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Bryk-Wiązania AH, Minasyan M, Świątkowska-Stodulska R, Undas A, Hubalewska-Dydejczyk A, Webb SM, Valassi E, Gilis-Januszewska A. The thrombotic risk in Cushing's syndrome-questions, answers, and the algorithm to consider in its assessment: part I-thrombotic risk not related to surgery. Front Endocrinol (Lausanne) 2024; 15:1350010. [PMID: 38529392 PMCID: PMC10961355 DOI: 10.3389/fendo.2024.1350010] [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: 12/05/2023] [Accepted: 02/12/2024] [Indexed: 03/27/2024] Open
Abstract
Introduction Recently, it has been reported that there is a great diversity in strategies used for thromboprophylaxis in patients with Cushing's syndrome (CS). An aim of this review was to discuss these practices in light of the existing data on the thrombotic risk in patients with CS and guidelines for medically ill patients. Methods The four relevant topics and questions on thrombotic risk in CS were identified. The current guidelines on prevention and diagnosis of venous thromboembolism (VTE) were reviewed for the answers. An algorithm to consider in the assessment of the thrombotic risk in patients with CS was proposed. Results To address both generic and CS-specific risk factors for VTE, the algorithm includes the stepwise approach consisting of Padua Score, urine free cortisol, and CS-VTE score, with no indication for routine thrombophilia testing in the prediction of an index VTE episode. Having confirmed VTE, selected patients require thrombophilia testing to aid the duration of anticoagulant treatment. The separate part of the algorithm is devoted to patients with ectopic adrenocorticotropic hormone syndrome in whom exclusion of VTE precedes introducing routine thromboprophylaxis to prevent VTE. The cancer-related VTE also prompts thromboprophylaxis, with the possible vessel invasion. The algorithm presents a unifactorial and multifactorial approach to exclude high-bleeding risks and safely introduce thromboprophylaxis with low-molecular-weight heparin. Summary Our article is the first to present an algorithm to consider in the thrombotic risk assessment among patients with Cushing's syndrome as a starting point for a broader discussion in the environment. A plethora of factors affect the VTE risk in patients with CS, but no studies have conclusively evaluated the best thromboprophylaxis strategy so far. Future studies are needed to set standards of care.
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Affiliation(s)
- Agata Hanna Bryk-Wiązania
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
| | - Mari Minasyan
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
| | - Renata Świątkowska-Stodulska
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Anetta Undas
- The John Paul II Hospital, Kraków, Poland
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Alicja Hubalewska-Dydejczyk
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
| | - Susan M. Webb
- Department of Endocrinology, Hospital S Pau, Barcelona, Spain
- Sant Pau Biomedical Research Institute (IIB-Sant Pau), Research Center for Pituitary Diseases, Barcelona, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER) Unit 747, Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elena Valassi
- Centre for Biomedical Network Research on Rare Diseases (CIBERER) Unit 747, Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Endocrinología, Hospital e Institut de Recerca Germans Trias i Pujol, Badalona, Barcelona, Spain
- Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Aleksandra Gilis-Januszewska
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
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Yamashita A, Nagae C, Umezawa Y, Mori M, Ashikaga T, Akita M, Suzuki N, Yamazaki S, Takayama S, Taki M. Hemostatic balance between pro- and anticoagulant is maintained during glucocorticoid treatment. Pediatr Blood Cancer 2024; 71:e30812. [PMID: 38078567 DOI: 10.1002/pbc.30812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/27/2023] [Accepted: 11/29/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Glucocorticoids are associated with an increased risk of venous thrombosis. Glucocorticoid treatment increases coagulation factor and anticoagulant levels; however, its effect on hemostatic function remains unclear. This study aimed to investigate the changes in comprehensive coagulation profiles after glucocorticoid treatment in noninflammatory diseases to elucidate the direct contribution of glucocorticoids to hemostatic function. PROCEDURE Patients diagnosed with primary immune thrombocytopenia requiring glucocorticoid treatment were prospectively enrolled in this study. Changes in coagulation factors and anticoagulants during glucocorticoid treatment and changes in thrombin generation potential were determined in the absence and presence of soluble thrombomodulin (sTM). RESULTS Seven treatment cases (four for steroid pulse therapy and three for oral glucocorticoid therapy) in six patients with immune thrombocytopenia were examined. After glucocorticoid treatment, activated partial thromboplastin time significantly shortened, and activities of factor VIII, IX, XI, and XII significantly increased, except for von Willebrand factor antigen. Moreover, antithrombin and protein C (PC) activities significantly increased after glucocorticoid treatment. Two major parameters of thrombin generation potential, endogenous thrombin potential (ETP) and peak thrombin (Peak), significantly increased in the absence of sTM after glucocorticoid treatment. However, no significant increases in either parameter were observed in the presence of sTM. ETP-TM and Peak-TM ratios, which represent resistance to the anticoagulant effect of the PC pathway, significantly decreased after glucocorticoid treatment, suggesting that anticoagulant function via the PC pathway is elevated after glucocorticoid treatment. CONCLUSIONS As glucocorticoids increase intrinsic coagulation factor and anticoagulant levels, hemostatic balance between pro- and anticoagulant functions is maintained.
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Affiliation(s)
- Atsuki Yamashita
- Department of Pediatrics, St. Marianna University Yokohama Seibu Hospital, Yokohama, Japan
| | - Chiai Nagae
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yotaro Umezawa
- Department of Pediatrics, St. Marianna University Yokohama Seibu Hospital, Yokohama, Japan
| | - Mika Mori
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Tomoko Ashikaga
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Mieko Akita
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Noriko Suzuki
- Department of Clinical Laboratory, St Marianna University School of Medicine Hospital, Kawasaki, Japan
| | - Satoshi Yamazaki
- Department of Clinical Laboratory, St Marianna University School of Medicine Hospital, Kawasaki, Japan
| | - Shigenobu Takayama
- Faculty of Health Science, Daito Bunka University, Higashimatsuyama, Japan
| | - Masashi Taki
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan
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Utsumi T, Iijima S, Sugizaki Y, Mori T, Somoto T, Kato S, Oka R, Endo T, Kamiya N, Suzuki H. Laparoscopic adrenalectomy for adrenal tumors with endocrine activity: Perioperative management pathways for reduced complications and improved outcomes. Int J Urol 2023; 30:818-826. [PMID: 37376729 DOI: 10.1111/iju.15218] [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: 12/19/2022] [Accepted: 05/15/2023] [Indexed: 06/29/2023]
Abstract
The major adrenal tumors with endocrine activity are primary aldosteronism, Cushing's syndrome/mild autonomous cortisol secretion, and pheochromocytoma/paraganglioma. Excessive aldosterone secretion in primary aldosteronism causes cardiovascular, renal, and other organ damage in addition to hypertension and hypokalemia. Cortisol hypersecretion in Cushing's syndrome/mild autonomous cortisol secretion causes obesity, hypertension, impaired glucose tolerance, and cardiometabolic syndrome. Massive secretion of catecholamines in pheochromocytoma/paraganglioma causes hypertension and cerebrocardiovascular disease due to rapid blood pressure fluctuation. Moreover, pheochromocytoma multi-system crisis is a feared and possibly fatal presentation of pheochromocytoma/paraganglioma. Thus, adrenal tumors with endocrine activity are considered an indication for adrenalectomy, and perioperative management is very important. They have a risk of perioperative complications, either due to direct hemodynamic effects of the hormone hypersecretion or due to hormone-related comorbidities. In the last decades, deliberate preoperative evaluation and advanced perioperative management have significantly reduced complications and improved outcomes. Furthermore, improvements in anesthesia and surgical techniques with the feasibility of laparoscopic adrenalectomy have contributed to reduced morbidity and mortality. However, there are still several challenges to be considered in the perioperative care of these patients. There are very few data available prospectively to guide clinical management, due to the rarity of adrenal tumors with endocrine activity. Therefore, most guidelines are based on retrospective data analyses or small case series. In this review, the latest knowledge is summarized, and practical pathways to reduce perioperative complications and improve outcomes in adrenal tumors with endocrine activity are presented.
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Affiliation(s)
- Takanobu Utsumi
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Shota Iijima
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Yuka Sugizaki
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Takamichi Mori
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Takatoshi Somoto
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Seiji Kato
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Ryo Oka
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Takumi Endo
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Naoto Kamiya
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Hiroyoshi Suzuki
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
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Hindré R, Poté N, Mordant P, Le Guen P. [Infectious pneumonia favored by paraneoplastic Cushing syndrome in a pulmonary carcinoid tumor]. Rev Mal Respir 2023; 40:716-722. [PMID: 37633811 DOI: 10.1016/j.rmr.2023.06.007] [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: 06/20/2022] [Accepted: 06/29/2023] [Indexed: 08/28/2023]
Abstract
INTRODUCTION Ectopic Cushing's syndrome (CS) is a rare condition nevertheless well-known to endocrinologists. The pneumologist may be called upon to treat CS not only because bronchial carcinoid tumors are the most frequent source of ectopic ACTH secretion, but also due to the fact that the immunosuppression induced by hypercorticism favors lower respiratory tract infections. CASE REPORT We report the case of a female patient presenting with acute respiratory failure secondary to Enterobacter cloacae pneumonia exacerbated by SC. Further investigations confirmed ectopic ACTH secretion and revealed a right upper lobe pulmonary nodule. After appropriate antibiotic therapy, the patient received preoperative adrenolytic treatment. Management by right upper lobectomy resulted in the extraction of a 12mm tumor. Pathological analysis was consistent with the diagnosis of a typical carcinoid tumor. Immunohistochemistry confirmed ACTH secretion by the tumor. Even though the postoperative course showed CS regression, the patient developed adrenal insufficiency. CONCLUSION Ectopic CS induces immunosuppression, which aggravates lower respiratory tract infections. Search for a pulmonary neuroendocrine tumor should be systematic. Following control of the secretory syndrome by adrenolytic treatment, and if the diagnosis of carcinoid tumor is confirmed, surgical treatment is the preferred option.
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Affiliation(s)
- R Hindré
- Service de pneumologie, centre de référence des maladies pulmonaires rares, FHU APOLLO, hôpital Bichat, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France
| | - N Poté
- Département d'anatomo-pathologie, hôpital Bichat, AP-HP, 75018 Paris, France
| | - P Mordant
- Service de chirurgie vasculaire, thoracique, et transplantation pulmonaire, hôpital Bichat, AP-HP, 75018 Paris, France
| | - P Le Guen
- Service de pneumologie, centre de référence des maladies pulmonaires rares, FHU APOLLO, hôpital Bichat, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France.
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Lopes V, Marques O, De Sousa Lages A. Preventive strategies for hypercoagulation in Cushing's syndrome: when and how. Thromb J 2023; 21:72. [PMID: 37400845 DOI: 10.1186/s12959-023-00515-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/19/2023] [Indexed: 07/05/2023] Open
Abstract
PURPOSE The endogenous hypercortisolism that characterizes Cushing's syndrome (CS) is associated with a state of hypercoagulability that significantly increases the risk of thromboembolic disease, especially, venous events. Despite this certainty, there is no consensus on the best thromboprophylaxis strategy (TPS) for these patients. Our aim was to summarize the published data about different thromboprophylaxis strategies, and to review available clinical tools assisting thromboprophylaxis decision making. METHODS Narrative review of thromboprophylaxis strategies in patients with Cushing's syndrome. A search was carried out on PubMed, Scopus and EBSCO until November 14th, 2022, and articles were selected based on their relevance and excluded in case of redundant content. RESULTS Literature is scarce regarding thromboprophylaxis strategies to be adopted in the context of endogenous hypercortisolism, most often being a case-by-case decision according to the centre expertise. Only three retrospective studies, with a small number of patients enrolled, evaluated the use of hypocoagulation for the thromboprophylaxis of patients with CS in the post-operative period of transsphenoidal surgery and/or adrenalectomy, but all of them with favourable results. The use of low molecular weight heparin is the most frequent option as TPS in CS context. There are numerous venous thromboembolism risk assessment scores validated for different medical purposes, but just one specifically developed for CS, that must be validated to ensure solid recommendations in this context. The use of preoperative medical therapy is not routinely recommended to decrease the risk of postoperative venous thromboembolic events. The peak of venous thromboembolic events occurs in the first three months post-surgery. CONCLUSION The need to hypocoagulate CS patients, mainly in the post-operative period of a transsphenoidal surgery or an adrenalectomy, is undoubtable, especially in patients with an elevated risk of venous thromboembolic events, but the precise duration and the hypocoagulation regimen to institute is yet to be determined with prospective studies.
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Affiliation(s)
- Valentim Lopes
- Endocrinology Department of Hospital of Braga, Braga, Portugal.
| | - Olinda Marques
- Endocrinology Department of Hospital of Braga, Braga, Portugal
| | - Adriana De Sousa Lages
- Endocrinology Department of Hospital of Braga, Braga, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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6
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Multiple deep vein thromboses after curative surgery for Cushing’s disease: A case presentation and review. AACE Clin Case Rep 2022; 8:247-250. [DOI: 10.1016/j.aace.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 07/14/2022] [Accepted: 08/01/2022] [Indexed: 11/20/2022] Open
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van Haalen FM, Kaya M, Pelsma ICM, Dekkers OM, Biermasz NR, Cannegieter SC, Huisman MV, van Vlijmen BJM, Feelders RA, Klok FA, Pereira AM. Current clinical practice for thromboprophylaxis management in patients with Cushing's syndrome across reference centers of the European Reference Network on Rare Endocrine Conditions (Endo-ERN). Orphanet J Rare Dis 2022; 17:178. [PMID: 35505430 PMCID: PMC9062860 DOI: 10.1186/s13023-022-02320-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 04/09/2022] [Indexed: 11/22/2022] Open
Abstract
Background Cushing’s syndrome (CS) is associated with an hypercoagulable state and an increased risk of venous thromboembolism (VTE). Evidence-based guidelines on thromboprophylaxis strategies in patients with CS are currently lacking. We aimed to map the current clinical practice for thromboprophylaxis management in patients with CS across reference centers (RCs) of the European Reference Network on Rare Endocrine Conditions (Endo-ERN), which are endorsed specifically for the diagnosis and treatment of CS. Using the EU survey tool, a primary screening survey, and subsequently a secondary, more in-depth survey were developed. Results The majority of the RCs provided thromboprophylaxis to patients with CS (n = 23/25), although only one center had a standardized thromboprophylaxis protocol (n = 1/23). RCs most frequently started thromboprophylaxis from CS diagnosis onwards (n = 11/23), and the majority stopped thromboprophylaxis based on individual patient characteristics, rather than standardized treatment duration (n = 15/23). Factors influencing the initiation of thromboprophylaxis were ‘medical history of VTE’ (n = 15/23) and ‘severity of hypercortisolism’ (n = 15/23). Low-Molecular-Weight-Heparin was selected as the first-choice anticoagulant drug for thromboprophylaxis by all RCs (n = 23/23). Postoperatively, the majority of RCs reported ‘severe immobilization’ as an indication to start thromboprophylaxis in patients with CS (n = 15/25). Most RCs (n = 19/25) did not provide standardized testing for variables of hemostasis in the postoperative care of CS. Furthermore, the majority of the RCs provided preoperative medical treatment to patients with CS (n = 23/25). About half of these RCs (n = 12/23) took a previous VTE into account when starting preoperative medical treatment, and about two-thirds (n = 15/23) included ‘reduction of VTE risk’ as a goal of treatment. Conclusions There is a large practice variation regarding thromboprophylaxis management and perioperative medical treatment in patients with CS, even in Endo-ERN RCs. Randomized controlled trials are needed to establish the optimal prophylactic anticoagulant regimen, carefully balancing the increased risk of (perioperative) bleeding, and the presence of additional risk factors for thrombosis. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02320-x.
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Affiliation(s)
- F M van Haalen
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands.
| | - M Kaya
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
| | - I C M Pelsma
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
| | - O M Dekkers
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - N R Biermasz
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
| | - S C Cannegieter
- Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - M V Huisman
- Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - B J M van Vlijmen
- Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - R A Feelders
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands.,Department of Medicine, Division of Endocrinology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - F A Klok
- Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - A M Pereira
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
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Waqar M, Chadwick A, Kersey J, Horner D, Kearney T, Karabatsou K, Gnanalingham KK, Pathmanaban ON. Venous thromboembolism chemical prophylaxis after endoscopic trans-sphenoidal pituitary surgery. Pituitary 2022; 25:267-274. [PMID: 34843070 PMCID: PMC8894148 DOI: 10.1007/s11102-021-01195-8] [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] [Accepted: 11/15/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE There is no compelling outcome data or clear guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using low molecular weight heparin (chemoprophylaxis) in patients undergoing pituitary surgery. Here we describe our experience of early chemoprophylaxis (post-operative day 1) following trans-sphenoidal pituitary surgery. METHODS Single-centre review of a prospective surgical database and VTE records. Adults undergoing first time trans-sphenoidal pituitary surgery were included (2009-2018). VTE was defined as either deep vein thrombosis and/or pulmonary embolism within 3 months of surgery. Postoperative haematomas were those associated with a clinical deterioration together with radiological evidence. RESULTS 651 Patients included with a median age of 55 years (range 16-86 years). Most (99%) patients underwent trans-sphenoidal surgery using a standard endoscopic single nostril or bi-nostril trans-sphenoidal technique. More than three quarters had pituitary adenomas (n = 520, 80%). Postoperative chemoprophylaxis to prevent VTE was administered in 478 patients (73%). Chemoprophylaxis was initiated at a median of 1 day post-procedure (range 1-5 days postoperatively; 92% on postoperative day 1). Tinzaparin was used in 465/478 patients (97%) and enoxaparin was used in 14/478 (3%). There were no cases of VTE, even in 78 ACTH-dependent Cushing's disease patients. Six patients (1%) developed postoperative haematomas. Chemoprophylaxis was not associated with a significantly higher rate of postoperative haematoma formation (Fisher's Exact, p = 0.99) or epistaxis (Fisher's Exact, p > 0.99). CONCLUSIONS Chemoprophylaxis after trans-sphenoidal pituitary surgery on post-operative day 1 is a safe strategy to reduce the risk of VTE without significantly increasing the risk of postoperative bleeding events.
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Affiliation(s)
- Mueez Waqar
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
| | - Annabel Chadwick
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- School of Medicine, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
| | - James Kersey
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- Department of Neurocritical Care, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Daniel Horner
- Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
- Department of Neurocritical Care, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
- School of Medicine, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK
| | - Tara Kearney
- Department of Endocrinology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Konstantina Karabatsou
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Kanna K Gnanalingham
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester, UK.
- Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, The University of Manchester, Manchester, UK.
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McCormick JP, Sun M, Shafqat I, Heaney AP, Bergsneider M, Wang MB. Venous thromboembolic (VTE) prophylaxis in Cushing disease patients undergoing transsphenoidal surgery. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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10
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Covantev S, Volkov SI, Samsonova KI. Alternative Management of Cushing's Syndrome During Covid-19 Pandemic. CORONAVIRUSES 2022; 3. [DOI: 10.2174/2666796702666210913095645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/28/2021] [Accepted: 07/06/2021] [Indexed: 07/26/2024]
Abstract
:
Cushing's syndrome results from prolonged exposure to glucocorticoids. Surgery is often
the first-line treatment for this condition, regardless of etiology. However, the COVID-19 pandemic
caused a decrease in surgical procedures due to the risk of infection transmission. There are
still emergency cases of Cushing’s syndrome that are admitted to the hospital and require urgent
management. The current treatment should be focused on medical management and endovascular
embolization in selective cases. Embolization can be performed in facilities where there aretrained
personnel with experience in adrenal embolization. Surgery, which traditionally is a first-line therapy,
can increase the risk of infection, therefore, it should be avoided. The current review provides a
brief description of the possible options for the management of adrenal Cushing’s syndrome during
the COVID-19 pandemic.
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Affiliation(s)
- Serghei Covantev
- Department of Human Anatomy, State University of Medicine and Pharmacy N. Testemitanu, Moldova
| | - Stanislav I. Volkov
- Department
of Endocrinology, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - Kristina I. Samsonova
- Department of
Clinical Pharmacology, Multidisciplinary Medical Clinic of JSC “Medicine,” Moscow, Russia
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Abstract
PURPOSE OF REVIEW Endogenous Cushing's syndrome (CS) is associated with increased patient morbidity (hypertension, diabetes mellitus, dyslipidemia, visceral obesity, osteoporosis, cognitive alterations, and impaired quality of life). Both arterial and venous thromboembolic events (TE) due to alterations in the hemostatic system and prothrombotic state are widely reported in patients with CS, more so postoperatively. Increased mortality, if not appropriately treated, is largely due to cardiovascular events and infections. RECENT FINDINGS Patients with CS have markedly increased risk of thromboembolic episodes compared to the general population. The prothrombotic state is mediated by increased levels of procoagulant factors, but also by an impaired fibrinolytic capacity. All contribute to TE, atherosclerosis, and subsequent cardiovascular morbidity and mortality. Some abnormalities progressively improve after CS remission, but do not fully normalize for at least 1 year or more. SUMMARY Due to the additional thrombotic risk of surgery or any invasive procedure, anticoagulation prophylaxis should be at least considered in patients with CS and balanced with individual bleeding risk. However, a clear protocol of thromboprophylaxis is lacking and increased awareness regarding risks per se is needed. Large prospective trials will clarify, which patients with CS are at the highest risk and the optimal prevention protocol to minimize risks and maximize efficacy.
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Affiliation(s)
- Cristina Capatina
- Department of Endocrinology, University of Medicine and Pharmacy 'Carol Davila' Bucharest, and Department of Pituitary and Neuroendocrine Pathology, C.I. Parhon National Institute of Endocrinology, Bucharest, Romania
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
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St-Jean M, Lim DST, Langlois F. Hypercoagulability in Cushing's syndrome: From arterial to venous disease. Best Pract Res Clin Endocrinol Metab 2021; 35:101496. [PMID: 33795197 DOI: 10.1016/j.beem.2021.101496] [Citation(s) in RCA: 9] [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] [Indexed: 01/30/2023]
Abstract
Cushing's syndrome (CS) is associated with multisystemic complications; the hematological system is not spared. Alteration in hemostatic parameters and in vivo endothelial dysfunction lead to increased thrombotic events. Arterial and venous thrombotic events carry significant morbidity and mortality. Death from cardiovascular and pulmonary embolism account for more than 50% of mortality. Surgery is a critical period; close to 50% of events occur in the 1-2 months after intervention. The evaluation and risk stratification of patients with CS is key to prevent events, balancing the risk-benefit of anticoagulation in this population. This current review will focus on up-to-date data on epidemiology, pathophysiology and management of hypercoagulability in CS.
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Affiliation(s)
- Matthieu St-Jean
- Division of Endocrinology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada.
| | - Dawn S T Lim
- Department of Endocrinology, Singapore General Hospital, Singapore.
| | - 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, Québec, Canada.
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13
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Koraćević G, Stojanović M, Petrović S, Simić D, Sakač D, Vlajković M, Stevic M, Kocić M, Đorđević M, Koraćević M. CUSHING'S SYNDROME, A RISK FACTOR FOR VENOUS THROMBOEMBOLISM IS A CANDIDATE FOR GUIDELINES. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2020; 16:123-128. [PMID: 33029226 PMCID: PMC7535883 DOI: 10.4183/aeb.2020.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The present paper aims to review important contemporary information about VTE risk in endogenous and exogenous CS, as a substantial discrepancy exists between the results of a recent meta-analysis confirming the increased risk for VTE and the absence of CS in VTE guidelines. METHODS An extensive search of relevant databases (e.g. PubMed, Google Scholar, and Scopus) was performed in order to establish the interconnectedness of the following terms: Cushing's syndrome, venous thromboembolism, deep vein thrombosis, pulmonary embolism. RESULTS The analysis demonstrated that patients with CS have about ten times the risk for VTE, particularly during the first year following the diagnosis of CS. Oral glucocorticoid users (with iatrogenic CS) have a 3-fold increase in risk of VTE in comparison with non-users. The most recent 2019 meta-analysis encompassed 7142 patients with endogenous CS (including Cushing's disease) undergoing transsphenoidal surgery or adrenalectomy, and their risk of unprovoked VTE was almost 18 times higher in comparison with a healthy population. CONCLUSION Over the past 50 years considerable evidence of increased VTE risk in CS has been accumulated. It pertains to both endogenous and exogenous type of CS and has been confirmed in the vast majority, if not all the available studies, including meta-analyses. Nevertheless, official CS guidelines make no mention of CS as a VTE risk factor, even though it is important that not only physicians who treat CS, but also physicians who manage patients with suspected VTE be aware of increased VTE risk.
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Affiliation(s)
- G. Koraćević
- Clinical Centre Niš - Department for Cardiovascular Diseases, Novi Sad Serbia
- Clinical Centre Niš - University of Niš, Faculty of Medicine, Novi Sad Serbia
| | - M. Stojanović
- Clinical Centre Niš - Institute for Treatment and Rehabilitation, Niška Banja, Novi Sad Serbia
| | - S. Petrović
- Clinical Centre Niš - Department of Radiology, Novi Sad Serbia
- Clinical Centre Niš - University of Niš, Faculty of Medicine, Novi Sad Serbia
| | - D. Simić
- Clinical Centre Niš - Clinical Center of Serbia - Division of Cardiology, Novi Sad Serbia
- Clinical Centre Niš - University of Belgrade Faculty of Medicine, Beograd, Novi Sad Serbia
| | - D. Sakač
- Clinical Centre Niš - Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Vojvodina, Novi Sad Serbia
- Clinical Centre Niš - University of Novi Sad Medical Faculty, Novi Sad Serbia
| | - M. Vlajković
- Clinical Centre Niš - Department of Nuclear Medicine, Novi Sad Serbia
- Clinical Centre Niš - University of Niš, Faculty of Medicine, Novi Sad Serbia
| | - M. Stevic
- Clinical Centre Niš - Center of Nuclear Medicine, Novi Sad Serbia
- Clinical Centre Niš - University of Niš, Faculty of Medicine, Novi Sad Serbia
| | - M. Kocić
- Clinical Centre Niš - Department of Rehabilitation, Novi Sad Serbia
- Clinical Centre Niš - University of Niš, Faculty of Medicine, Novi Sad Serbia
| | - M. Đorđević
- Clinical Centre Niš - Health Centre Jagodina - Emergency Medical Service, Novi Sad Serbia
| | - M. Koraćević
- Clinical Centre Niš - University of Niš, Faculty of Medicine, Novi Sad Serbia
- Clinical Centre Niš - University of Nis - Innovation Centre, Niš, Novi Sad Serbia
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14
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Suarez MG, Stack M, Hinojosa-Amaya JM, Mitchell MD, Varlamov EV, Yedinak CG, Cetas JS, Sheppard B, Fleseriu M. Hypercoagulability in Cushing Syndrome, Prevalence of Thrombotic Events: A Large, Single-Center, Retrospective Study. J Endocr Soc 2019; 4:bvz033. [PMID: 32064411 PMCID: PMC7009121 DOI: 10.1210/jendso/bvz033] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/12/2019] [Indexed: 12/16/2022] Open
Abstract
Background The risk of Cushing syndrome (CS) patients experiencing a thrombotic event (TE) is significantly higher (odds ratio; OR 18%) than that of the general population. However, there are currently no anticoagulation guidelines. Methods A retrospective, single-center, longitudinal study of patients undergoing all types of treatment—surgical (pituitary, unilateral, and bilateral adrenalectomy) and medical treatment—was undertaken. TEs were recorded at any point up until last patient follow-up; myocardial infarction (MI), deep venous thrombosis (DVT), and pulmonary embolism (PE) or stroke. Patients’ doses and complications of anticoagulation were recorded. Results Included were 208 patients; a total of 165 (79.3%) were women, and mean age at presentation was 44 ± 14.7 years. Thirty-nine (18.2%) patients had a TE; extremity DVT (38%), cerebrovascular accident (27%), MI (21%), and PE (14%). Of 56 TEs, 27 (48%) were arterial and 29 (52%) were venous. Patients who underwent bilateral adrenalectomy (BLA) had an odds ratio of 3.74 (95% CI 1.69-8.27) of developing a TE. Of patients with TEs, 40.5% experienced the event within the first 60 days after surgery. Baseline 24-hour urinary free cortisol levels did not differ in patients with or without TE after BLA. Of 197 patients who underwent surgery, 50 (25.38%) received anticoagulation after surgery, with 2% having bleeding complications. Conclusions The risk of TEs in patients with CS was approximately 20%. Many patients had more than 1 event, with higher risk 30 to 60 days postoperatively. The optimal prophylactic anticoagulation duration is unknown, but most likely needs to continue up to 60 days postoperatively, particularly after BLA.
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Affiliation(s)
- Maria Gabriela Suarez
- Department of Medicine (Endocrinology), Oregon Health & Science University, Portland, Oregon, USA.,Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Madeleine Stack
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Jose Miguel Hinojosa-Amaya
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA.,Endocrinology Division, Department of Medicine, Hospital Universitario "Dr. Jose E. Gonzalez", Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | | | - Elena V Varlamov
- Department of Medicine (Endocrinology), Oregon Health & Science University, Portland, Oregon, USA.,Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Chris G Yedinak
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Justin S Cetas
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA.,Operative Care Division, Portland Veterans Administration Hospital, Portland, Oregon, USA
| | - Brett Sheppard
- Department of General Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Maria Fleseriu
- Department of Medicine (Endocrinology), Oregon Health & Science University, Portland, Oregon, USA.,Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.,Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
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15
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Lamos EM, Munir KM. Cushing disease: highlighting the importance of early diagnosis for both de novo and recurrent disease in light of evolving treatment patterns. Endocr Pract 2019; 20:945-55. [PMID: 25100372 DOI: 10.4158/ep14068.ra] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To highlight and summarize current literature on Cushing disease (CD)-related morbidity and mortality, focusing on residual complications after "cure" and the changing role of pharmacologic therapy in CD. METHODS Current journal articles on the consequences of untreated or undertreated CD, CD recurrence, and recent trends in CD treatment were collected from PubMed searches and analyzed in combination in view of the authors' clinical experience. RESULTS Timely recognition and treatment of de novo and recurrent CD remains a singular clinical challenge. Chronic excess cortisol exposure leads to potentially irreversible sequelae and death, stressing the importance of early diagnosis and treatment. Disease relapse after primary pituitary adenomectomy is prevalent and recurrence may manifest decades after initial surgery. Increased risk for mortality and hypercortisolism-related complications in postsurgical CD patients may indicate persistent subclinical disease and further underscores the need for cautious, ongoing observation and testing. Potential long-term pharmacologic treatment options (e.g., pasireotide, mifepristone) have recently emerged that may provide biochemical and symptomatic remission for those with refractory CD, or those for whom surgery is contraindicated. CONCLUSION Delays in CD diagnosis, management, and follow-up are common and lead to increased adverse metabolic complications and mortality. Rapid recognition and treatment as well as vigilant monitoring are therefore essential. After surgical treatment, some patients may suffer from persistent subclinical CD that remains difficult to detect with routine testing. Although long-term pharmacologic treatment has historically been limited by adverse reactions or escape from response, new treatments may offer more options for patients with refractory disease.
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Affiliation(s)
- Elizabeth M Lamos
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kashif M Munir
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, Maryland
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16
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Babic B, De Roulet A, Volpe A, Nilubol N. Is VTE Prophylaxis Necessary on Discharge for Patients Undergoing Adrenalectomy for Cushing Syndrome? J Endocr Soc 2018; 3:304-313. [PMID: 30652131 PMCID: PMC6330172 DOI: 10.1210/js.2018-00278] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/07/2018] [Indexed: 11/19/2022] Open
Abstract
Background Patients with Cushing syndrome (CS) have an increased risk for venous thromboembolism (VTE). However, it is unclear whether patients undergoing adrenalectomy for CS are at increased risk for postoperative VTE. The aim of this study was to determine the rate of postoperative VTE in patients undergoing adrenalectomy for CS. Methods A retrospective analysis of patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent adrenalectomy from 2005 to 2016 was performed. We compared the clinical characteristics and 30-day postoperative VTE occurrence in patients with and without CS. Results A total of 4217 patients were analyzed; 2607 (61.8%) were female and 310 (7.4%) had CS. The overall prevalence of postoperative VTE was 1.0% (n = 45). The rates of VTE were higher in patients with CS (2.6% vs 0.9%; P = 0.007). In the two groups, CS was associated with younger age, increased body mass index, and diabetes mellitus (P < 0.001). CS was also associated with longer length of operation and longer hospital length of stay (P < 0.001). In the subgroup of patients who had diagnosed VTE, CS was associated with longer length of operation (P < 0.001). Rates of laparoscopic vs open surgery were equivalent between patients with and without CS, and VTE events did not differ. The median time to VTE event was 14.5 days (range, 1 to 23 days) in the CS group and 4 days (range, 2 to 25 days) in the group without CS. Conclusions The prevalence of postoperative VTE was increased in patients undergoing adrenalectomy for CS. In patients with CS undergoing adrenalectomy, VTE prophylaxis for 28 days should be considered upon discharge.
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Affiliation(s)
- Bruna Babic
- Department of Surgery, New York Presbyterian-Queens, Flushing, New York
| | - Amory De Roulet
- Department of Surgery, New York Presbyterian-Queens, Flushing, New York
| | - Anita Volpe
- Department of Surgery, New York Presbyterian-Queens, Flushing, New York
| | - Naris Nilubol
- Endocrine Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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17
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Koracevic G, Stojkovic M, Lovic D, Pavlovic M, Kostic T, Kutlesic M, Micic S, Koracevic M, Djordjevic M. Should Cushing's Syndrome be Considered as a Disease with High Cardiovascular Risk in Relevant Guidelines? Curr Vasc Pharmacol 2018; 18:12-24. [PMID: 30289080 DOI: 10.2174/1570161116666181005122339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/29/2018] [Accepted: 09/29/2018] [Indexed: 12/27/2022]
Abstract
A considerable amount of data supports a 1.8-7.4-fold increased mortality associated with Cushing's syndrome (CS). This is attributed to a high occurrence of several cardiovascular disease (CVD) risk factors in CS [e.g. adiposity, arterial hypertension (AHT), dyslipidaemia and type 2 diabetes mellitus (T2DM)]. Therefore, practically all patients with CS have the metabolic syndrome (MetS), which represents a high CVD risk. Characteristically, despite a relatively young average age, numerous patients with CS display a 'high' or 'very high' CVD risk (i.e. risk of a major CVD event >20% in the following 10 years). Although T2DM is listed as a condition with a high CVD risk, CS is not, despite the fact that a considerable proportion of the CS population will develop T2DM or impaired glucose tolerance. CS is also regarded as a risk factor for aortic dissection in current guidelines. This review considers the evidence supporting listing CS among high CVD risk conditions.
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Affiliation(s)
- Goran Koracevic
- Department for Cardiovascular Diseases, Clinical Centre, Nis, Serbia.,Medical Faculty, University of Nis, Nis, Serbia
| | | | - Dragan Lovic
- Clinic for Internal Medicine Intermedica, Nis, Serbia
| | - Milan Pavlovic
- Department for Cardiovascular Diseases, Clinical Centre, Nis, Serbia.,Medical Faculty, University of Nis, Nis, Serbia
| | - Tomislav Kostic
- Department for Cardiovascular Diseases, Clinical Centre, Nis, Serbia.,Medical Faculty, University of Nis, Nis, Serbia
| | | | | | | | - Milan Djordjevic
- Health Centre Jagodina, Emergency Medical Service, Jagodina, Serbia
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18
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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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19
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Wagner J, Langlois F, Lim DST, McCartney S, Fleseriu M. Hypercoagulability and Risk of Venous Thromboembolic Events in Endogenous Cushing's Syndrome: A Systematic Meta-Analysis. Front Endocrinol (Lausanne) 2018; 9:805. [PMID: 30745894 PMCID: PMC6360168 DOI: 10.3389/fendo.2018.00805] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/21/2018] [Indexed: 12/16/2022] Open
Abstract
Background: Hypercortisolism has been implicated in the development of venous thromboembolic events (VTE). We aimed to characterize VTE risk in endogenous Cushing's syndrome (CS) patients, compare that risk to other pathologies, and determine if there are any associated coagulation factor changes. Methods: Medline and Scopus search for "hypercortisolism" and "thromboembolic disease" from January 1980 to April 2017 to include studies that reported VTE rates and/or coagulation profile of CS patients. A systematic review and meta-analysis were performed. Results: Forty-eight studies met inclusion criteria. There were 7,142 CS patients, average age was 42 years and 77.7% female. Odds ratio of spontaneous VTE in CS is 17.82 (95%CI 15.24-20.85, p < 0.00001) when comparing to a healthy population. For CS patients undergoing surgery, the odds ratio (both with / without anticoagulation) of spontaneous VTE is 0.26 (95%CI 0.07-0.11, p < 0.00001)/0.34 (0.19-0.36, p < 0.00001) when compared to patients undergoing hip fracture surgery who were not treated with anticoagulants. Coagulation profiles in patients with CS showed statistically significant differences compared to controls, as reflected by increases in von Willebrand factor (180.11 vs. 112.53 IU/dL, p < 0.01), as well as decreases in activated partial thromboplastin time (aPTT; 26.91 vs. 30.65, p < 0.001) and increases in factor VIII (169 vs. 137 IU/dL, p < 0.05). Conclusion: CS is associated with significantly increased VTE odds vs. general population, but lower than in patients undergoing major orthopedic surgery. Although exact timing, type, and dose of anticoagulation medication remains to be established, clinicians might consider monitoring vWF, PTT, and factor VIII when evaluating CS patients and balance advantages of thromboprophylaxis with risk of bleeding.
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Affiliation(s)
- Jeffrey Wagner
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
| | - Fabienne Langlois
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
- Centre Hospitalier Universitaire de Sherbrooke, Fleurimont, QC, Canada
| | - Dawn Shao Ting Lim
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
- Singapore General Hospital, Singapore, Singapore
| | - Shirley McCartney
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
| | - Maria Fleseriu
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
- *Correspondence: Maria Fleseriu
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20
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Tripodi A, Ammollo CT, Semeraro F, Colucci M, Malchiodi E, Verrua E, Ferrante E, Arnaldi G, Trementino L, Padovan L, Chantarangkul V, Peyvandi F, Mantovani G. Hypercoagulability in patients with Cushing disease detected by thrombin generation assay is associated with increased levels of neutrophil extracellular trap-related factors. Endocrine 2017; 56:298-307. [PMID: 27448294 DOI: 10.1007/s12020-016-1027-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/16/2016] [Indexed: 10/21/2022]
Abstract
Patients with Cushing disease (CD) are at increased risk of venous thromboembolism (VTE). It was surmised, but not conclusively shown that the risk is related to plasma hypercoagulability secondary to the glucocorticoids effect. This study is aimed at detecting hypercoagulability in patients with CD. Case-control study of 48 CD patients and controls enrolled at two Italian clinics for whom we assessed the thrombin-forming-potential in the presence of optimal activation of protein C obtained by adding into the assay system its main endothelial activator, thrombomodulin. These experimental conditions mimic more closely than any other test the in vivo situation. We observed enhanced thrombin-generation in CD patients, as shown by the modification of thrombin-generation parameters [i.e., shortened lag-time and time-to-peak, increased thrombin peak and endogenous thrombin potential (ETP)]. Moreover, the ETP ratio (with/without thrombomodulin), recognized as an index of hypercoagulability, was increased in patients as compared to controls. We attempted to explain such hypercoagulability by measuring both procoagulant and anticoagulant factors, and some other non-coagulation parameters (i.e., neutrophil extracellular traps (NET), recently associated with the VTE risk and/or increased hypercoagulability. We showed that the hypercoagulability in patients with CD is associated with increased levels of factor VIII and NET-related variables. We detected plasma hypercoagulability in patients with CD and found experimental explanation for its occurrence. Whether this hypercoagulability can entirely explain the occurrence of VTE in patients with CD should be investigated by ad-hoc clinical trials. However, until these studies will be available the evidence supports the concept that patients with CD are candidates for antithrombotic prophylaxis.
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Affiliation(s)
- Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy.
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy.
| | - Concetta T Ammollo
- Department of Biomedical Sciences and Human Oncology, Aldo Moro University, Bari, Italy
| | - Fabrizio Semeraro
- Department of Biomedical Sciences and Human Oncology, Aldo Moro University, Bari, Italy
| | - Mario Colucci
- Department of Biomedical Sciences and Human Oncology, Aldo Moro University, Bari, Italy
| | - Elena Malchiodi
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
- Unit of Endocrinology and Diabetology, Milano, Italy
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
| | - Elisa Verrua
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
- Unit of Endocrinology and Diabetology, Milano, Italy
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
| | - Emanuele Ferrante
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
- Unit of Endocrinology and Diabetology, Milano, Italy
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
| | - Giorgio Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Laura Trementino
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Lidia Padovan
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
| | - Veena Chantarangkul
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
| | - Giovanna Mantovani
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
- Unit of Endocrinology and Diabetology, Milano, Italy
- IRCCS Cà Granda Maggiore Hospital Foundation, Milano, Italy
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21
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Zilio M, Mazzai L, Sartori MT, Barbot M, Ceccato F, Daidone V, Casonato A, Saggiorato G, Noventa F, Trementino L, Prandoni P, Boscaro M, Arnaldi G, Scaroni C. A venous thromboembolism risk assessment model for patients with Cushing's syndrome. Endocrine 2016; 52:322-32. [PMID: 26113424 DOI: 10.1007/s12020-015-0665-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 06/12/2015] [Indexed: 11/28/2022]
Abstract
Cushing's syndrome (CS) is associated with an incidence of venous thromboembolism (VTE) about ten times higher than in the normal population. The aim of our study was to develop a model for identifying CS patients at higher risk of VTE. We considered clinical, hormonal, and coagulation data from 176 active CS patients and used a forward stepwise logistic multivariate regression analysis to select the major independent risk factors for thrombosis. The risk of VTE was calculated as a 'CS-VTE score' from the sum of points of present risk factors. VTE developed in 20 patients (4 pulmonary embolism). The group of CS patients with VTE were older (p < 0.001) and had more cardiovascular events (p < 0.05), infections and reduced mobility (both p < 0.001), higher midnight plasma cortisol levels (p < 0.05), and shorter APTT (p < 0.01) than those without. We identified six major independent risk factors for VTE: age ≥69 years and reduced mobility were given two points each, whereas acute severe infections, previous cardiovascular events, midnight plasma cortisol level >3.15 times the normality and shortened APTT were given one point each. A CS-VTE score <2 anticipated no risk of VTE; a CS-VTE score of two mild risk (10 %); a CS-VTE score of three moderate risk (46 %); a CS-VTE score ≥4 high risk (85 %). Considering a score ≥3 as predictive of VTE, 94 % of the patients were correctly classified. A simple score helps stratify the VTE risk in CS patients and identify those who could benefit from thromboprophylaxis.
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Affiliation(s)
- Marialuisa Zilio
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105 35128, Padua, Italy.
| | - Linda Mazzai
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105 35128, Padua, Italy
| | - Maria Teresa Sartori
- Clinical Medicine II, Department of Cardiac, Thoracic and Vascular Sciences, University-Hospital of Padova, Padua, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105 35128, Padua, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105 35128, Padua, Italy
| | - Viviana Daidone
- Clinical Medicine II, Department of Cardiac, Thoracic and Vascular Sciences, University-Hospital of Padova, Padua, Italy
| | - Alessandra Casonato
- Clinical Medicine II, Department of Cardiac, Thoracic and Vascular Sciences, University-Hospital of Padova, Padua, Italy
| | - Graziella Saggiorato
- Clinical Medicine II, Department of Cardiac, Thoracic and Vascular Sciences, University-Hospital of Padova, Padua, Italy
| | - Franco Noventa
- Clinical Medicine V, Department of Medicine DIMED, University-Hospital of Padova, Padua, Italy
| | - Laura Trementino
- Endocrinology Unit, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Prandoni
- Clinical Medicine II, Department of Cardiac, Thoracic and Vascular Sciences, University-Hospital of Padova, Padua, Italy
| | - Marco Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105 35128, Padua, Italy
| | - Giorgio Arnaldi
- Endocrinology Unit, Polytechnic University of Marche, Ancona, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale, 105 35128, Padua, Italy
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Sarkar S, Rajaratnam S, Chacko G, Mani S, Hesargatta AS, Chacko AG. Pure endoscopic transsphenoidal surgery for functional pituitary adenomas: outcomes with Cushing's disease. Acta Neurochir (Wien) 2016; 158:77-86; discussion 86. [PMID: 26577636 DOI: 10.1007/s00701-015-2638-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 11/05/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND This study was performed to examine patient outcomes following pure endoscopic transsphenoidal surgery (ETS) for Cushing's disease (CD). METHOD We studied 64 consecutive patients who underwent 69 endoscopic transsphenoidal procedures. Radiological evaluation comprised detailed examination of preoperative magnetic resonance images (MRI), including positron emission tomography (PET) for select cases. Inferior petrosal sinus sampling (IPSS) was not performed for any patient. Remission was defined by the presence of hypocortisolemia with requirement for steroid replacement therapy or eucortisolemia with suppression to <1.8 μg/dl after 1 mg dexamethasone on evaluation at least 3 months after surgery. RESULTS Preoperative MRI was abnormal in 87.5 % of cases and included 11 macroadenomas (17.2 %). PET was used to localize the adenoma in four cases. For microadenomas, operative procedures executed were as follows: selective adenomectomy (n = 15), enlarged adenomectomy (n = 21) and subtotal/hemihypophysectomy (n = 17). Overall, pathological confirmation of an adenoma was possible in 58 patients (90.6 %). Forty-nine patients (76.6 %) developed hypocortisolemia (<5 μg/dl) in the early postoperative period. Mean follow-up was 20 months (range 6-18 months). Remission was confirmed in 79.7 % of the 59 cases followed up for >3 months and was superior for microadenomas (86.4 %) versus macroadenomas (55.6 %) and equivocal MRI adenomas (66.7 %). Postoperative CSF rhinorrhea occurred in five patients, and new endocrine deficits were noted in 17.1 % patients. A nadir postoperative cortisol <2 μg/dl in the 1st week after surgery was highly predictive of remission (p = 0.001). CONCLUSION ETS allows for enhanced intrasellar identification of adenomatous tissue, providing remission rates that are comparable to traditional microsurgery for CD. The best predictor of remission remains induction of profound hypocortisolemia in the early postoperative period.
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Affiliation(s)
- Sauradeep Sarkar
- Sections of Neurosurgery Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Simon Rajaratnam
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
| | - Geeta Chacko
- Neuropathology, Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Sunithi Mani
- Department of Radiodiagnosis, Christian Medical College, Vellore, India
| | - Asha S Hesargatta
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
| | - Ari George Chacko
- Sections of Neurosurgery Department of Neurological Sciences, Christian Medical College, Vellore, India.
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Coelho MCA, Santos CV, Vieira Neto L, Gadelha MR. Adverse effects of glucocorticoids: coagulopathy. Eur J Endocrinol 2015; 173:M11-21. [PMID: 25971647 DOI: 10.1530/eje-15-0198] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/11/2015] [Indexed: 11/08/2022]
Abstract
Hypercortisolism is associated with various systemic manifestations, including central obesity, arterial hypertension, glucose intolerance/diabetes mellitus, dyslipidemia, nephrolithiasis, osteoporosis, gonadal dysfunction, susceptibility to infections, psychiatric disorders, and hypercoagulability. The activation of the hemostatic system contributes to the development of atherosclerosis and subsequent cardiovascular morbidity and mortality. Previous studies have identified an increased risk of both unprovoked and postoperative thromboembolic events in patients with endogenous and exogenous Cushing's syndrome (CS). The risk for postoperative venous thromboembolism in endogenous CS is comparable to the risk after total hip or knee replacement under short-term prophylaxis. The mechanisms that are involved in the thromboembolic complications in hypercortisolism include endothelial dysfunction, hypercoagulability, and stasis (Virchow's triad). It seems that at least two factors from Virchow's triad must be present for the occurrence of a thrombotic event in these patients. Most studies have demonstrated that this hypercoagulable state is explained by increased levels of procoagulant factors, mainly factors VIII, IX, and von Willebrand factor, and also by an impaired fibrinolytic capacity, which mainly results from an elevation in plasminogen activator inhibitor 1. Consequently, there is a shortening of activated partial thromboplastin time and increased thrombin generation. For these reasons, anticoagulant prophylaxis might be considered in patients with CS whenever they have concomitant prothrombotic risk factors. However, multicenter studies are needed to determine which patients will benefit from anticoagulant therapy and the dose and time of anticoagulation.
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Affiliation(s)
- Maria Caroline Alves Coelho
- Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil
| | - Camila Vicente Santos
- Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil
| | - Leonardo Vieira Neto
- Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrinology SectionMedical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rua Prof. Rodolpho Paulo Rocco, 255, 9th Floor, Ilha do Fundo, Rio de Janeiro 21941-913, BrazilEndocrine SectionHospital Pedro Ernesto, Rio de Janeiro, BrazilEndocrine SectionInstituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE), Rio de Janeiro, BrazilEndocrine SectionHospital Federal da Lagoa, Rio de Janeiro, Brazil
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Bartz SK, Karaviti LP, Brandt ML, Lopez ME, Masand P, Devaraj S, Hicks J, Anderson L, Lodish M, Keil M, Stratakis CA. Residual manifestations of hypercortisolemia following surgical treatment in a patient with Cushing syndrome. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2015; 2015:19. [PMID: 26322079 PMCID: PMC4551381 DOI: 10.1186/s13633-015-0014-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 07/07/2015] [Indexed: 11/26/2022]
Abstract
Context Cushing Syndrome is difficult to diagnose, and the comorbidities and persistent late effects of hypercortisolemia after treatment of the primary disease are challenging for the patient and the endocrinologist. Objective To report the case of a girl with obesity and hypertension, ultimately diagnosed with Cushing syndrome due to primary pigmented nodular adrenocortical disease. In this case, the complications of hypercortisolism persisted short term despite surgical intervention. Patient A 4 year old morbidly obese African-American girl with developmental delay presented with hypertensive emergency in the ER and 18-month history of progressive weight gain. Her previous history included premature adrenarche, hypertension, seizures and a random high cortisol with suppressed ACTH. She was subsequently stabilized, and a diagnostic work-up persistently demonstrated elevated cortisol and suppressed ACTH. An abdominal MRI showed bilateral adrenal multinodular disease, consistent with multinodular hyperplasia of the adrenal glands. Based on these findings the patient underwent a bilateral adrenalectomy, which confirmed primary pigmented nodular adrenocortical disease. The patient had a complicated, protracted post-operative course requiring adjustment of therapy for persistent hypertension. Two months after surgery, she was readmitted to the Emergency Department with hyperpyrexia and hypertension and succumbed to the complications of sepsis. Conclusions and outcome This case highlights the significant diagnostic and therapeutic challenges in treating children with Cushing syndrome. Resolution of the source of hypercortisolemia does not imply regression of hypertension or recovery of the immune system. Although the child underwent bilateral adrenalectomy, persistent consequences of prolonged severe hypercortisolism contributed to her death two months later.
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Affiliation(s)
- Sara K Bartz
- Department of Pediatric Endocrinology and Metabolism, Texas Children's Hospital, Houston, TX USA
| | - Lefkothea P Karaviti
- Department of Pediatric Endocrinology and Metabolism, Texas Children's Hospital, Houston, TX USA
| | - Mary L Brandt
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX USA
| | - Monica E Lopez
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX USA
| | - Prakash Masand
- Department of Radiology, Texas Children's Hospital, Houston, TX USA
| | - Sridevi Devaraj
- Medical Director of Clinical Chemistry and POCT, Texas Children's Hospital and Baylor College of Medicine, Houston, TX USA
| | - John Hicks
- Department of Pathology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX USA
| | | | - Maya Lodish
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH, Houston, TX USA
| | - Meg Keil
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH, Houston, TX USA
| | - Constantine A Stratakis
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH, Houston, TX USA
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25
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Barbot M, Daidone V, Zilio M, Albiger N, Mazzai L, Sartori MT, Frigo AC, Scanarini M, Denaro L, Boscaro M, Casonato S, Ceccato F, Scaroni C. Perioperative thromboprophylaxis in Cushing's disease: What we did and what we are doing? Pituitary 2015; 18:487-93. [PMID: 25239557 DOI: 10.1007/s11102-014-0600-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Cushing's disease (CD) is associated with an increased risk of thrombotic events, particularly after surgery. No guidelines are available on the management of patients with CD undergoing pituitary transsphenoidal surgery (TSS). We aimed to compare the effectiveness of different prophylactic procedures on the prevention of thrombotic events after surgery in CD. METHODS We retrospectively collected data on 78 consecutive patients who underwent TSS for CD between 2001 and 2012 at Padova's Neurosurgical Unit, recording their hemostatic, hormonal and anthropometric parameters. Patients were divided into two groups according to their perioperative management. Group A (34 patients) received fractionated heparin for a maximum of 14 days after surgery. Patients in group B (44 patients) were given no early glucocorticoid replacement therapy, and treated with subcutaneous enoxaparin 4,000-8,000 U/daily (depending on their weight) for 30 days plus graduated elastic stockings until mobilization, and early ambulation. RESULTS The whole cohort of patients had clotting and anticoagulant factors significantly higher than the normal range. The two groups were comparable for age, BMI, ACTH, urinary free cortisol levels, outcome of surgery, and main clotting parameters. The surgical procedure did not change during the study period. Three venous thrombotic events [venous thromboembolic events (VTE), 2 associated with pulmonary embolism] were recorded in group A, none in group B (p = 0.079). No hemorrhagic events were reported. CONCLUSIONS Provoked thrombotic events pose a major problem in the management of CD patients after surgery, regardless of the procedure's outcome. The prophylactic regimen proposed in this paper afforded an efficacy prophylaxis against postoperative VTE in patients with CD. Due to the rarity of CD, a multicenter study on a larger sample of cases would be warranted in order to collect more thrombotic events.
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Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 35128, Padua, Italy,
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26
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Coelho MCA, Vieira Neto L, Kasuki L, Wildemberg LE, Santos CVD, Castro G, Gouvêa G, Veloso OCG, Gadelha T, Gadelha MR. Rotation thromboelastometry and the hypercoagulable state in Cushing's syndrome. Clin Endocrinol (Oxf) 2014; 81:657-64. [PMID: 24815846 DOI: 10.1111/cen.12491] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 02/20/2014] [Accepted: 05/02/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Rotation thromboelastometry (ROTEM®) can be used for hypercoagulability evaluation. Cushing's syndrome (CS) is associated with hypercoagulability; however, ROTEM® has never been evaluated in this setting. OBJECTIVE To evaluate hypercoagulability in CS using ROTEM® and to correlate these parameters with coagulation markers and with the presence of deep vein thrombosis. DESIGN AND METHODS Thirty patients with active CS (26 women) and 30 controls matched for age, sex, body mass index, diabetes mellitus, arterial hypertension, ABO blood group and smoking were included. We measured levels of activated partial thromboplastin time (aPTT), platelets, fibrinogen, D-dimer, factor VIII (FVIII), von Willebrand factor (vWF) and C-reactive protein. ROTEM® was used to evaluate the intrinsic (INTEM), extrinsic (EXTEM) and fibrinogen (FIBTEM) pathways. Doppler ultrasonography was performed to search for lower limbs deep vein thrombosis. RESULTS INTEM clotting time using ROTEM® was shorter in patients than in controls (P = 0·04). Other ROTEM® parameters were not different. Mean aPTT was shorter in patients than in controls (P = 0·001). The FVIII, vWF and D-dimer levels were higher in patients than in controls (P = 0·001, 0·001 and 0·02, respectively). Obese CS patients presented higher levels of platelets and alterations in maximum clot formation (MCF), alpha angle and maximum speed of clot formation of INTEM (P = 0·03, 0·02 and 0·02, respectively) and an increase in the MCF of FIBTEM (P = 0·02). No deep vein thrombosis was found. CONCLUSIONS Although FVIII and vWF were abnormal in CS patients, only the initiation clot formation was different in the ROTEM® methodology and no deep vein thrombosis was found.
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Affiliation(s)
- Maria Caroline Alves Coelho
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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27
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Terzolo M, Allasino B, Pia A, Peraga G, Daffara F, Laino F, Ardito A, Termine A, Paccotti P, Berchialla P, Migliaretti G, Reimondo G. Surgical remission of Cushing's syndrome reduces cardiovascular risk. Eur J Endocrinol 2014; 171:127-36. [PMID: 24801586 DOI: 10.1530/eje-13-0555] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Recent studies have questioned the reversibility of complications of Cushing's syndrome (CS) after successful surgical treatment. The aim of this study was to assess the outcome of patients with CS who achieved disease remission compared with those patients with persistent hypercortisolism and matched controls. DESIGN A retrospective study of 75 patients with CS followed at an academic center. METHODS Cardiovascular risk profile was evaluated in 51 patients with CS in remission (group 1) and 24 patients with persistent disease (group 2) and compared with 60 controls. Mortality of patients with CS was compared with the background population. RESULTS In group 1, the frequency of cardiovascular risk factors dropped after disease remission even if it remained higher at the last follow-up than in the control group. In group 2, the frequency of cardiovascular risk factors remained unchanged during follow-up. The rate of cardiovascular and thromboembolic events was higher in group 2 than in group 1, as was the mortality rate (two deaths in group 1 and nine in group 2; ratio of two SMRs, 0.11; 95% CI, 0.011-0.512). Survival was significantly longer in group 1 than in group 2 (87 months, 80-98 vs 48 months, 38-62; P<0.0001). CONCLUSIONS Successful surgical treatment of hypercortisolism significantly improves cardiovascular risk and may reduce the mortality rate. Patients with persistent disease have increased morbidity and mortality when compared with patients in remission.
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Affiliation(s)
- M Terzolo
- Internal Medicine IStatistical UnitDepartment of Clinical and Biological Sciences, University of Turin, A.O.U. San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Italy
| | - B Allasino
- Internal Medicine IStatistical UnitDepartment of Clinical and Biological Sciences, University of Turin, A.O.U. San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Italy
| | - A Pia
- Internal Medicine IStatistical UnitDepartment of Clinical and Biological Sciences, University of Turin, A.O.U. San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Italy
| | - G Peraga
- Internal Medicine IStatistical UnitDepartment of Clinical and Biological Sciences, University of Turin, A.O.U. San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Italy
| | - F Daffara
- Internal Medicine IStatistical UnitDepartment of Clinical and Biological Sciences, University of Turin, A.O.U. San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Italy
| | - F Laino
- Internal Medicine IStatistical UnitDepartment of Clinical and Biological Sciences, University of Turin, A.O.U. San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Italy
| | - A Ardito
- Internal Medicine IStatistical UnitDepartment of Clinical and Biological Sciences, University of Turin, A.O.U. San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Italy
| | - A Termine
- Internal Medicine IStatistical UnitDepartment of Clinical and Biological Sciences, University of Turin, A.O.U. San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Italy
| | - P Paccotti
- Internal Medicine IStatistical UnitDepartment of Clinical and Biological Sciences, University of Turin, A.O.U. San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Italy
| | - P Berchialla
- Internal Medicine IStatistical UnitDepartment of Clinical and Biological Sciences, University of Turin, A.O.U. San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Italy
| | - G Migliaretti
- Internal Medicine IStatistical UnitDepartment of Clinical and Biological Sciences, University of Turin, A.O.U. San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Italy
| | - G Reimondo
- Internal Medicine IStatistical UnitDepartment of Clinical and Biological Sciences, University of Turin, A.O.U. San Luigi Gonzaga, Regione Gonzole 10, 10043 Orbassano, Italy
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Fukuoka H, Takeuchi T, Matsumoto R, Bando H, Suda K, Nishizawa H, Takahashi M, Hirota Y, Iguchi G, Takahashi Y. D-dimer as a significant marker of deep vein thrombosis in patients with subclinical or overt Cushing's syndrome. Endocr J 2014; 61:1003-10. [PMID: 25100148 DOI: 10.1507/endocrj.ej14-0102] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Venous thromboembolism (VTE) is frequently associated with hypercortisolemia. This retrospective single-center study aimed to clarify the significance of plasma D-dimer levels for VTE screening in patients with subclinical or overt Cushing's syndrome (soCS). A total of 72 consecutive treatment-naïve patients with soCS diagnosed at Kobe University Hospital between 2002 and 2014 were enrolled. Patients with both lower extremity ultrasound and D-dimer measurement data (n = 19) were recruited in study 1 and divided into 2 groups, a deep vein thrombosis (DVT) (-) group (n = 12) and DVT (+) group (n = 7) for a comparison of the associated factors. The age and D-dimer levels were higher in the DVT (+) group than in the DVT (-) group (p = 0.04 and 0.02, respectively). A receiver operating characteristic analysis found that D-dimer level ≥2.6 μg/mL correlated with the presence of DVT (sensitivity, 100%; specificity, 91.7%). Next, patients with D-dimer measurement data (n = 36) were recruited in study 2 and divided into 2 groups according to D-dimer level: D-dimer (-), <1 μg/mL group (n = 23) and D-dimer (+), ≥1 μg/mL group (n = 13); the groups were compared with respect to various VTE-related risk factors. A logistic regression analysis revealed that elevated cortisol level after low-dose dexamethasone suppression was a significant risk factor for D-dimer elevation (OR = 1.21, p = 0.02). In conclusion, these data demonstrate that a D-dimer level ≥2.6 μg/mL is an indicator of DVT in treatment naïve patients with soCS and suggests that relatively high autonomous cortisol secretion may be associated with thrombus formation.
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Affiliation(s)
- Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe 650-0017, Japan
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van der Pas R, Leebeek FWG, Hofland LJ, de Herder WW, Feelders RA. Hypercoagulability in Cushing's syndrome: prevalence, pathogenesis and treatment. Clin Endocrinol (Oxf) 2013; 78:481-8. [PMID: 23134530 DOI: 10.1111/cen.12094] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 10/23/2012] [Accepted: 10/31/2012] [Indexed: 12/27/2022]
Abstract
Cushing's syndrome is not only accompanied by an increased prevalence of cardiovascular disease but also by a hypercoagulable state that is reflected by an increased incidence of venous thromboembolism. Overall, patients with CS have been reported to have a more than 10-fold increased risk of developing venous thromboembolism. Moreover, the incidence of postoperative thrombosis has been shown to be comparable to the risk after major orthopaedic surgery. Hypercoagulability in CS is due to both increased production of procoagulant factors with activation of the coagulation cascade and an impaired fibrinolytic capacity, resulting in a shortened activated partial thromboplastin time and an increased clot lysis time respectively. Although these abnormalities seem to improve 1 year following successful surgery, they do not yet normalize. Therefore, sustained biochemical remission might be required to fully resolve the hypercoagulable state in CS. Considering the risk of venous thromboembolism in uncontrolled CS there may be a rationale to give patients with active CS thromboprophylaxis. So far this seems warranted following surgical interventions. However, further studies are needed to determine the optimal dosage and duration of thromboprophylaxis.
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Affiliation(s)
- R van der Pas
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, Rotterdam, The Netherlands.
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