for the tailored therapy of patients with CD who present with glucose intolerance or DM, however, additional clinical studies are needed to determine the optimal management strategies. In this article, we discuss the pathophysiology of impaired glucose metabolism caused by cortisol excess and review the clinical efficacy of medical therapies of CD, with particular emphasis on their effects on glucose homeostasis.
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Affiliation(s)
- Anna Mehlich
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Marek Bolanowski
- Chair and Department of Endocrinology, Diabetes, and Isotope Treatment, Wroclaw Medical University, Wroclaw, Poland
| | - Dawid Mehlich
- Laboratory of Molecular OncoSignalling, International Institute of Molecular Mechanisms and Machines (IMol) Polish Academy of Sciences, Warsaw, Poland
- Doctoral School of Medical University of Warsaw, Medical University of Warsaw, Warsaw, Poland
- Laboratory of Experimental Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
- *Correspondence: Przemysław Witek,
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8
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Dzialach L, Sobolewska J, Respondek W, Wojciechowska-Luzniak A, Witek P. Cushing's syndrome: a combined treatment with etomidate and osilodrostat in severe life-threatening hypercortisolemia. Hormones (Athens) 2022; 21:735-742. [PMID: 36129663 PMCID: PMC9712315 DOI: 10.1007/s42000-022-00397-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/12/2022] [Indexed: 01/23/2023]
Abstract
Endogenous Cushing's syndrome (CS) is associated with increased morbidity and mortality. Early diagnosis and initiation of therapy are essential, but effective treatment remains a challenge. In a long-term follow-up, biochemical control of hypercortisolemia, especially when severe, is difficult to achieve. Life-threatening hypercortisolemia is difficult to control due to the limitations of pharmacotherapy, including its side effects, and may require etomidate infusion in the intensive care unit (ICU) to rapidly lower cortisol levels. The effectiveness of hypercortisolemia management can be increased by a dual blockade of cortisol production. We report the efficacy, safety, and tolerability of combined therapy with two steroidogenesis inhibitors, etomidate, and osilodrostat, in a 32-year-old woman diagnosed with severe ACTH-dependent hypercortisolemia, subsequently maintaining a stable level of cortisol with osilodrostat monotherapy. This approach enabled achievement of relatively rapid control of the hypercortisolemia while using an etomidate infusion and concomitant increasing doses of oral osilodrostat applying a "titrations strategy." Our experience shows that it is worth taking advantage of the synergistic anticortisolic action of etomidate with osilodrostat.
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Affiliation(s)
- Lukasz Dzialach
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Sobolewska
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland.
| | - Wioleta Respondek
- Department of Internal Medicine, Endocrinology and Diabetes, Mazovian Brodnowski Hospital, Warsaw, Poland
| | | | - Przemyslaw Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
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9
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Abstract
Cushing's disease (CD), caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary tumor, is the most common form of Cushing's syndrome (CS), accounting for approximately 70% of cases. CD requires a prompt diagnosis, an adequate treatment selection, and long-term management to limit hypercortisolism duration and long-term complications and improve patient outcomes. Pituitary surgery is the first-line option, which is non-curative in one third of patients, therefore requiring additional treatments. Medical therapy has recently acquired an emerging role, with the availability of several drugs with different therapeutic targets, efficacy and safety profiles. The current review focuses on efficacy and safety of steroidogenesis inhibitors, and particularly the historical drugs, ketoconazole and metyrapone, and the novel drugs levoketoconazole and osilodrostat, which seem to offer a rapid, sustained, and effective disease control. Ketoconazole should be preferred in females and in patients without severe liver disease; levoketoconazole may offer an alternative to classical ketoconazole, appearing characterized by a higher potency and potential lower hepatotoxicity compared to ketoconazole. Metyrapone should be preferred in males and in patients without severe or uncontrolled hypokalemia. Both ketoconazole and metyrapone may be preferred for short-term more than for long-term treatment. Osilodrostat may represent the best choice for long-term treatment, in patients with poor compliance to the multiple daily administration schedule, and in patients without severe or uncontrolled hypokalemia. Steroidogenesis inhibitors may be used alone or in combination, and associated with pituitary directed drugs, to improve the efficacy of the single drugs, allowing a potential use of lower doses for each drug, and hypothetically reducing the rate of adverse events associated with the single drugs. Clinicians may tailor medical therapy on the specific clinical scenario, considering disease history together with patients' characteristics and hypercortisolism's degree, addressing the needs of each patient in order to improve the therapeutic outcome and to reduce the burden of illness, particularly in patients with persistent or recurrent CD.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Naples, Italy.
- Unesco Chair for Health Education and Sustainable Development, University "Federico II", Naples, Italy.
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Naples, Italy
| | - Nicola Di Paola
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Naples, Italy
- Unesco Chair for Health Education and Sustainable Development, University "Federico II", Naples, Italy
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10
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Pivonello R, Pivonello C, Simeoli C, De Martino MC, Colao A. The dopaminergic control of Cushing's syndrome. J Endocrinol Invest 2022; 45:1297-1315. [PMID: 35460460 PMCID: PMC9184412 DOI: 10.1007/s40618-021-01661-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 08/06/2021] [Indexed: 12/14/2022]
Abstract
Cushing's Syndrome (CS), or chronic endogenous hypercortisolism, is a rare and serious disease due to corticotroph pituitary (Cushing's disease, CD) and extra-pituitary (ectopic CS) tumours overproducing ACTH, or cortisol-secreting adrenal tumours or lesions (adrenal CS). The first-line treatment for CS is represented by the surgical removal of the responsible tumour, but surgery might be unfeasible or ineffective and medical treatment can be required in a relevant percentage of patients with CS, especially CD and ectopic CS. Corticotroph pituitary and extra-pituitary tumours, as well as adrenal tumours and lesions responsible for CS express dopamine receptors (DRs), which have been found to mediate inhibition of hormone secretion and/or cell proliferation in experimental setting, suggesting that dopaminergic system, particularly DRs, might represent a target for the treatment of CS. Dopamine agonists (DAs), particularly cabergoline (CAB), are currently used as off-label treatment for CD, the most common form of CS, demonstrating efficacy in controlling hormone secretion and tumour growth in a relevant number of cases, with the improvement of clinical picture, and displaying good safety profile. Therefore, CAB may be considered a reasonable alternative treatment for persistent or recurrent CD after pituitary surgery failure, but occasionally also before pituitary surgery, as adjuvant treatment, or even instead of pituitary surgery as first-line treatment in case of surgery contraindications or refusal. A certain beneficial effect of CAB has been also reported in ectopic CS. However, the role of DAs in the clinical management of the different types of CS requires further evaluations.
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Affiliation(s)
- R Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Università Federico II Di Napoli, Naples, Italy.
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy.
| | - C Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Università Federico II Di Napoli, Naples, Italy
| | - C Simeoli
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Università Federico II Di Napoli, Naples, Italy
| | - M C De Martino
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Università Federico II Di Napoli, Naples, Italy
| | - A Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Università Federico II Di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
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11
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Aydin B, Yildirim E, Erdogan O, Arga KY, Yilmaz BK, Bozkurt SU, Bayrakli F, Turanli B. Past, Present, and Future of Therapies for Pituitary Neuroendocrine Tumors: Need for Omics and Drug Repositioning Guidance. OMICS : A JOURNAL OF INTEGRATIVE BIOLOGY 2022; 26:115-129. [PMID: 35172108 DOI: 10.1089/omi.2021.0221] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Innovation roadmaps are important, because they encourage the actors in an innovation ecosystem to creatively imagine multiple possible science future(s), while anticipating the prospects and challenges on the innovation trajectory. In this overarching context, this expert review highlights the present unmet need for therapeutic innovations for pituitary neuroendocrine tumors (PitNETs), also known as pituitary adenomas. Although there are many drugs used in practice to treat PitNETs, many of these drugs can have negative side effects and show highly variable outcomes in terms of overall recovery. Building innovation roadmaps for PitNETs' treatments can allow incorporation of systems biology approaches to bring about insights at multiple levels of cell biology, from genes to proteins to metabolites. Using the systems biology techniques, it will then be possible to offer potential therapeutic strategies for the convergence of preventive approaches and patient-centered disease treatment. Here, we first provide a comprehensive overview of the molecular subtypes of PitNETs and therapeutics for these tumors from the past to the present. We then discuss examples of clinical trials and drug repositioning studies and how multi-omics studies can help in discovery and rational development of new therapeutics for PitNETs. Finally, this expert review offers new public health and personalized medicine approaches on cases that are refractory to conventional treatment or recur despite currently used surgical and/or drug therapy.
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Affiliation(s)
- Busra Aydin
- Department of Bioengineering, Faculty of Engineering, Marmara University, Istanbul, Turkey
| | - Esra Yildirim
- Department of Bioengineering, Faculty of Engineering, Marmara University, Istanbul, Turkey
| | - Onur Erdogan
- Department of Neurosurgery, School of Medicine, Marmara University, Istanbul, Turkey
| | - Kazim Yalcin Arga
- Department of Bioengineering, Faculty of Engineering, Marmara University, Istanbul, Turkey
- Genetic and Metabolic Diseases Research and Investigation Center, Marmara University, Istanbul, Turkey
| | - Betul Karademir Yilmaz
- Genetic and Metabolic Diseases Research and Investigation Center, Marmara University, Istanbul, Turkey
- Department of Biochemistry and School of Medicine, Marmara University, Istanbul, Turkey
| | - Suheyla Uyar Bozkurt
- Department of Medical Pathology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Fatih Bayrakli
- Department of Neurosurgery, School of Medicine, Marmara University, Istanbul, Turkey
- Institute of Neurological Sciences, Marmara University, Istanbul, Turkey
| | - Beste Turanli
- Department of Bioengineering, Faculty of Engineering, Marmara University, Istanbul, Turkey
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Vega-Beyhart A, Laguna-Moreno J, Díaz-Catalán D, Boswell L, Mora M, Halperin I, Casals G, Hanzu FA. Ketoconazole- and Metyrapone-Induced Reductions on Urinary Steroid Metabolites Alter the Urinary Free Cortisol Immunoassay Reliability in Cushing Syndrome. Front Endocrinol (Lausanne) 2022; 13:833644. [PMID: 35282465 PMCID: PMC8905543 DOI: 10.3389/fendo.2022.833644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Twenty-four-hour urinary free cortisol (24h-UFC) is the most used test for follow-up decision-making in patients with Cushing syndrome (CS) under medical treatment. However, 24h-UFC determinations by immunoassays (IA) are commonly overestimated because of steroid metabolites' cross-reaction. It is still uncertain how ketoconazole (KTZ)- and metyrapone (MTP)-induced changes on the urinary steroid metabolites can alter the 24h-UFC*IA determinations' reliability. METHODS 24h-UFC was analyzed by IA and gas chromatography-mass spectrometry (GC-MS) in 193 samples (81 before treatment, 73 during KTZ, and 39 during MTP) from 34 CS patients. In addition, urinary steroidome was analyzed by GC-MS on each patient before and during treatment. RESULTS Before treatment, 24h-UFC*IA determinations were overestimated by a factor of 1.75 (95% CI 1.60-1.94) compared to those by GC-MS. However, during KTZ treatment, 24h-UFC*IA results were similar (0.98:1) to those by GC-MS (95% CI, 0.83-1.20). In patients taking MTP, IA bias only decreased 0.55, resulting in persistence of an overestimation factor of 1.33:1 (95% CI, 1.09-1.76). High method agreement between GC-MS and IA before treatment (R2 = 0.954) declined in patients under KTZ (R2 = 0.632) but not in MTP (R2 = 0.917). Upper limit normal (ULN) reductions in patients taking KTZ were 27% larger when using 24h-UFC*IA compared to 24h-UFC*GC-MS, which resulted in higher false efficacy and misleading biochemical classification of 15% of patients. Urinary excretion changes of 22 urinary steroid metabolites explained 86% of the 24h-UFC*IA interference. Larger urinary excretion reductions of 6β-hydroxy-cortisol, 20α-dihydrocortisol, and 18-hydroxy-cortisol in patients with KTZ elucidated the higher 24h-UFC*IA bias decrement compared to MTP-treated patients. CONCLUSION KTZ and MTP alter the urinary excretion of IA cross-reactive steroid metabolites, thus decreasing the cross-reactive interference of 24h-UFC*IA determinations present before treatment. Consequently, this interference reduction in 24h-UFC*IA leads to loss of method agreement with GC-MS and high risk of overestimating the biochemical impact of KTZ and MTP in controlling CS because of poor reliability of reference ranges and ULN.
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Affiliation(s)
- Arturo Vega-Beyhart
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | | | - Daniela Díaz-Catalán
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Laura Boswell
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Mireia Mora
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Irene Halperin
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Gregori Casals
- Biomedical Diagnostics Center, Hospital Clinic, Barcelona, Spain
| | - Felicia A. Hanzu
- Group of Endocrine Disorders, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
- *Correspondence: Felicia A. Hanzu,
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Viecceli C, Mattos ACV, Costa MCB, de Melo RB, Rodrigues TDC, Czepielewski MA. Evaluation of ketoconazole as a treatment for Cushing's disease in a retrospective cohort. Front Endocrinol (Lausanne) 2022; 13:1017331. [PMID: 36277689 PMCID: PMC9585352 DOI: 10.3389/fendo.2022.1017331] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/06/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The first-line treatment for Cushing's disease is transsphenoidal surgery, after which the rates of remission are 60 to 80%, with long-term recurrence of 20 to 30%, even in those with real initial remission. Drug therapies are indicated for patients without initial remission or with surgical contraindications or recurrence, and ketoconazole is one of the main available therapies. The objective of this study was to evaluate the safety profile of and the treatment response to ketoconazole in Cushing's disease patients followed up at the endocrinology outpatient clinic of a Brazilian university hospital. PATIENTS AND METHODS This was a retrospective cohort of Cushing's disease patients with active hypercortisolism who used ketoconazole at any stage of follow-up. Patients who were followed up for less than 7 days, who did not adhere to treatment, or who were lost to follow-up were excluded. RESULTS Of the 172 Cushing's disease patients who were followed up between 2004 and 2020, 38 received ketoconazole. However, complete data was only available for 33 of these patients. Of these, 26 (78%) underwent transsphenoidal surgery prior to using ketoconazole, five of whom (15%) had also undergone radiotherapy; seven used ketoconazole as a primary treatment. Ketoconazole use ranged from 14 days to 14.5 years. A total of 22 patients had a complete response (66%), three patients had a partial response (9%), and eight patients had no response to treatment (24%), including those who underwent radiotherapy while using ketoconazole. Patients whose hypercortisolism was controlled or partially controlled with ketoconazole had lower baseline 24-h urinary free cortisol levels than the uncontrolled group [times above the upper limit of normal: 0.62 (SD, 0.41) vs. 5.3 (SD, 8.21); p < 0.005, respectively] in addition to more frequent previous transsphenoidal surgery (p < 0.04). The prevalence of uncontrolled patients remained stable over time (approximately 30%) despite ketoconazole dose adjustments or association with other drugs, which had no significant effect. One patient received adjuvant cabergoline from the beginning of the follow-up, and it was prescribed to nine others due to clinical non-response to ketoconazole alone. Ten patients (30%) reported mild adverse effects, such as nausea, vomiting, dizziness, and loss of appetite. Only four patients had serious adverse effects that warranted discontinuation. There were 20 confirmed episodes of hypokalemia among 10/33 patients (30%). CONCLUSION Ketoconazole effectively controlled hypercortisolism in 66% of Cushing's disease patients, being a relatively safe drug for those without remission after transsphenoidal surgery or whose symptoms must be controlled until a new definitive therapy is carried out. Hypokalemia is a frequent metabolic effect not yet described in other series, which should be monitored during treatment.
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Affiliation(s)
- Camila Viecceli
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil
| | - Ana Carolina Viana Mattos
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
| | | | | | - Ticiana da Costa Rodrigues
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Mauro Antonio Czepielewski
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- *Correspondence: Mauro Antonio Czepielewski,
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15
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Varlamov EV, Han AJ, Fleseriu M. Updates in adrenal steroidogenesis inhibitors for Cushing's syndrome - A practical guide. Best Pract Res Clin Endocrinol Metab 2021; 35:101490. [PMID: 33707082 DOI: 10.1016/j.beem.2021.101490] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Medical therapy is essential in the management of patients with Cushing's syndrome (CS) when curative surgery has failed, surgery is not feasible, when awaiting radiation effect, and in recurrent cases of CS. Steroidogenesis inhibitors have a rapid onset of action and are effective in reducing hypercortisolism, however, adverse effects, including adrenal insufficiency require very close patient monitoring. Osilodrostat is the only steroidogenesis inhibitor to have been assessed in prospective randomized controlled trials and approved for Cushing's disease (CD) by the US Food and Drug Administration and for CS by the European Medical Agency (EMA). Osilodrostat has been shown to be highly effective at maintaining normal urinary free cortisol in patients with CD. Drugs such as metyrapone, ketoconazole (both EMA approved), and etomidate lack prospective evaluation(s). There is, however, considerable clinical experience and retrospective data that show a very wide efficacy range in treating patients with CS. In the absence of head-to-head comparative clinical trials, therapy choice is determined by the specific clinical setting, risk of adverse events, cost, availability, and other factors. In this review practical points to help clinicians who are managing patients with CS being treated with steroidogenesis inhibitors are presented.
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Affiliation(s)
- Elena V Varlamov
- Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Mail Code CH8N, 3303 South Bond Avenue, Portland, OR, 97239, USA
| | - Ashley J Han
- School of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Pk. Rd, Portland, OR, 97239, USA
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Mail Code CH8N, 3303 South Bond Avenue, Portland, OR, 97239, USA.
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Pivonello C, Patalano R, Negri M, Pirchio R, Colao A, Pivonello R, Auriemma RS. Resistance to Dopamine Agonists in Pituitary Tumors: Molecular Mechanisms. Front Endocrinol (Lausanne) 2021; 12:791633. [PMID: 35095761 PMCID: PMC8789681 DOI: 10.3389/fendo.2021.791633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/16/2021] [Indexed: 11/24/2022] Open
Abstract
Pituitary neuroendocrine tumors (PitNET) are commonly benign tumors accounting for 10-25% of intracranial tumors. Prolactin-secreting adenomas represent the most predominant type of all PitNET and for this subtype of tumors, the medical therapy relies on the use of dopamine agonists (DAs). DAs yield an excellent therapeutic response in reducing tumor size and hormonal secretion targeting the dopamine receptor type 2 (D2DR) whose higher expression in prolactin-secreting adenomas compared to other PitNET is now well established. Moreover, although DAs therapy does not represent the first-line therapy for other PitNET, off-label use of DAs is considered in PitNET expressing D2DR. Nevertheless, DAs primary or secondary resistance, occurring in a subset of patients, may involve several molecular mechanisms, presently not fully elucidated. Dopamine receptors (DRs) expression is a prerequisite for a proper DA function in PitNET and several molecular events may negatively modify DR membrane expression, through the DRs down-regulation and intracellular trafficking, and DR signal transduction pathway. The current mini-review will summarise the presently known molecular events that underpin the unsuccessful therapy with DAs.
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Affiliation(s)
- Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università di Napoli (Federico II), Naples, Italy
- *Correspondence: Claudia Pivonello, ;
| | - Roberta Patalano
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università di Napoli (Federico II), Naples, Italy
- Dipartimento di Sanità Pubblica, Università di Napoli (Federico II), Naples, Italy
| | - Mariarosaria Negri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università di Napoli (Federico II), Naples, Italy
| | - Rosa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università di Napoli (Federico II), Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università di Napoli (Federico II), Naples, Italy
- United Nations Educational, Scientific and Cultural Organization (UNESCO) Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università di Napoli (Federico II), Naples, Italy
- United Nations Educational, Scientific and Cultural Organization (UNESCO) Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - Renata Simona Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università di Napoli (Federico II), Naples, Italy
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Simões Corrêa Galendi J, Correa Neto ANS, Demetres M, Boguszewski CL, Nogueira VDSN. Effectiveness of Medical Treatment of Cushing's Disease: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2021; 12:732240. [PMID: 34603209 PMCID: PMC8485729 DOI: 10.3389/fendo.2021.732240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/20/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE The objective of this systematic review was to evaluate the effectiveness and safety of pasireotide, cabergoline, ketoconazole, levoketoconazole, metyrapone, osilodrostat, and temozolomide for the treatment of Cushing's disease (CD). METHODS The primary outcomes were the proportion of CD control, adverse events (AE), and reduction of urinary free cortisol. Search strategies were applied to Embase, Medline, and CENTRAL. Independent reviewers assessed the study eligibility, extracted data, and evaluated risk of bias. Standardized mean difference was calculated with 95% confidence interval (CI) for continuous data (i.e., pre- and post-intervention). Random meta-analyses for the proportion of CD control and AE were conducted. RESULTS Twenty-nine controlled and non-controlled studies were included. No study with temozolomide and levoketoconazole and one study with osilodrostat fulfilled the inclusion criteria. The meta-analyses of proportion of CD control was 35% for cabergoline (95% CI: 27-43%, six studies, 141 participants), 44% for pasireotide (95% CI: 25-35%, eight studies, 522 participants), 41% for ketoconazole (95% CI: 36-46%, six studies, 450 participants), 66% for metyrapone (95% CI: 46-87%, four studies, 66 participants), and of 66.4% for osilodrostat (95% CI: 57.9, 74.3, 97 participants, one study). One study compared two different treatments (cabergoline vs. ketoconazole), and no statistical difference was observed in CD control (RR: 0.53, 95% CI: 0.15 to 1.87, 14 participants, very low certainty of evidence). The most frequent AE associated with pasireotide was hyperglycemia, dizziness and nausea with cabergoline and metyrapone, and elevated transaminases with ketoconazole. CONCLUSION The superiority of one drug over another could not be determined due to lack of controlled studies, but the proportion of disease control identified in our meta-analysis may support clinical decision. New therapeutic options should be investigated due to the limited efficacy and tolerability of the currently available medical treatment for patients with Cushing's disease. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020205567, identifier CRD42020205567.
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Affiliation(s)
- Julia Simões Corrêa Galendi
- University of Cologne, Faculty of Medicine and University Hospital of Cologne, Institute of Health Economics and Clinical Epidemiology, Cologne, Germany
| | | | - Michelle Demetres
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY, United States
| | - Cesar Luiz Boguszewski
- Department of Internal Medicine, Endocrine Division (SEMPR), Federal University of Parana, Curitiba, Brazil
| | - Vania dos Santos Nunes Nogueira
- Department of Internal Medicine, São Paulo State University/UNESP, Medical School, Botucatu, São Paulo, Brazil
- *Correspondence: Vania dos Santos Nunes Nogueira,
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Nakano-Tateno T, Lau KJ, Wang J, McMahon C, Kawakami Y, Tateno T, Araki T. Multimodal Non-Surgical Treatments of Aggressive Pituitary Tumors. Front Endocrinol (Lausanne) 2021; 12:624686. [PMID: 33841328 PMCID: PMC8033019 DOI: 10.3389/fendo.2021.624686] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/12/2021] [Indexed: 12/20/2022] Open
Abstract
Up to 35% of aggressive pituitary tumors recur and significantly affect mortality and quality of life. Management can be challenging and often requires multimodal treatment. Current treatment options, including surgery, conventional medical therapies such as dopamine agonists, somatostatin receptor agonists and radiotherapy, often fail to inhibit pituitary tumor growth. Recently, anti-tumor effects of chemotherapeutic drugs such as Temozolomide, Capecitabine, and Everolimus, as well as peptide receptor radionuclide therapy on aggressive pituitary tumors have been increasingly investigated and yield mixed, although sometimes promising, outcomes. The purpose of this review is to provide thorough information on non-surgical medical therapies and their efficacies and used protocols for aggressive pituitary adenomas from pre-clinical level to clinical use.
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Affiliation(s)
- Tae Nakano-Tateno
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kheng Joe Lau
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Justin Wang
- Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis, MN, United States
| | - Cailin McMahon
- Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis, MN, United States
| | - Yasuhiko Kawakami
- Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis, MN, United States
- Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States
| | - Toru Tateno
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Toru Tateno, ; Takako Araki,
| | - Takako Araki
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- *Correspondence: Toru Tateno, ; Takako Araki,
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Abstract
Medical therapy has an adjunctive role in management of Cushing disease. Medical therapy is recommended for patients who received pituitary radiotherapy and are awaiting its salutary effects. Medications are used preoperatively to stabilize the condition of seriously ill patients before surgery. Medical therapy is used to control hypercortisolism in patients with uncertain tumor location. Medical therapies available for management of patients with Cushing disease include steroidogenesis inhibitors, centrally acting agents, and glucocorticoid receptor antagonists. All agents require careful monitoring to optimize clinical effectiveness and manage adverse effects. Novel agents in development may expand the armamentarium for management of this condition.
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Affiliation(s)
- Nicholas A Tritos
- Neuroendocrine Unit, Neuroendocrine and Pituitary Tumor Clinical Center, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Suite 140, Boston, MA 02114, USA.
| | - Beverly M K Biller
- Neuroendocrine Unit, Neuroendocrine and Pituitary Tumor Clinical Center, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Suite 140, Boston, MA 02114, USA
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Abstract
Dopamine agonist therapy is the primary therapy for prolactin-secreting adenomas and usually results in normoprolactinemia, eugonadism, and tumor reduction. Cabergoline is superior to bromocriptine with regard to efficacy and tolerance. Withdrawal of cabergoline can be attempted in patients with normal prolactin levels on low doses of medication and evidence of radiographic tumor involution. Dopamine agonists have been used off label in patients with acromegaly, Cushing disease, and nonfunctioning adenomas. A trial of cabergoline monotherapy can be effective in patients with biochemically mild acromegaly. Cabergoline combination with somatostatin receptor ligands or pegvisomant improves insulin-like growth factor level 1 in majority of patients.
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Affiliation(s)
- Erica A Giraldi
- Department of Medicine: Endocrinology and Metabolism, Emory University, Atlanta, GA 30322, USA
| | - Adriana G Ioachimescu
- Department of Medicine: Endocrinology and Metabolism, Emory University, Atlanta, GA 30322, USA; Department of Neurosurgery, Emory University, Atlanta, GA, USA.
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Albani A, Theodoropoulou M. Persistent Cushing's Disease after Transsphenoidal Surgery: Challenges and Solutions. Exp Clin Endocrinol Diabetes 2020; 129:208-215. [PMID: 32838436 DOI: 10.1055/a-1220-6056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Transsphenoidal surgery remains the primary treatment for Cushing's disease (CD). However, despite the vast improvements in pituitary surgery, successful treatment of CD remains a great challenge. Although selective transsphenoidal removal of the pituitary tumor is a safe and effective procedure, the disease persists in around 22% of CD patients due to incomplete tumor resection. The persistence of hypercortisolism after pituitary surgery may also be the consequence of a misdiagnosis, as can occur in case of ectopic ACTH secretion or pseudo-Cushing. Considering the elevated mortality and morbidity characterizing the disease, a multidisciplinary approach is needed to minimize potential pitfalls occurring during the diagnosis, avoid surgical failure and provide the best care in those patients who have undergone unsuccessful surgery. In this review, we analyze the factors that could predict remission or persistence of CD after pituitary surgery and revise the therapeutic options in case of surgical failure.
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Affiliation(s)
- Adriana Albani
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
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Singh R, Didwania P, Lehrer EJ, Sheehan D, Sheehan K, Trifiletti DM, Sheehan JP. Stereotactic radiosurgery for acromegaly: an international systematic review and meta-analysis of clinical outcomes. J Neurooncol 2020; 148:401-418. [PMID: 32506372 DOI: 10.1007/s11060-020-03552-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/30/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION We performed a systematic review and meta-analysis of clinical outcomes for patients with acromegaly treated with stereotactic radiosurgery (SRS). METHODS Primary outcomes were 5- and 10-year endocrine remission (ER) and endocrine control (EC). Secondary outcomes were 10-year radiographic local control (LC), visual toxicity, and hypopituitarism rates. Weighted random effects meta-analyses using the DerSimonian and Laird methods were conducted to characterize and compare effect sizes. Mixed effects regression models were used to examine correlations between potential prognostic factors and primary and secondary outcomes. RESULTS In total, 1533 patients across 20 published studies with acromegaly treated with SRS were included. At 5-years, estimated ER and EC rates were 43.2% (95% CI 31.7-54.6%) and 55.0% (95% CI 27.6-82.4%), respectively. At 10-years, estimated ER and EC rates were 56.9% (95% CI 47.5-66.4%) and 69.7% (95% CI 47.7-91.8%), respectively. The estimated 10-year LC rate was 92.8% (95% CI 83.0-100%). Visual toxicity and hypopituitarism following SRS were estimated to be 2.7% (95% CI 1.3-4.2%) and 26.8% (95% CI 16.9-36.7%), respectively. Every 1 Gy increase in margin prescription dose beyond 17 Gy was estimated to result in a 0.41% increased risk of visual toxicity (p = 0.03). No prognostic factors were associated with EC, ER, LC, or hypopituitarism. CONCLUSIONS SRS was well-tolerated in the management of pituitary acromegaly resulting in gradually improving ER and EC rates over time that approached 60% and 70%. SRS-related visual loss is an uncommon treatment-related side effect, and patient-specific clinical decision making remains critical.
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Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Prabhanjan Didwania
- Rady School of Management, University of California at San Diego, San Diego, CA, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Darrah Sheehan
- Department of Neurosurgery, University of Virginia, School of Medicine, Box 800212, Charlottesville, VA, 22903, USA
| | - Kimball Sheehan
- Department of Neurosurgery, University of Virginia, School of Medicine, Box 800212, Charlottesville, VA, 22903, USA
| | | | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, School of Medicine, Box 800212, Charlottesville, VA, 22903, USA.
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Solari D, Pivonello R, Caggiano C, Guadagno E, Chiaramonte C, Miccoli G, Cavallo LM, Del Basso De Caro M, Colao A, Cappabianca P. Pituitary Adenomas: What Are the Key Features? What Are the Current Treatments? Where Is the Future Taking Us? World Neurosurg 2020; 127:695-709. [PMID: 31266132 DOI: 10.1016/j.wneu.2019.03.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/05/2019] [Indexed: 12/18/2022]
Abstract
Pituitary tumors are a heterogeneous group of lesions (usually benign) and proper understanding of the anatomy, physiology, and pathology of the hypothalamic/pituitary region is essential to make an accurate diagnosis and define the essential treatment options (i.e., surgery, medical therapies, and radiotherapy, alone or in combination). Surgery is the primary treatment for acromegaly, Cushing disease, thyroid-stimulating hormone-secreting adenomas, resistant prolactinomas, and nonfunctioning pituitary adenomas causing mass effect. Medical and radiation therapy are reserved in cases in which surgery is not possible or does not provide a complete cure. In the last decades, tremendous innovations (i.e., targeted drugs and refined surgical tools and techniques) have expanded the treatment strategies for pituitary adenomas. We herein report the current indications for and depiction of the surgical techniques in pituitary surgery, review current medical treatments, and provide a glimpse of future possibilities.
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Affiliation(s)
- Domenico Solari
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy.
| | - Rosario Pivonello
- Division of Endocrinology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Chiara Caggiano
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Elia Guadagno
- Department of Advanced Biomedical Sciences, Section of Pathology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Carmela Chiaramonte
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Giovanni Miccoli
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Marialaura Del Basso De Caro
- Department of Advanced Biomedical Sciences, Section of Pathology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Annamaria Colao
- Division of Endocrinology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
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24
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Pivonello R, Ferrigno R, De Martino MC, Simeoli C, Di Paola N, Pivonello C, Barba L, Negri M, De Angelis C, Colao A. Medical Treatment of Cushing's Disease: An Overview of the Current and Recent Clinical Trials. Front Endocrinol (Lausanne) 2020; 11:648. [PMID: 33363514 PMCID: PMC7753248 DOI: 10.3389/fendo.2020.00648] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/07/2020] [Indexed: 12/20/2022] Open
Abstract
Cushing's disease (CD) is a serious endocrine disorder characterized by chronic hypercortisolism, or Cushing's syndrome (CS), caused by a corticotroph pituitary tumor, which induces an excessive adrenocorticotropic hormone (ACTH) and consequently cortisol secretion. CD presents a severe clinical burden, with impairment of the quality of life and increase in mortality. Pituitary surgery represents the first-line therapy, but it is non-curative in one third of patients, requiring additional treatments. Among second-line treatments, medical therapy is gradually gaining importance, although the current medical treatments are unable to reach optimal efficacy and safety profile. Therefore, new drugs and new formulations of presently available drugs are currently under clinical investigation in international clinical trials, in order to assess their efficacy and safety in CD, or in the general population of CS. Among pituitary-directed agents, pasireotide, in the twice-daily subcutaneous formulation, has been demonstrated to be an effective treatment both in clinical trials and in real-world studies, and extension studies of the phase II and III clinical trials reported evidence of long-term efficacy with general good safety profile, although associated with frequent hyperglycemia, which requires monitoring of glucose metabolism. Moreover, the most recent once-monthly intramuscular formulation, pasireotide long-acting release (LAR), showed similar efficacy and safety, but associated with potential better compliance profile in CD. Roscovitine is an experimental drug currently under investigation. Among adrenal-directed agents, metyrapone is the only historical agent currently under investigation in a prospective, multicenter, international clinical trial, that would likely clarify its efficacy and safety in a large population of patients with CS. Osilodrostat, a novel agent with a mechanism of action similar to metyrapone, seems to offer a rapid, sustained, and effective disease control of CD, according to recently completed clinical trials, whereas levoketoconazole, a different chemical formulation of the historical agent ketoconazole, is still under investigation in clinical trials, with preliminary evidences showing an effective and safe control of CS. ATR-101 is an experimental drug currently under investigation. Among glucocorticoid receptor-directed drugs, mifepristone has been demonstrated to improve clinical syndrome and comorbidities, especially hypertension and impairment of glucose metabolism, but the occurrence of hypokalemia and in women uterine disorders, due to the concomitant action on progestin receptor, requires caution, whereas the preliminary evidence on relacorilant, characterized by high selectivity for glucocorticoid receptor, suggested good efficacy in the control of hypertension and impairment of glucose metabolism, as well as a good safety profile, in CS. Finally, a limited experience has demonstrated that combination therapy might be an interesting approach in the management of CD. The current review provides a summary of the available evidences from current and recent clinical trials on CD, with a specific focus on preliminary data.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Maria Cristina De Martino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Nicola Di Paola
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Livia Barba
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Mariarosaria Negri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Cristina De Angelis
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
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25
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Lin S, Zhang A, Zhang X, Wu ZB. Treatment of Pituitary and Other Tumours with Cabergoline: New Mechanisms and Potential Broader Applications. Neuroendocrinology 2020; 110:477-488. [PMID: 31597135 DOI: 10.1159/000504000] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/09/2019] [Indexed: 11/19/2022]
Abstract
Cabergoline is a dopamine agonist that has been used as the first-line treatment option for prolactin-secreting pituitary adenomas for several decades. It not only suppresses hormone production from these prolactinomas, but also causes tumour shrinkage. Recent studies revealed some novel mechanisms by which cabergoline suppresses tumour cell proliferation and induces cell death. In this article, we review the most recent findings in cabergoline studies, focusing on its anti-tumour function. These studies suggest the potential broader clinical use of cabergoline in the treatment of other tumours such as breast cancer, pancreatic neuroendocrine tumours, and lung cancer.
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Affiliation(s)
- Shaojian Lin
- Center of Pituitary Tumour, Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Anke Zhang
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xun Zhang
- Neuroendocrine Research Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Zhe Bao Wu
- Center of Pituitary Tumour, Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,
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26
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Nishioka H, Yamada S. Cushing's Disease. J Clin Med 2019; 8:jcm8111951. [PMID: 31726770 PMCID: PMC6912360 DOI: 10.3390/jcm8111951] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022] Open
Abstract
In patients with Cushing's disease (CD), prompt diagnosis and treatment are essential for favorable long-term outcomes, although this remains a challenging task. The differential diagnosis of CD is still difficult in some patients, even with an organized stepwise diagnostic approach. Moreover, despite the use of high-resolution magnetic resonance imaging (MRI) combined with advanced fine sequences, some tumors remain invisible. Surgery, using various surgical approaches for safe maximum tumor removal, still remains the first-line treatment for most patients with CD. Persistent or recurrent CD after unsuccessful surgery requires further treatment, including repeat surgery, medical therapy, radiotherapy, or sometimes, bilateral adrenalectomy. These treatments have their own advantages and disadvantages. However, the most important thing is that this complex disease should be managed by a multidisciplinary team with collaborating experts. In addition, a personalized and individual-based approach is paramount to achieve high success rates while minimizing the occurrence of adverse events and improving the patients' quality of life. Finally, the recent new insights into the pathophysiology of CD at the molecular level are highly anticipated to lead to the introduction of more accurate diagnostic tests and efficacious therapies for this devastating disease in the near future.
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Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary surgery, Toranomon Hospital, Tokyo 1058470, Japan;
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
| | - Shozo Yamada
- Hypothalamic and Pituitary Center, Moriyama Neurological Center Hospital, Tokyo 1340081, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
- Correspondence: ; Tel.: +81-336-751-211
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Varlamov EV, McCartney S, Fleseriu M. Functioning Pituitary Adenomas - Current Treatment Options and Emerging Medical Therapies. EUROPEAN ENDOCRINOLOGY 2019; 15:30-40. [PMID: 31244908 PMCID: PMC6587904 DOI: 10.17925/ee.2019.15.1.30] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/11/2019] [Indexed: 12/12/2022]
Abstract
Pituitary adenomas are benign tumours comprising approximately 16% of all primary cranial neoplasms. Functioning pituitary adenomas (prolactinomas, somatotroph, corticotroph, thyrotroph and rarely gonadotroph adenomas) cause complex clinical syndromes and require prompt treatment to reduce associated morbidity and mortality. Treatment approaches include transsphenoidal surgery, medical therapy and radiation. Medical therapy is the primary therapy for prolactinomas, and surgery by a skilled neurosurgeon is the first-line approach for other functioning pituitary adenomas. A multimodal treatment is frequently necessary to achieve biochemical and clinical control, especially, when surgery is not curative or when medical therapy fails. Several emerging, novel, medical treatments for acromegaly, Cushing's disease and prolactinomas are in phase II and III clinical trials and may become effective additions to the current drug armamentarium. The availability of various management options will allow an individualised treatment approach based on the unique tumour type, clinical situation and patient preference.
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28
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Feelders RA, Newell-Price J, Pivonello R, Nieman LK, Hofland LJ, Lacroix A. Advances in the medical treatment of Cushing's syndrome. Lancet Diabetes Endocrinol 2019; 7:300-312. [PMID: 30033041 DOI: 10.1016/s2213-8587(18)30155-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 01/05/2023]
Abstract
Cushing's syndrome is associated with multisystem morbidity and, when suboptimally treated, increased mortality. Medical therapy is an option for patients if surgery is not successful and can be classified into pituitary-directed drugs, steroid synthesis inhibitors, and glucocorticoid receptor antagonists. In the last decade there have been new developments in each drug category. Targeting dopamine and somatostatin receptors on corticotroph adenomas with cabergoline or pasireotide, or both, controls cortisol production in up to 40% of patients. Potential new targets in corticotroph adenomas include the epidermal growth factor receptor, cyclin-dependent kinases, and heat shock protein 90. Osilodrostat and levoketoconazole are new inhibitors of steroidogenesis and are currently being evaluated in multicentre trials. CORT125134 is a new selective glucocorticoid receptor antagonist under investigation. We summarise the drug therapies for various forms of Cushing's syndrome and focus on emerging drugs and drug targets that have the potential for new and effective tailor-made pharmacotherapy for patients with Cushing's syndrome.
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Affiliation(s)
- Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Centre, Rotterdam, Netherlands.
| | - John Newell-Price
- Academic Unit of Endocrinology, University of Sheffield, Sheffield, UK
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Lynnette K Nieman
- Eunice Kennedy Shriver National Institute of Diabetes and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
| | - Leo J Hofland
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Andre Lacroix
- Division of Endocrinology, Department of Medicine and Research Centre, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
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29
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Beaudoin MA, Schillo F. Les traitements du syndrome de Cushing. ACTUALITES PHARMACEUTIQUES 2019. [DOI: 10.1016/j.actpha.2019.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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30
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Sickler T, Trarbach EB, Frassetto FP, Dettoni JB, Alves VAF, Fragoso MCBV, Machado MC, Cardoso EF, Bronstein MD, Glezer A. Filamin A and DRD2 expression in corticotrophinomas. Pituitary 2019; 22:163-169. [PMID: 30799513 DOI: 10.1007/s11102-019-00947-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE Filamin A (FLNA) expression is related to dopamine receptor type 2 (DRD2) expression in prolactinomas. Nevertheless, in corticotrophinomas, there are few studies about DRD2 expression and no data on FLNA. Therefore, we evaluated FLNA and DRD2 expression in corticotrophinomas and their association with tumor characteristics. METHODS DRD2 and FLNA expression by immunohistochemistry, using H-score, based on the percentage of positive cells in a continuous scale of 0-300, were evaluated in 23 corticotrophinomas samples from patients submitted to neurosurgery. In six patients, treatment with cabergoline was indicated after non curative surgery. RESULTS Twenty-two patients were female and one male. Regarding tumor size, 10 were micro and 12 were macroadenomas. DRD2 expression was found in 89% of cases and did not correlate with FLNA expression. Moreover, the response to cabergoline, observed in 33% of the cases, did not correlate with DRD2 nor FLNA expression. FLNA expression was not associated with clinical and tumor characteristics, except for sphenoid sinus invasion. CONCLUSIONS In our cohort of corticotrophinomas, DRD2 expression was not associated with FLNA expression nor to the response to CAB. Nonetheless, FLNA expression could be related to tumor invasiveness.
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Affiliation(s)
- Thais Sickler
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas & Laboratory of Cellular and Molecular Endocrinology LIM-25, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Ericka Barbosa Trarbach
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas & Laboratory of Cellular and Molecular Endocrinology LIM-25, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Fernando Pereira Frassetto
- Pathology Unit, Hospital das Clínicas & Laboratory of Pathology, LIM-14, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | | | - Venâncio Avancini Ferreira Alves
- Pathology Unit, Hospital das Clínicas & Laboratory of Pathology, LIM-14, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Maria Candida Barisson Villares Fragoso
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas & Laboratory of Cellular and Molecular Endocrinology LIM-25, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Marcio Carlos Machado
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas & Laboratory of Cellular and Molecular Endocrinology LIM-25, University of Sao Paulo Medical School, São Paulo, SP, Brazil
- Endocrinology Service, AC Camargo Cancer Center, São Paulo, SP, Brazil
| | | | - Marcello Delano Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas & Laboratory of Cellular and Molecular Endocrinology LIM-25, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - Andrea Glezer
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas & Laboratory of Cellular and Molecular Endocrinology LIM-25, University of Sao Paulo Medical School, São Paulo, SP, Brazil.
- Medical School, University of Sao Paulo, Rua Dr. Enéas de Carvalho Aguiar, no 155, 8° andar, bloco 3 (Endocrinologia), São Paulo, SP, 05403-000, Brazil.
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Palui R, Sahoo J, Kamalanathan S, Kar SS, Selvarajan S, Durgia H. Effect of cabergoline monotherapy in Cushing's disease: an individual participant data meta-analysis. J Endocrinol Invest 2018; 41:1445-1455. [PMID: 30097903 DOI: 10.1007/s40618-018-0936-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/03/2018] [Indexed: 02/08/2023]
Abstract
CONTEXT The primary treatment of choice for Cushing's disease (CD) is the removal of the pituitary adenoma by transsphenoidal surgery (TSS). The surgical failure is seen in up to 75% of cases depending on the experience of the surgeon in different studies. Medical therapy is one of the options for the treatment of recurrent or persistent CD. METHODOLOGY The primary outcome of this meta-analysis was to find the proportion of patients achieving normalisation of 24-h urinary free cortisol (remission of CD) following cabergoline monotherapy. Literature search was conducted in January 2018 in PubMed/MEDLINE database from its date of inception to 31st December 2017. The search strategy used was "[(cushing) OR Cushing's] AND cabergoline". Individual participant data were extracted from the included studies and risk of bias was analysed by review checklist proposed by MOOSE. RESULTS The individual participant data of 124 patients from six observational studies were included in this meta-analysis. 92 patients (74.2%) had past pituitary surgery. The proportion of patients achieving remission of Cushing’s disease (CD) with cabergoline monotherapy was 34% (95% confidence interval 0.26–0.43; P = 0.001) [corrected]. The previous surgery [odds ratio (OR) 28.4], duration of cabergoline monotherapy (OR 1.31) and maximum cabergoline dose (OR 0.19) were predictors for remission of CD. Mild and severe side effects were reported in 37.3% and 5.6% of patients, respectively, during cabergoline monotherapy. CONCLUSIONS This meta-analysis shows that cabergoline monotherapy is a reasonable alternative for subjects with persistent or recurrent CD after TSS. It can also be used in CD patients either as a bridge therapy while waiting for surgery or in those unwilling for surgery or have contraindication to it.
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Affiliation(s)
- R Palui
- Department of Endocrinology, JIPMER, Fourth Floor, Superspecialty Block, Puducherry, 605006, India
| | - J Sahoo
- Department of Endocrinology, JIPMER, Fourth Floor, Superspecialty Block, Puducherry, 605006, India.
| | - S Kamalanathan
- Department of Endocrinology, JIPMER, Fourth Floor, Superspecialty Block, Puducherry, 605006, India
| | - S S Kar
- Department of Preventive and Social Medicine, JIPMER, Puducherry, India
| | - S Selvarajan
- Department of Clinical Pharmacology, JIPMER, Puducherry, India
| | - H Durgia
- Department of Endocrinology, JIPMER, Fourth Floor, Superspecialty Block, Puducherry, 605006, India
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Broersen LHA, Jha M, Biermasz NR, Pereira AM, Dekkers OM. Effectiveness of medical treatment for Cushing's syndrome: a systematic review and meta-analysis. Pituitary 2018; 21:631-641. [PMID: 29855779 PMCID: PMC6244780 DOI: 10.1007/s11102-018-0897-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To systematically review the effectiveness of medical treatment for Cushing's syndrome in clinical practice, regarding cortisol secretion, clinical symptom improvement, and quality of life. To assess the occurrence of side effects of these medical therapies. METHODS Eight electronic databases were searched in March 2017 to identify potentially relevant articles. Randomized controlled trials and cohort studies assessing the effectiveness of medical treatment in patients with Cushing's syndrome, were eligible. Pooled proportions were reported including 95% confidence intervals. RESULTS We included 35 articles with in total 1520 patients in this meta-analysis. Most included patients had Cushing's disease. Pooled reported percentage of patients with normalization of cortisol ranged from 35.7% for cabergoline to 81.8% for mitotane in Cushing's disease. Patients using medication monotherapy showed a lower percentage of cortisol normalization compared to use of multiple medical agents (49.4 vs. 65.7%); this was even higher for patients with concurrent or previous radiotherapy (83.6%). Mild side effects were reported in 39.9%, and severe side effects were seen in 15.2% of patients after medical treatment. No meta-analyses were performed for clinical symptom improvement or quality of life due to lack of sufficient data. CONCLUSIONS This meta-analysis shows that medication induces cortisol normalization effectively in a large percentage of patients. Medical treatment for Cushing's disease patients is thus a reasonable option in case of a contraindication for surgery, a recurrence, or in patients choosing not to have surgery. When experiencing side effects or no treatment effect, an alternate medical therapy or combination therapy can be considered.
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Affiliation(s)
- Leonie H A Broersen
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Department of Endocrinology, Diabetes and Nutrition, Charité Universitätsmedizin Berlin, Chariteplatz 1, 10117, Berlin, Germany.
| | - Meghna Jha
- Department of Endocrinology, Diabetes and Nutrition, Charité Universitätsmedizin Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Nienke R Biermasz
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Alberto M Pereira
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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Abstract
INTRODUCTION Cushing's disease is a rare systemic and disabling disease due to oversecretion of adrenocorticotrophic hormone (ACTH) resulting in excess cortisol levels. Diagnosis and treatment are difficult; despite the availability of various pharmaceutical treatment options, there is an ongoing, unmet need for even more effective treatment. AREAS COVERED The present review aims at providing an overview of available drugs and presenting new developments. Focusing on the pituitary as a target, the review covers compounds targeting pituitary cell signaling or cell cycle control such as heat shock protein inhibitors (e.g. silibinin), histone deacetylase inhibitors (trichostatin A, vorinostat), kinase inhibitors (gefitinib, seliciclib), and others (such as triptolide, AT-101). Levoketoconazole and osilodrostat are in clinical testing and inhibit steroidogenesis. Blockade of ACTH receptor binding at the adrenal level is explained as a theoretical drug target. Inhibition of binding of the glucocorticoid receptor in the peripheral tissue plays a minor role due to its lack of biomonitoring options. EXPERT OPINION In our opinion, further research and drug development of pituitary-directed targets are necessary. Combination therapies may exert synergistic effects and allow for smaller and better tolerated doses, but more experience and data are needed to guide such treatment schemes.
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Affiliation(s)
- Sylvère Störmann
- a Medizinische Klinik und Poliklinik IV , Klinikum der Universität München , München , Germany
| | - Jochen Schopohl
- a Medizinische Klinik und Poliklinik IV , Klinikum der Universität München , München , Germany
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Nieman LK. Recent Updates on the Diagnosis and Management of Cushing's Syndrome. Endocrinol Metab (Seoul) 2018; 33:139-146. [PMID: 29947171 PMCID: PMC6021313 DOI: 10.3803/enm.2018.33.2.139] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 04/23/2018] [Accepted: 05/16/2018] [Indexed: 12/31/2022] Open
Abstract
Cushing's syndrome, a potentially lethal disorder characterized by endogenous hypercortisolism, may be difficult to recognize, especially when it is mild and the presenting features are common in the general population. However, there is a need to identify the condition at an early stage, as it tends to progress, accruing additional morbidity and increasing mortality rates. Once a clinical suspicion is raised, screening tests involve timed measurement of urine, serum or salivary cortisol at baseline or after administration of dexamethasone, 1 mg. Each test has caveats, so that the choice of tests must be individualized for each patient. Once the diagnosis is established, and the cause is determined, surgical resection of abnormal tumor/tissue is the optimal treatment. When this cannot be achieved, medical treatment (or bilateral adrenalectomy) must be used to normalize cortisol production. Recent updates in screening for and treating Cushing's syndrome are reviewed here.
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Affiliation(s)
- Lynnette K Nieman
- Diabetes, Endocrine and Obesity Branch, The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD, USA.
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Protein expression of somatostatin receptor 2, somatostatin receptor 5 and dopamine D2 receptor in normal pituitary gland and ACTH-secreting pituitary adenoma in dogs. Res Vet Sci 2018; 119:61-66. [PMID: 29864631 DOI: 10.1016/j.rvsc.2018.04.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 04/27/2018] [Accepted: 04/30/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the protein expression of somatostatin receptor (SSTR) 2, SSTR5 and dopamine D2 receptor (DA2R)-targets of somatostatin analogs and dopamine agonists-in normal canine pituitary and canine adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas. METHODS Six normal canine pituitary glands and 14 canine ACTH-secreting pituitary adenoma cases were included in this study. The protein expression of SSTR2, SSTR5 and DA2R was determined by double-label immunofluorescence staining of these receptors and ACTH. RESULTS SSTR2, SSTR5, and DA2R proteins were expressed in the anterior and intermediate lobes of normal canine pituitary glands. In the anterior pituitary lobes, the percentages of SSTR2-, SSTR5-, and DA2R-positive cells among the ACTH-positive population were 27.0 ± 8.6%, 27.9 ± 5.9%, and 34.0 ± 9.4%, respectively. In contrast, the corresponding percentages in the intermediate pituitary lobes were 97.8 ± 1.5%, 94.1 ± 4.4%, and 96.1 ± 6.6%, respectively. Of the 14 ACTH-secreting pituitary adenoma cases, 11, 12, and 6 cases expressed SSTR2, SSTR5, and DA2R, respectively. Additionally, four cases showed strong positive staining for both SSTR2 and SSTR5. Two of these were ACTH-secreting pituitary adenomas likely derived from the intermediate pituitary lobe, because these are α-Melanocyte-stimulation hormone (α-MSH)-positive stains. CONCLUSION Immunohistological detection and characterization of SSTR2, SSTR5 and DA2R may provide useful additional information for determining treatment options when an ACTH-secreting pituitary adenoma cannot be completely resected, or in the case of recurrence.
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Machado MC, Fragoso MCBV, Moreira AC, Boguszewski CL, Vieira Neto L, Naves LA, Vilar L, Araújo LAD, Musolino NRC, Miranda PAC, Czepielewski MA, Gadelha MR, Bronstein MD, Ribeiro-Oliveira A. A review of Cushing's disease treatment by the Department of Neuroendocrinology of the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:87-105. [PMID: 29694638 PMCID: PMC10118687 DOI: 10.20945/2359-3997000000014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 10/02/2017] [Indexed: 11/23/2022]
Abstract
The treatment objectives for a patient with Cushing's disease (CD) are remission of hypercortisolism, adequate management of co-morbidities, restoration of the hypothalamic-pituitary-adrenal axis, preservation of fertility and pituitary function, and improvement of visual defects in cases of macroadenomas with suprasellar extension. Transsphenoidal pituitary surgery is the main treatment option for the majority of cases, even in macroadenomas with low probability of remission. In cases of surgical failure, another subsequent pituitary surgery might be indicated in cases with persistent tumor imaging at post surgical magnetic resonance imaging (MRI) and/or pathology analysis of adrenocorticotropic hormone-positive (ACTH+) positive pituitary adenoma in the first procedure. Medical treatment, radiotherapy and adrenalectomy are the other options when transsphenoidal pituitary surgery fails. There are several options of medical treatment, although cabergoline and ketoconazole are the most commonly used alone or in combination. Novel treatments are also addressed in this review. Different therapeutic approaches are frequently needed on an individual basis, both before and, particularly, after surgery, and they should be individualized. The objective of the present review is to provide the necessary information to achieve a more effective treatment for CD. It is recommended that patients with CD be followed at tertiary care centers with experience in treating this condition.
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Affiliation(s)
- Márcio Carlos Machado
- Unidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Maria Candida Barisson Vilares Fragoso
- Unidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Ayrton Custódio Moreira
- Divisão de Endocrinologia e Metabologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - César Luiz Boguszewski
- Serviço de Endocrinologia e Metabologia (SEMPR), Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Leonardo Vieira Neto
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Luciana A Naves
- Serviço de Endocrinologia, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, DF, Brasil
| | - Lucio Vilar
- Serviço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Pernambuco, Recife, PE, Brasil
| | | | - Nina Rosa Castro Musolino
- Divisão de Neurocirurgia Funcional, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | - Mauro A Czepielewski
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Monica R Gadelha
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Marcello Delano Bronstein
- Unidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Antônio Ribeiro-Oliveira
- Serviço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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Cooper O, Greenman Y. Dopamine Agonists for Pituitary Adenomas. Front Endocrinol (Lausanne) 2018; 9:469. [PMID: 30186234 PMCID: PMC6110840 DOI: 10.3389/fendo.2018.00469] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/30/2018] [Indexed: 12/26/2022] Open
Abstract
Dopamine agonists (DA) are well established as first-line therapy for prolactinomas. These tumors express high levels of dopamine 2 receptors (D2R), leading to the strong efficacy of DA in reducing tumor size and hormonal secretion. Other pituitary tumor subtypes express D2R to varying degrees, leading to an extensive body of research into potential off-label use of DA in non-prolactinoma pituitary tumors. Preclinical models of Cushing's disease, acromegaly, and nonfunctioning pituitary tumors (NFPT) demonstrate D2R expression in cell lines and cultured tumors as well as effectiveness of DA in reducing hormonal secretion in functioning tumors and arresting tumor proliferation. Clinical studies have shown some efficacy of DA in treatment of these tumors. In Cushing's disease, DA therapy results in normalization of urinary cortisol levels in approximately 25% of patients, but reported rates of tumor shrinkage are very low; in acromegaly, DA therapy leads to normalization of insulin-like growth factor I and tumor shrinkage in approximately one-third of patients, and improved responses when used in combination with somatostatin receptor ligands. Among patients with NFPT, pooled results show 30% experience reduction of tumor size and 58% show stabilization of disease. DA therapy appears to have some clinical benefit in patients with non-prolactinoma pituitary tumors, and may be an option for medical therapy in some clinical scenarios.
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Affiliation(s)
- Odelia Cooper
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- *Correspondence: Odelia Cooper
| | - Yona Greenman
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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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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Scaroni C, Zilio M, Foti M, Boscaro M. Glucose Metabolism Abnormalities in Cushing Syndrome: From Molecular Basis to Clinical Management. Endocr Rev 2017; 38:189-219. [PMID: 28368467 DOI: 10.1210/er.2016-1105] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 03/15/2017] [Indexed: 12/13/2022]
Abstract
An impaired glucose metabolism, which often leads to the onset of diabetes mellitus (DM), is a common complication of chronic exposure to exogenous and endogenous glucocorticoid (GC) excess and plays an important part in contributing to morbidity and mortality in patients with Cushing syndrome (CS). This article reviews the pathogenesis, epidemiology, diagnosis, and management of changes in glucose metabolism associated with hypercortisolism, addressing both the pathophysiological aspects and the clinical and therapeutic implications. Chronic hypercortisolism may have pleiotropic effects on all major peripheral tissues governing glucose homeostasis. Adding further complexity, both genomic and nongenomic mechanisms are directly induced by GCs in a context-specific and cell-/organ-dependent manner. In this paper, the discussion focuses on established and potential pathologic molecular mechanisms that are induced by chronically excessive circulating levels of GCs and affect glucose homeostasis in various tissues. The management of patients with CS and DM includes treating their hyperglycemia and correcting their GC excess. The effects on glycemic control of various medical therapies for CS are reviewed in this paper. The association between DM and subclinical CS and the role of screening for CS in diabetic patients are also discussed.
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Affiliation(s)
- Carla Scaroni
- Endocrinology Unit, Department of Medicine, DIMED, University of Padova, Via Ospedale 105, 35128 Padua, Italy
| | - Marialuisa Zilio
- Endocrinology Unit, Department of Medicine, DIMED, University of Padova, Via Ospedale 105, 35128 Padua, Italy
| | - Michelangelo Foti
- Department of Cell Physiology & Metabolism, Centre Médical Universitaire, 1 Rue Michel Servet, 1211 Genèva, Switzerland
| | - Marco Boscaro
- Endocrinology Unit, Department of Medicine, DIMED, University of Padova, Via Ospedale 105, 35128 Padua, Italy
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Ferriere A, Cortet C, Chanson P, Delemer B, Caron P, Chabre O, Reznik Y, Bertherat J, Rohmer V, Briet C, Raingeard I, Castinetti F, Beckers A, Vroonen L, Maiter D, Cephise-Velayoudom FL, Nunes ML, Haissaguerre M, Tabarin A. Cabergoline for Cushing's disease: a large retrospective multicenter study. Eur J Endocrinol 2017; 176:305-314. [PMID: 28007845 DOI: 10.1530/eje-16-0662] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 11/19/2016] [Accepted: 12/22/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The efficacy of cabergoline in Cushing's disease (CD) is controversial. The aim of this study was to assess the efficacy and tolerability of cabergoline in a large contemporary cohort of patients with CD. DESIGN We conducted a retrospective multicenter study from thirteen French and Belgian university hospitals. METHODS Sixty-two patients with CD received cabergoline monotherapy or add-on therapy. Symptom score, biological markers of hypercortisolism and adverse effects were recorded. RESULTS Twenty-one (40%) of 53 patients who received cabergoline monotherapy had normal urinary free cortisol (UFC) values within 12 months (complete responders), and five of these patients developed corticotropic insufficiency. The fall in UFC was associated with significant reductions in midnight cortisol and plasma ACTH, and with clinical improvement. Compared to other patients, complete responders had similar median baseline UFC (2.0 vs 2.5xULN) and plasma prolactin concentrations but received lower doses of cabergoline (1.5 vs 3.5 mg/week, P < 0.05). During long-term treatment (>12 months), cabergoline was withdrawn in 28% of complete responders because of treatment escape or intolerance. Overall, sustained control of hypercortisolism was obtained in 23% of patients for 32.5 months (19-105). Nine patients on steroidogenesis inhibitors received cabergoline add-on therapy for 19 months (1-240). Hypercortisolism was controlled in 56% of these patients during the first year of treatment with cabergoline at 1.0 mg/week (0.5-3.5). CONCLUSIONS About 20-25% of CD patients are good responders to cabergoline therapy allowing long-term control of hypercortisolism at relatively low dosages and with acceptable tolerability. No single parameter, including the baseline UFC and prolactin levels, predicted the response to cabergoline.
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Affiliation(s)
- A Ferriere
- CHU BordeauxHôpital Haut-Lévêque, Service d'Endocrinologie, Diabétologie et Nutrition, Pessac, France or INSERM U862, Neurocentre Magendie, Université Bordeaux, Bordeaux Cedex, France
| | - C Cortet
- CHRU LilleService d'Endocrinologie, Diabétologie et Métabolisme, Lille Cedex, France
| | - P Chanson
- Assistance Publique-Hôpitaux de ParisHôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, France
| | - B Delemer
- CHU ReimsHôpital Robert Debré, Service d'Endocrinologie, Diabétologie et Nutrition, Reims, France
| | - P Caron
- CHU ToulouseHôpital Larrey, Service d'Endocrinologie, Maladies Métaboliques et Nutrition, Toulouse cedex 9, France
| | - O Chabre
- CHU Grenoble AlpesService d'Endocrinologie-Diabétologie, Boulevard de la Chantourne, La Tronche, France
| | - Y Reznik
- CHU CaenService d'Endocrinologie-Diabétologie, CAEN cedex 9, France
| | - J Bertherat
- Assistance Publique-Hôpitaux de ParisHôpitaux universitaires Paris-Centre, Hôpital Cochin, Service d'Endocrinologie et Maladies Métaboliques, Paris, France
| | - V Rohmer
- CHU AngersDépartement d'Endocrinologie-Diabétologie-Nutrition, Angers Cedex 9, France
| | - C Briet
- CHU AngersDépartement d'Endocrinologie-Diabétologie-Nutrition, Angers Cedex 9, France
| | - I Raingeard
- CHU MontpellierService d'Endocrinologie, Diabète, Maladies métaboliques, Montpellier, France
| | - F Castinetti
- Assistance Publique-Hôpitaux de MarseilleHôpital de la Conception, Service d'Endocrinologie, Diabètes et Maladies Métaboliques, Marseille, France
| | - A Beckers
- CHU LiègeService d'Endocrinologie, Domaine Universitaire du Sart Tilman, Liège, Belgique
| | - L Vroonen
- CHU LiègeService d'Endocrinologie, Domaine Universitaire du Sart Tilman, Liège, Belgique
| | - D Maiter
- Clinique Universitaire Saint LucService d'Endocrinologie et de Nutrition, Bruxelles, Belgique
| | | | - M L Nunes
- CHU BordeauxHôpital Haut-Lévêque, Service d'Endocrinologie, Diabétologie et Nutrition, Pessac, France or INSERM U862, Neurocentre Magendie, Université Bordeaux, Bordeaux Cedex, France
| | - M Haissaguerre
- CHU BordeauxHôpital Haut-Lévêque, Service d'Endocrinologie, Diabétologie et Nutrition, Pessac, France or INSERM U862, Neurocentre Magendie, Université Bordeaux, Bordeaux Cedex, France
| | - A Tabarin
- CHU BordeauxHôpital Haut-Lévêque, Service d'Endocrinologie, Diabétologie et Nutrition, Pessac, France or INSERM U862, Neurocentre Magendie, Université Bordeaux, Bordeaux Cedex, France
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Cuevas-Ramos D, Lim DST, Fleseriu M. Update on medical treatment for Cushing's disease. Clin Diabetes Endocrinol 2016; 2:16. [PMID: 28702250 PMCID: PMC5471955 DOI: 10.1186/s40842-016-0033-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 08/25/2016] [Indexed: 12/30/2022] Open
Abstract
Cushing's disease (CD) is the most common cause of endogenous Cushing's syndrome (CS). The goal of treatment is to rapidly control cortisol excess and achieve long-term remission, to reverse the clinical features and reduce long-term complications associated with increased mortality. While pituitary surgery remains first line therapy, pituitary radiotherapy and bilateral adrenalectomy have traditionally been seen as second-line therapies for persistent hypercortisolism. Medical therapy is now recognized to play a key role in the control of cortisol excess. In this review, all currently available medical therapies are summarized, and novel medical therapies in phase 3 clinical trials, such as osilodrostat and levoketoconazole are discussed, with an emphasis on indications, efficacy and safety. Emerging data suggests increased efficacy and better tolerability with these novel therapies and combination treatment strategies, and potentially increases the therapeutic options for treatment of CD. New insights into the pathophysiology of CD are highlighted, along with potential therapeutic applications. Future treatments on the horizon such as R-roscovitine, retinoic acid, epidermal growth factor receptor inhibitors and somatostatin-dopamine chimeric compounds are also described, with a focus on potential clinical utility.
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Affiliation(s)
- Daniel Cuevas-Ramos
- Department of Endocrinology and Metabolism, Neuroendocrinology Clinic, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Sección XVI, Tlalpan, Mexico City, 14030 Mexico
| | - Dawn Shao Ting Lim
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR 97239 USA
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University, 3303 SW Bond Ave, Mail Code CH8N, Portland, OR 97239 USA
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Ambrogio AG, Cavagnini F. Role of "old" pharmacological agents in the treatment of Cushing's syndrome. J Endocrinol Invest 2016; 39:957-65. [PMID: 27086313 PMCID: PMC4987391 DOI: 10.1007/s40618-016-0462-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 03/16/2016] [Indexed: 12/13/2022]
Abstract
Despite recent advances in the management of endogenous Cushing's syndrome (CS), its treatment remains a challenge. When surgery has been unsuccessful or unfeasible as well in case of recurrence, the "old" pharmacological agents represent an important alternative for both ACTH-dependent and independent hypercortisolism. Especially in the latter, the advent of novel molecules directly targeting ACTH secretion has not outweighed the "old" drugs, which continue to be largely employed and have recently undergone a reappraisal. This review provides a survey of the "old" pharmacological agents in the treatment of CS.
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Affiliation(s)
- A G Ambrogio
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Neuroendocrinology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - F Cavagnini
- Neuroendocrinology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy.
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Morgan SA, Hassan-Smith ZK, Lavery GG. MECHANISMS IN ENDOCRINOLOGY: Tissue-specific activation of cortisol in Cushing's syndrome. Eur J Endocrinol 2016; 175:R83-9. [PMID: 26957494 DOI: 10.1530/eje-15-1237] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/07/2016] [Indexed: 12/26/2022]
Abstract
Glucocorticoids are widely prescribed for their anti-inflammatory properties, but have 'Cushingoid' side effects including visceral obesity, muscle myopathy, hypertension, insulin resistance, type 2 diabetes mellitus, osteoporosis, and hepatic steatosis. These features are replicated in patients with much rarer endogenous glucocorticoid (GC) excess (Cushing's syndrome), which has devastating consequences if left untreated. Current medical therapeutic options that reverse the tissue-specific consequences of hypercortisolism are limited. In this article, we review the current evidence that local GC metabolism via the enzyme 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) plays a central role in mediating the adverse metabolic complications associated with circulatory GC excess - challenging our current view that simple delivery of active GCs from the circulation represents the most important mode of GC action. Furthermore, we explore the potential for targeting this enzyme as a novel therapeutic strategy for the treatment of both endogenous and exogenous Cushing's syndrome.
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Affiliation(s)
- Stuart A Morgan
- Institute of Metabolism and Systems ResearchInstitute of Biomedical Research, University of Birmingham, Birmingham, UK Centre for Endocrinology Diabetes and MetabolismBirmingham Health Partners, University of Birmingham, Birmingham, UK
| | - Zaki K Hassan-Smith
- Institute of Metabolism and Systems ResearchInstitute of Biomedical Research, University of Birmingham, Birmingham, UK Centre for Endocrinology Diabetes and MetabolismBirmingham Health Partners, University of Birmingham, Birmingham, UK
| | - Gareth G Lavery
- Institute of Metabolism and Systems ResearchInstitute of Biomedical Research, University of Birmingham, Birmingham, UK Centre for Endocrinology Diabetes and MetabolismBirmingham Health Partners, University of Birmingham, Birmingham, UK
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Bertagna X. Therapeutic innovations in endocrine diseases – Part 1: New medical treatments for chronic excess of endogenous cortisol (Cushing's syndrome). Presse Med 2016; 45:e201-4. [DOI: 10.1016/j.lpm.2016.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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45
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Baroni MG, Giorgino F, Pezzino V, Scaroni C, Avogaro A. Italian Society for the Study of Diabetes (SID)/Italian Endocrinological Society (SIE) guidelines on the treatment of hyperglycemia in Cushing's syndrome and acromegaly. J Endocrinol Invest 2016; 39:235-55. [PMID: 26718207 DOI: 10.1007/s40618-015-0404-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/27/2015] [Indexed: 12/27/2022]
Abstract
Hyperglycemia is a common feature associated with states of increased growth hormone secretion and glucocorticoid levels. The purpose of these guidelines is to assist clinicians and other health care providers to take evidence-based therapeutic decisions for the treatment of hyperglycemia in patients with growth hormone and corticosteroid excess. Both the SID and SIE appointed members to represent each society and to collaborate in Guidelines writing. Members were chosen for their specific knowledge in the field. Each member agreed to produce-and regularly update-conflicts of interest. The authors of these guidelines prepared their contributions following the recommendations for the development of Guidelines, using the standard classes of recommendation shown below. All members of the writing committee provided editing and systematic review of each part of the manuscript, and discussed the grading of evidence. Consensus was guided by a systematic review of all available trials and by interactive discussions.
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Affiliation(s)
- M G Baroni
- Endocrinology and Diabetes, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - F Giorgino
- Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - V Pezzino
- Endocrinology, Department of Clinical and Molecular Bio-Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - C Scaroni
- Section of Endocrinology, Department of Medicine, University of Padova, Padua, Italy
| | - A Avogaro
- Section of Metabolic Diseases, Department of Medicine, University of Padova, Via Giustiniani, 2, 3128, Padua, Italy.
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Baroni MG, Giorgino F, Pezzino V, Scaroni C, Avogaro A. Italian Society for the Study of Diabetes (SID)/Italian Endocrinological Society (SIE) guidelines on the treatment of hyperglycemia in Cushing's syndrome and acromegaly. Nutr Metab Cardiovasc Dis 2016; 26:85-102. [PMID: 26905474 DOI: 10.1016/j.numecd.2016.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hyperglycemia is a common feature associated with states of increased growth hormone secretion and glucocorticoid levels. AIMS The purpose of these guidelines is to assist clinicians and other health care providers to take evidence-based therapeutic decisions for the treatment of hyperglycemia in patients with growth hormone and corticosteroid excess. METHODOLOGY Both the SID and SIE appointed members to represent each society and to collaborate in Guidelines writing. Members were chosen for their specific knowledge in the field. Each member agreed to produce--and regularly update--conflicts of interest. The Authors of these guidelines prepared their contributions following the recommendations for the development of Guidelines, using the standard classes of recommendation shown below. All members of the writing committee provided editing and systematic review of each part of the manuscript, and discussed the grading of evidence. Consensus was guided by a systematic review of all available trials and by interactive discussions.
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Affiliation(s)
- M G Baroni
- Endocrinology and Diabetes, Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - F Giorgino
- Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Italy
| | - V Pezzino
- Endocrinology, Department of Clinical and Molecular Bio-Medicine, Cannizzaro Hospital, University of Catania, Italy
| | - C Scaroni
- Section of Endocrinology, Department of Medicine, University of Padova, Italy
| | - A Avogaro
- Section of Metabolic Diseases, Department of Medicine, University of Padova, Italy.
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Burman P, Edén-Engström B, Ekman B, Karlsson FA, Schwarcz E, Wahlberg J. Limited value of cabergoline in Cushing's disease: a prospective study of a 6-week treatment in 20 patients. Eur J Endocrinol 2016; 174:17-24. [PMID: 26582653 DOI: 10.1530/eje-15-0807] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CONTEXT AND OBJECTIVE The role of cabergoline in Cushing's disease (CD) remains controversial. The experience is limited to case reports and few open studies that report the effects determined after ≥1 month of treatment. In prolactinomas and dopamine-responsive GH-secreting tumours, effects of cabergoline are seen within days or weeks. Here, we searched for short-term effects of cabergoline in CD. DESIGN Twenty patients (19 naïve and one recurrent) were included in a prospective study. Cabergoline was administered in increasing doses of 0.5-5 mg/week over 6 weeks. METHODS Urinary free cortisol (UFC) 24 h, morning cortisol and ACTH, and salivary cortisol at 0800, 1600 and 2300 h were determined once weekly throughout. Diurnal curves (six samples) of serum cortisol were measured at start and end. RESULTS At study end, the median cabergoline dose was 5 mg, range 2.5-5 mg/week. The prolactin levels, markers of compliance, were suppressed in all patients. During the treatment, hypercortisolism varied, gradual and dose-dependent reductions were not seen. Five patients had a >50% decrease of UFC, three had a >50% rise of UFC. Salivary cortisol at 2300 h showed a congruent >50% change with UFC in two of the five cases with decreased UFC, and in one of the three cases with increased UFC. One patient with decreases in both UFC and 2300 h salivary cortisol also had a reduction in diurnal serum cortisol during the course of the study. CONCLUSIONS Cabergoline seems to be of little value in the management of CD. Only one patient had a response-like pattern. Given the known variability of disease activity in CD, this might represent a chance finding.
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Affiliation(s)
| | - Britt Edén-Engström
- Department of EndocrinologySkane University Hospital Malmö, University of Lund, 20502 Malmö, SwedenDepartment of DiabetesEndocrinology and Metabolism, University Hospital, Uppsala University, Uppsala, SwedenDepartments of Endocrinology and Medical and Health SciencesLinköping University, Linköping, SwedenDepartment of Internal MedicineFaculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Bertil Ekman
- Department of EndocrinologySkane University Hospital Malmö, University of Lund, 20502 Malmö, SwedenDepartment of DiabetesEndocrinology and Metabolism, University Hospital, Uppsala University, Uppsala, SwedenDepartments of Endocrinology and Medical and Health SciencesLinköping University, Linköping, SwedenDepartment of Internal MedicineFaculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - F Anders Karlsson
- Department of EndocrinologySkane University Hospital Malmö, University of Lund, 20502 Malmö, SwedenDepartment of DiabetesEndocrinology and Metabolism, University Hospital, Uppsala University, Uppsala, SwedenDepartments of Endocrinology and Medical and Health SciencesLinköping University, Linköping, SwedenDepartment of Internal MedicineFaculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Erik Schwarcz
- Department of EndocrinologySkane University Hospital Malmö, University of Lund, 20502 Malmö, SwedenDepartment of DiabetesEndocrinology and Metabolism, University Hospital, Uppsala University, Uppsala, SwedenDepartments of Endocrinology and Medical and Health SciencesLinköping University, Linköping, SwedenDepartment of Internal MedicineFaculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jeanette Wahlberg
- Department of EndocrinologySkane University Hospital Malmö, University of Lund, 20502 Malmö, SwedenDepartment of DiabetesEndocrinology and Metabolism, University Hospital, Uppsala University, Uppsala, SwedenDepartments of Endocrinology and Medical and Health SciencesLinköping University, Linköping, SwedenDepartment of Internal MedicineFaculty of Medicine and Health, Örebro University, Örebro, Sweden
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Vilar L, Albuquerque JL, Lyra R, Trovão Diniz E, Rangel Filho F, Gadelha P, Thé AC, Ibiapina GR, Gomes BS, Santos V, Melo da Fonseca M, Frasão Viana K, Lopes IG, Araújo D, Naves L. The Role of Isotretinoin Therapy for Cushing's Disease: Results of a Prospective Study. Int J Endocrinol 2016; 2016:8173182. [PMID: 27034666 PMCID: PMC4789464 DOI: 10.1155/2016/8173182] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 01/20/2016] [Indexed: 11/18/2022] Open
Abstract
Objective. This prospective open trial aimed to evaluate the efficacy and safety of isotretinoin (13-cis-retinoic acid) in patients with Cushing's disease (CD). Methods. Sixteen patients with CD and persistent or recurrent hypercortisolism after transsphenoidal surgery were given isotretinoin orally for 6-12 months. The drug was started on 20 mg daily and the dosage was increased up to 80 mg daily if needed and tolerated. Clinical, biochemical, and hormonal parameters were evaluated at baseline and monthly for 6-12 months. Results. Of the 16 subjects, 4% (25%) persisted with normal urinary free cortisol (UFC) levels at the end of the study. UFC reductions of up to 52.1% were found in the rest. Only patients with UFC levels below 2.5-fold of the upper limit of normal achieved sustained UFC normalization. Improvements of clinical and biochemical parameters were also noted mostly in responsive patients. Typical isotretinoin side-effects were experienced by 7 patients (43.7%), though they were mild and mostly transient. We also observed that the combination of isotretinoin with cabergoline, in relatively low doses, may occasionally be more effective than either drug alone. Conclusions. Isotretinoin may be an effective and safe therapy for some CD patients, particularly those with mild hypercortisolism.
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Affiliation(s)
- Lucio Vilar
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - José Luciano Albuquerque
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Ruy Lyra
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Erik Trovão Diniz
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Frederico Rangel Filho
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Patrícia Gadelha
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Ana Carolina Thé
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - George Robson Ibiapina
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Barbara Sales Gomes
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Vera Santos
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Maíra Melo da Fonseca
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Karoline Frasão Viana
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Isis Gabriella Lopes
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Douglas Araújo
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Luciana Naves
- Division of Endocrinology, Brasilia University Hospital, Brasilia, DF, Brazil
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Simeoli C, Auriemma RS, Tortora F, De Leo M, Iacuaniello D, Cozzolino A, De Martino MC, Pivonello C, Mainolfi CG, Rossi R, Cirillo S, Colao A, Pivonello R. The treatment with pasireotide in Cushing's disease: effects of long-term treatment on tumor mass in the experience of a single center. Endocrine 2015; 50:725-40. [PMID: 25743263 DOI: 10.1007/s12020-015-0557-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/17/2015] [Indexed: 01/10/2023]
Abstract
Pasireotide is the first medical therapy officially approved for the treatment of adult patients with Cushing's disease (CD) who experienced a failure of pituitary surgery or are not candidates for surgery and require medical therapeutic intervention. The current study aimed at investigating the effects of long-term treatment with pasireotide (up to 24 months) on tumor mass in a group of patients with CD, participating to a phase III study. Fourteen CD patients entered the phase III clinical trial CSOM230B2305 at Naples Center, and eight (seven women, one man, aged 38.9 ± 17.6 years), including seven with a microadenoma and one with a macroadenoma, received treatment with pasireotide at the dose of 600-1200 µg bid for at least 6 months, and were considered for the analysis of the study. These eight patients were subjected to the evaluation of pituitary tumor volume by pituitary MRI, together with the evaluation of urinary cortisol levels, at baseline and every 6 months for the entire period of treatment. Pasireotide treatment induced full disease control in 37.5 % and partial disease control in 37.5 % after 6 months, whereas full and partial disease control after 12 months was obtained in 28.6 % and in 57.1 % of patients, respectively. A significant (>25 %) reduction in tumor volume was found in 62.5 % and in 100 % of patients, after 6 and 12 months, respectively. In particular, after 6 months, a slight tumor shrinkage (between 25.1 and 50 %) was observed in 25 %, moderate (50.1-75 %) in 25 %, and marked (>75 %) in 12.5 % of patients, whereas after 12 months, a slight tumor shrinkage was observed in 43 %, moderate in 14 %, and marked in 43 % of patients. In 25 % of patients (two patients), a marked tumor shrinkage was recorded, with tumor mass disappearance in one case; this tumor shrinkage was associated to rapid and sustained biochemical remission up to 24 months of continuous pasireotide treatment. These two cases represent the first cases with a documentation of such a notable effect of pasireotide on tumor mass. Pasireotide induces significant tumor shrinkage in 62.5 % of patients after 6 months and in 100 % of patients after 12 months, and occasionally induces a radiological disappearance of the tumor. This evidence supports and strengthens the role of pasireotide as medical treatment specifically addressed to patients with CD, particularly in those who had unsuccessful pituitary surgery, or are not candidates for surgery.
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Affiliation(s)
- Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | | | - Fabio Tortora
- Department of Internal and Experimental Medicine, Division of Neurological Sciences, Second University of Naples, Naples, Italy
| | - Monica De Leo
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Davide Iacuaniello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Alessia Cozzolino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Maria Cristina De Martino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | | | - Riccardo Rossi
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Sossio Cirillo
- Department of Internal and Experimental Medicine, Division of Neurological Sciences, Second University of Naples, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II", Via Sergio Pansini 5, 80131, Naples, Italy.
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50
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Abstract
Chronic exposure to excess glucorticoids results in diverse manifestations of Cushing's syndrome, including debilitating morbidities and increased mortality. Genetic and molecular mechanisms responsible for excess cortisol secretion by primary adrenal lesions and adrenocorticotropic hormone (ACTH) secretion from corticotroph or ectopic tumours have been identified. New biochemical and imaging diagnostic approaches and progress in surgical and radiotherapy techniques have improved the management of patients. The therapeutic goal is to normalise tissue exposure to cortisol to reverse increased morbidity and mortality. Optimum treatment consisting of selective and complete resection of the causative tumour is necessay to allow eventual normalisation of the hypothalamic-pituitary-adrenal axis, maintenance of pituitary function, and avoidance of tumour recurrence. The development of new drugs offers clinicians several choices to treat patients with residual cortisol excess. However, for patients affected by this challenging syndrome, the long-term effects and comorbidities associated with hypercortisolism need ongoing care.
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Affiliation(s)
- André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada.
| | - Richard A Feelders
- Division of Endocrinology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Constantine A Stratakis
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Lynnette K Nieman
- Program on Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
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