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Shafiq I, Williams ZR, Vates GE. Advancement in perioperative management of pituitary adenomas-Current concepts and best practices. J Neuroendocrinol 2024:e13427. [PMID: 38964869 DOI: 10.1111/jne.13427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/30/2024] [Accepted: 06/16/2024] [Indexed: 07/06/2024]
Abstract
Pituitary adenomas are very common representing 18.1% of all brain tumors and are the second most common brain pathology. Transsphenoidal surgery is the mainstay of treatment for all pituitary adenomas except for prolactinomas which are primarily treated medically with dopamine agonists. A thorough endocrine evaluation of pituitary adenoma preoperatively is crucial to identify hormonal compromise caused by the large sellar mass, identifying prolactin-producing tumors and comorbidities associated with Cushing and acromegaly to improve patient care and outcome. Transsphenoidal surgery is relatively safe in the hands of experienced surgeons, but still carries a substantial risk of causing hypopituitarism that required close follow-up in the immediate postoperative period to decrease mortality. A multidisciplinary team approach with endocrinologists, ophthalmologists, and neurosurgeons is the cornerstone in the perioperative management of pituitary adenomas.
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Affiliation(s)
- Ismat Shafiq
- Division of Endocrinology, Diabetes, and Metabolism, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Zoë R Williams
- Department of Ophthalmology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - G Edward Vates
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Capatina C, Hanzu FA, Hinojosa-Amaya JM, Fleseriu M. Medical treatment of functional pituitary adenomas, trials and tribulations. J Neurooncol 2024; 168:197-213. [PMID: 38760632 DOI: 10.1007/s11060-024-04670-x] [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: 12/15/2023] [Accepted: 03/27/2024] [Indexed: 05/19/2024]
Abstract
CONTEXT Functioning pituitary adenomas (FPAs) include most frequently prolactinomas, somatotroph or corticotroph adenomas, while thyrotroph and gonadotroph adenomas are very rare. Despite their benign histological nature (aggressive tumors are rare and malignant ones exceptional), FPAs could cause significant morbidity and increased mortality due to complications associated with hormonal excess syndromes and/or mass effect leading to compression of adjacent structures. This mini review will focus on the increasing role of medical therapy in the multimodal treatment, which also includes transsphenoidal surgery (TSS) and radiotherapy. EVIDENCE SYNTHESIS Most patients with prolactinomas are treated only with medications, but surgery could be considered for some patients in a specialized pituitary center, if higher chances of cure. Dopamine agonists, especially cabergoline, are efficient in reducing tumor size and normalizing prolactin. TSS is the first-line treatment for all other FPAs, but most patients require complex adjuvant treatment, including a combination of therapeutic approaches. Medical therapy is the cornerstone of treatment in all patients after unsuccessful surgery or when surgery cannot be offered and includes somatostatin receptor ligands and dopamine agonists (almost all FPAs), growth hormone receptor antagonists (acromegaly), adrenal steroidogenesis inhibitors and glucocorticoid receptor blockers (Cushing's disease). Novel medical treatments, especially for acromegaly and Cushing's disease are under research. CONCLUSIONS An enlarged panel of effective drugs available with increased knowledge of predictive factors for response and/or adverse effects will enhance the possibility to offer a more individualized treatment. This would not only improve disease control and prognosis, but also quality of life.
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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
| | - Felicia Alexandra Hanzu
- Endocrinology Department, Hospital Clínic de Barcelona, Spain, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José Miguel Hinojosa-Amaya
- Endocrinology Division and Department of Medicine, Pituitary Clinic, Hospital Universitario U.A.N.L, Monterrey, Mexico
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health and Science University, Portland, OR, USA.
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3
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He A, Koszegi B, Uzun S, Bilgic A, Bozca BC, Yang B, Daneshpazhooh M, Boziou M, Patsatsi A, Kakuta R, Takahashi H, Nery D, Mundin C, Ramirez-Quizon M, Culton D, McAlpine S, Johal J, Shulruf B, Stone JH, Murrell DF. Autoimmune blistering diseases treated with glucocorticoids: An international study of steroid-induced myopathy. J Eur Acad Dermatol Venereol 2024. [PMID: 38818849 DOI: 10.1111/jdv.20149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 04/17/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Patients with autoimmune blistering diseases (AIBDs) are often exposed to chronic glucocorticoid (GC) treatment with many side effects. Glucocorticoid-induced myopathy (GIM) is a well-established side effect, which particularly affects the proximal muscles. The Glucocorticoid Toxicity Index (GTI) is a validated global assessment tool which quantifies GC toxicity over time. OBJECTIVES This study marks the first study which analyses GIM in patients with AIBDs. The objectives of this study were to utilize the GTI to investigate the nature and prevalence of GIM in AIBD patients and explore potential risk factors. METHODS This international cohort study was conducted in blistering disease clinics across Australia, China, Greece, Iran, Japan, the Philippines, Turkey and the United States of America between February 2019 and July 2023. The GTI tool was completed by a medical practitioner at each patient visit. Data related to glucocorticoid toxicity were entered into the Steritas GTI 2.0 to generate an aggregate improvement and cumulative worsening score at each visit. RESULTS The study included 139 patients. There were 132 episodes of myopathy, and 47.5% of patients developed muscle weakness at some point during the study period. Cumulative GC dose correlated positively with myopathy risk, while average dose and treatment duration were not significant. Older age, male gender and obesity more than doubled the likelihood of developing GIM. CONCLUSIONS GIM is a common side effect experienced by AIBD patients on GC treatment. Muscle weakness is less likely to occur if cumulative GC dose is less than 0.75 mg/kg/day. Studies of exercise programs to mitigate myopathy and newer alternative treatments to reduce cumulative GC dose should be considered.
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Affiliation(s)
- A He
- Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, UNSW, Sydney, Australia
| | - B Koszegi
- Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, UNSW, Sydney, Australia
| | - S Uzun
- Department of Dermatology and Venereology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - A Bilgic
- Department of Dermatology and Venereology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - B C Bozca
- Department of Dermatology and Venereology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - B Yang
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong Province, China
| | - M Daneshpazhooh
- Department of Dermatology, Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - M Boziou
- Second Dermatology Department, Aristotle University School of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - A Patsatsi
- Second Dermatology Department, Aristotle University School of Medicine, Papageorgiou General Hospital, Thessaloniki, Greece
| | - R Kakuta
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - H Takahashi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - D Nery
- Department of Dermatology, Rizal Medical Center, Pasig, Philippines
| | - C Mundin
- Department of Dermatology, Rizal Medical Center, Pasig, Philippines
| | - M Ramirez-Quizon
- Department of Dermatology, Rizal Medical Center, Pasig, Philippines
| | - D Culton
- Department of Dermatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - S McAlpine
- Department of Dermatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - J Johal
- Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, UNSW, Sydney, Australia
| | - B Shulruf
- Faculty of Medicine, UNSW, Sydney, Australia
| | - J H Stone
- Division of Rheumatology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - D F Murrell
- Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, UNSW, Sydney, Australia
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Yan S, Wang Y, Wang B, Zuo S, Yu Y. Thromboxane A 2 Modulates de novo Synthesis of Adrenal Corticosterone in Mice via p38/14-3-3γ/StAR Signaling. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2307926. [PMID: 38460156 PMCID: PMC11095200 DOI: 10.1002/advs.202307926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/21/2024] [Indexed: 03/11/2024]
Abstract
Prostanoids are endogenous lipid bioactive mediators that play essential roles in physiological processes such as glucocorticoid secretion. Here, it is found that the thromboxane (Tx)A2 receptor (TP) is highly expressed in the adrenal cortex of mice. Both global and adrenocortical-specific deletion of the TP receptor lead to increased adiposity in mice by elevating corticosterone synthesis. Mechanistically, the TP receptor deletion increases the phosphorylation of steroidogenic acute regulatory protein (StAR) and corticosterone synthesis in adrenal cortical cells by suppressing p-p38-mediated phosphorylation of 14-3-3γ adapter protein at S71. The activation of the p38 in the adrenal cortical cells by forced expression of the MKK6EE gene attenuates hypercortisolism in TP-deficient mice. These observations suggest that the TxA2/TP signaling regulates adrenal corticosterone homeostasis independent of the hypothalamic-pituitary-adrenal axis and the TP receptor may serve as a promising therapeutic target for hypercortisolism.
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Affiliation(s)
- Shuai Yan
- Department of PharmacologyTianjin Key Laboratory of Inflammatory BiologyState Key Laboratory of Experimental HematologyKey Laboratory of Immune Microenvironment and Disease (Ministry of Education)The Province and Ministry Co‐sponsored Collaborative Innovation Center for Medical EpigeneticsSchool of Basic Medical SciencesTianjin Medical UniversityTianjin300070P. R. China
- Division of Endocrinology, Diabetes, and MetabolismBeth Israel Deaconess Medical CenterHarvard Medical School330 Brookline AvenueBostonMassachusetts02115USA
| | - Yuanyang Wang
- Department of PharmacologyTianjin Key Laboratory of Inflammatory BiologyState Key Laboratory of Experimental HematologyKey Laboratory of Immune Microenvironment and Disease (Ministry of Education)The Province and Ministry Co‐sponsored Collaborative Innovation Center for Medical EpigeneticsSchool of Basic Medical SciencesTianjin Medical UniversityTianjin300070P. R. China
| | - Bei Wang
- Department of PharmacologyTianjin Key Laboratory of Inflammatory BiologyState Key Laboratory of Experimental HematologyKey Laboratory of Immune Microenvironment and Disease (Ministry of Education)The Province and Ministry Co‐sponsored Collaborative Innovation Center for Medical EpigeneticsSchool of Basic Medical SciencesTianjin Medical UniversityTianjin300070P. R. China
| | - Shengkai Zuo
- Department of PharmacologyTianjin Key Laboratory of Inflammatory BiologyState Key Laboratory of Experimental HematologyKey Laboratory of Immune Microenvironment and Disease (Ministry of Education)The Province and Ministry Co‐sponsored Collaborative Innovation Center for Medical EpigeneticsSchool of Basic Medical SciencesTianjin Medical UniversityTianjin300070P. R. China
- Department of BiopharmaceuticsTianjin Key Laboratory of Technologies Enabling Development of Clinical Therapeutics and DiagnosticsSchool of PharmacyTianjin Medical UniversityTianjin300070P. R. China
| | - Ying Yu
- Department of PharmacologyTianjin Key Laboratory of Inflammatory BiologyState Key Laboratory of Experimental HematologyKey Laboratory of Immune Microenvironment and Disease (Ministry of Education)The Province and Ministry Co‐sponsored Collaborative Innovation Center for Medical EpigeneticsSchool of Basic Medical SciencesTianjin Medical UniversityTianjin300070P. R. China
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Zhang CD, Ioachimescu AG. Challenges in the postsurgical recovery of cushing syndrome: glucocorticoid withdrawal syndrome. Front Endocrinol (Lausanne) 2024; 15:1353543. [PMID: 38681763 PMCID: PMC11045978 DOI: 10.3389/fendo.2024.1353543] [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: 12/10/2023] [Accepted: 03/29/2024] [Indexed: 05/01/2024] Open
Abstract
Glucocorticoid withdrawal syndrome is a challenging clinical phenomenon that can complicate the postsurgical recovery of Cushing syndrome. It is characterized by physical tolerance and dependence to supraphysiologic glucocorticoid exposure during active Cushing syndrome followed by the abrupt decline in cortisol levels after surgical treatment. The symptoms of glucocorticoid withdrawal often overlap with those of postoperative adrenal insufficiency and can be difficult for patients to cope with and for clinicians to treat. This mini review will discuss the clinical characteristics, pathophysiology, and management of glucocorticoid withdrawal syndrome while highlighting recent data in the field.
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Affiliation(s)
- Catherine D. Zhang
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Adriana G. Ioachimescu
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
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Birtolo MF, Giannini E, Antonini S, Lavezzi E, Lasio G, Da Rin G, Mazziotti G, Lania AG. Prediction of adrenal insufficiency after pituitary surgery: a retrospective study using beckman access cortisol assay. Pituitary 2024; 27:160-168. [PMID: 38170374 DOI: 10.1007/s11102-023-01368-7] [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] [Accepted: 11/27/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Identifying patients requiring glucocorticoid replacement therapy after pituitary surgery is challenging as the tests commonly used for the diagnosis of secondary adrenal insufficiency (SAI) are not recommended in the immediate postoperative period. There are controversial data on the role of postoperative days' morning cortisol, with no specific data for each cortisol assay. The aim of this study is to investigate the reliability of 8.00 a.m. cortisol of the first and second postoperative days in predicting SAI. METHODS Data of patients underwent pituitary surgery in Humanitas Research Hospital in Italy, from March 2017 to August 2022, were retrospectively analyzed. Definitive diagnosis of SAI was made through ACTH test 1 µg six weeks after surgery. Cortisol was measured through Beckman Access Cortisol and the diagnosis of SAI was made if cortisol peak was below 14.8 µg/dL (408 nmol/L) at 30 or 60 min after stimulus. RESULTS Of the sixty-four patients enrolled, seven developed SAI. The ROC curves demonstrated that both first- and second-day postoperative 8.00 a.m. cortisol predict SAI (AUC 0.94 and 0.95, respectively). The optimal thresholds were 15.6 µg/dL (430.3 nmol/L; accuracy 89%) for the first day and 11.5 µg/dL (317.2 nmol/L, accuracy 81%) for the second day. Patients who developed SAI had larger tumors (p = 0.004) and lower fT4 (p = 0.038) before surgery. CONCLUSIONS Clinicians might rely on the first- and second- postoperative days 8.00 a.m. cortisol to identify patients to discharge with glucocorticoid replacement therapy waiting for the confirmation of SAI through the ACTH test.
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Affiliation(s)
- Maria Francesca Birtolo
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Emma Giannini
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
| | - Simone Antonini
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Elisabetta Lavezzi
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Giovanni Lasio
- Department of Neurosurgery, IRCCS Humanitas Clinical and Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Giorgio Da Rin
- Laboratory Medicine, IRCCS Humanitas Clinical and Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Gherardo Mazziotti
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy.
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy.
| | - Andrea G Lania
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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Nyanyo DD, Mikamoto M, Galbiati F, Remba-Shapiro I, Bode K, Schoenfeld S, Jones PS, Swearingen B, Nachtigall LB. Autoimmune Disorders Associated With Surgical Remission of Cushing's Disease : A Cohort Study. Ann Intern Med 2024; 177:315-323. [PMID: 38373302 DOI: 10.7326/m23-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Glucocorticoids suppress inflammation. Autoimmune disease may occur after remission of Cushing's disease (CD). However, the development of autoimmune disease in this context is not well described. OBJECTIVE To determine 1) the incidence of autoimmune disease in patients with CD after surgical remission compared with patients with nonfunctioning pituitary adenomas (NFPAs) and 2) the clinical presentation of and risk factors for development of autoimmune disease in CD after remission. DESIGN Retrospective matched cohort analysis. SETTING Academic medical center/pituitary center. PATIENTS Patients with CD with surgical remission and surgically treated NFPA. MEASUREMENTS Cumulative incidence of new-onset autoimmune disease at 3 years after surgery. Assessment for hypercortisolemia included late-night salivary cortisol levels, 24-hour urine free cortisol (UFC) ratio (UFC value divided by the upper limit of the normal range for the assay), and dexamethasone suppression tests. RESULTS Cumulative incidence of new-onset autoimmune disease at 3 years after surgery was higher in patients with CD (10.4% [95% CI, 5.7% to 15.1%]) than in those with NFPAs (1.6% [CI, 0% to 4.6%]) (hazard ratio, 7.80 [CI, 2.88 to 21.10]). Patients with CD showed higher prevalence of postoperative adrenal insufficiency (93.8% vs. 16.5%) and lower postoperative nadir serum cortisol levels (63.8 vs. 282.3 nmol/L) than patients with NFPAs. Compared with patients with CD without autoimmune disease, those who developed autoimmune disease had a lower preoperative 24-hour UFC ratio (2.7 vs. 6.3) and a higher prevalence of family history of autoimmune disease (41.2% vs. 20.9%). LIMITATION The small sample of patients with autoimmune disease limited identification of independent risk factors. CONCLUSION Patients achieving surgical remission of CD have higher incidence of autoimmune disease than age- and sex-matched patients with NFPAs. Family history of autoimmune disease is a potential risk factor. Adrenal insufficiency may be a trigger. PRIMARY FUNDING SOURCE Recordati Rare Diseases Inc.
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Affiliation(s)
- Dennis Delasi Nyanyo
- The Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (D.D.N., F.G., I.R., K.B., L.B.N.)
| | - Masaaki Mikamoto
- The Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (M.M., P.S.J., B.S.)
| | - Francesca Galbiati
- The Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (D.D.N., F.G., I.R., K.B., L.B.N.)
| | - Ilan Remba-Shapiro
- The Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (D.D.N., F.G., I.R., K.B., L.B.N.)
| | - Kevin Bode
- The Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (D.D.N., F.G., I.R., K.B., L.B.N.)
| | - Sara Schoenfeld
- The Division of Rheumatology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (S.S.)
| | - Pamela S Jones
- The Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (M.M., P.S.J., B.S.)
| | - Brooke Swearingen
- The Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (M.M., P.S.J., B.S.)
| | - Lisa B Nachtigall
- The Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (D.D.N., F.G., I.R., K.B., L.B.N.)
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Altieri B, Kimpel O, Megerle F, Detomas M, Chifu I, Fuss CT, Quinkler M, Kroiss M, Fassnacht M. Recovery of adrenal function after stopping mitotane in patients with adrenocortical carcinoma. Eur J Endocrinol 2024; 190:139-150. [PMID: 38244214 DOI: 10.1093/ejendo/lvae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/21/2023] [Accepted: 12/28/2023] [Indexed: 01/22/2024]
Abstract
OBJECTIVE Mitotane is the standard therapy of adrenocortical carcinoma (ACC) due to its relative selectivity of its cytotoxic effects toward adrenocortical cells. Therefore, it virtually always leads to adrenal insufficiency. Frequency and characteristics of hypothalamic-pituitary-adrenal axis recovery after discontinuation are ill-defined. METHODS This was a retrospective study of patients with ACC adjuvantly treated with mitotane for ≥12 months who were disease-free at mitotane stop and had a minimum follow-up ≥1 year. Primary endpoint was adrenal recovery. Cox regression analyses were used to identify predictive factors. Moreover, mitotane plasma elimination rate and hormonal changes after mitotane stop were investigated. RESULTS Fifty-six patients (36 women) treated with mitotane for a median time of 25 months and an average daily dose of 2.8 g were included. Median time after discontinuation until mitotane levels dropped below 5 and 2 mg/L, and the detection limit was 152 days (interquartile range: 114-202), 280 days (192-370), and 395 days (227-546), respectively. Full adrenal recovery was documented in 32 (57%) patients after a median time of 26 months (95% confidence interval [CI] = 19.6-32.4). In 4 patients (7.1%), adrenal insufficiency persisted >5 years after discontinuation. Mitotane peak ≥ 27 mg/L significantly correlated with longer time to adrenal recovery (hazard ratio [HR] = 0.2, 95% CI = 0.1-0.8, P = .03). Twenty-seven of 38 patients (71%) followed in reference centers achieved adrenal recovery compared with only 5/18 (28%) followed up in non-reference centers (HR = 4.51, 95% CI = 1.71-11.89, P = .002). Other investigated factors were not associated with adrenal function after discontinuation. CONCLUSIONS Our study demonstrates that adrenal recovery occurs in most patients after stopping mitotane, particularly when followed up in specialized centers, but not in all. Elimination time of mitotane after treatment discontinuation is very long but individually quite variable.
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Affiliation(s)
- Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Otilia Kimpel
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Felix Megerle
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Mario Detomas
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Irina Chifu
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Carmina Teresa Fuss
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
| | - Marcus Quinkler
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, 10627 Berlin, Germany
| | - Matthias Kroiss
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
- Department of Internal Medicine IV, University Hospital, Ludwig-Maximilians-University Munich, Ziemssenstrasse 1, 80336 Munich, Germany
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Josef-Schneider-Strasse 6, 97080 Würzburg, Germany
- Central Laboratory, University Hospital Würzburg, Oberduerrbacher Strasse 6, 97080 Würzburg, Germany
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10
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Gadelha M, Gatto F, Wildemberg LE, Fleseriu M. Cushing's syndrome. Lancet 2023; 402:2237-2252. [PMID: 37984386 DOI: 10.1016/s0140-6736(23)01961-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/04/2023] [Accepted: 09/13/2023] [Indexed: 11/22/2023]
Abstract
Endogenous Cushing's syndrome results from excess glucocorticoid secretion, which leads to a myriad of clinical manifestations, comorbidities, and increased mortality despite treatment. Molecular mechanisms and genetic alterations associated with different causes of Cushing's syndrome have been described in the last decade. Imaging modalities and biochemical testing have evolved; however, both the diagnosis and management of Cushing's syndrome remain challenging. Surgery is the preferred treatment for all causes, but medical therapy has markedly advanced, with new drug options becoming available. Nevertheless, several comorbidities remain even after patient remission, which can affect quality of life. Accurate and timely diagnosis and treatment are essential for mitigating chronic complications of excess glucocorticoids and improving patient quality of life. In this Seminar, we aim to update several important aspects of diagnosis, complications, and treatment of endogenous Cushing's syndrome of all causes.
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Affiliation(s)
- Mônica Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Molecular Genetics Laboratory, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.
| | - Federico Gatto
- Endocrinology Unit, Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Maria Fleseriu
- Pituitary Center, Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
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11
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Fleseriu M, Varlamov EV, Hinojosa-Amaya JM, Langlois F, Melmed S. An individualized approach to the management of Cushing disease. Nat Rev Endocrinol 2023; 19:581-599. [PMID: 37537306 DOI: 10.1038/s41574-023-00868-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 08/05/2023]
Abstract
Cushing disease caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary corticotroph adenoma leads to hypercortisolaemia with high mortality due to metabolic, cardiovascular, immunological, neurocognitive, haematological and infectious conditions. The disorder is challenging to diagnose because of its common and heterogenous presenting features and the biochemical pitfalls of testing levels of hormones in the hypothalamic-pituitary-adrenal axis. Several late-night salivary cortisol and 24-h urinary free cortisol tests are usually required as well as serum levels of cortisol after a dexamethasone suppression test. MRI might only identify an adenoma in 60-75% of patients and many adenomas are small. Therefore, inferior petrosal sinus sampling remains the gold standard for confirmation of ACTH secretion from a pituitary source. Initial treatment is usually transsphenoidal adenoma resection, but preoperative medical therapy is increasingly being used in some countries and regions. Other management approaches are required if Cushing disease persists or recurs following surgery, including medications to modulate ACTH or block cortisol secretion or actions, pituitary radiation, and/or bilateral adrenalectomy. All patients require lifelong surveillance for persistent comorbidities, clinical and biochemical recurrence, and treatment-related adverse effects (including development of treatment-associated hypopituitarism). In this Review, we discuss challenges in the management of Cushing disease in adults and provide information to guide clinicians when planning an integrated and individualized approach for each patient.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA.
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
| | - Elena V Varlamov
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
| | - Jose M Hinojosa-Amaya
- Division of Endocrinology, Department of Medicine, Hospital Universitario "Dr. José E. González", Autonomous University of Nuevo León, Monterrey, Mexico
| | - Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Shlomo Melmed
- Department of Medicine and Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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12
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De Alcubierre D, Ferrari D, Mauro G, Isidori AM, Tomlinson JW, Pofi R. Glucocorticoids and cognitive function: a walkthrough in endogenous and exogenous alterations. J Endocrinol Invest 2023; 46:1961-1982. [PMID: 37058223 PMCID: PMC10514174 DOI: 10.1007/s40618-023-02091-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/05/2023] [Indexed: 04/15/2023]
Abstract
PURPOSE The hypothalamic-pituitary-adrenal (HPA) axis exerts many actions on the central nervous system (CNS) aside from stress regulation. Glucocorticoids (GCs) play an important role in affecting several cognitive functions through the effects on both glucocorticoid (GR) and mineralocorticoid receptors (MR). In this review, we aim to unravel the spectrum of cognitive dysfunction secondary to derangement of circulating levels of endogenous and exogenous glucocorticoids. METHODS All relevant human prospective and retrospective studies published up to 2022 in PubMed reporting information on HPA disorders, GCs, and cognition were included. RESULTS Cognitive impairment is commonly found in GC-related disorders. The main brain areas affected are the hippocampus and pre-frontal cortex, with memory being the most affected domain. Disease duration, circadian rhythm disruption, circulating GCs levels, and unbalanced MR/GR activation are all risk factors for cognitive decline in these patients, albeit with conflicting data among different conditions. Lack of normalization of cognitive dysfunction after treatment is potentially attributable to GC-dependent structural brain alterations, which can persist even after long-term remission. CONCLUSION The recognition of cognitive deficits in patients with GC-related disorders is challenging, often delayed, or mistaken. Prompt recognition and treatment of underlying disease may be important to avoid a long-lasting impact on GC-sensitive areas of the brain. However, the resolution of hormonal imbalance is not always followed by complete recovery, suggesting irreversible adverse effects on the CNS, for which there are no specific treatments. Further studies are needed to find the mechanisms involved, which may eventually be targeted for treatment strategies.
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Affiliation(s)
- D De Alcubierre
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - D Ferrari
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - G Mauro
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - J W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - R Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK.
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Zhang CD, Li D, Singh S, Suresh M, Thangamuthu K, Nathani R, Achenbach SJ, Atkinson EJ, Van Gompel JJ, Young WF, Bancos I. Glucocorticoid withdrawal syndrome following surgical remission of endogenous hypercortisolism: a longitudinal observational study. Eur J Endocrinol 2023; 188:592-602. [PMID: 37395115 PMCID: PMC10376560 DOI: 10.1093/ejendo/lvad073] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/19/2023] [Accepted: 05/25/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVE Glucocorticoid withdrawal syndrome (GWS) is a scarcely studied phenomenon that complicates the recovery following surgical remission of hypercortisolism. We aimed to characterize the presence and trajectory of glucocorticoid withdrawal symptoms in the postoperative period and to determine presurgical predictors of GWS severity. DESIGN Longitudinal observational study. METHODS Glucocorticoid withdrawal symptoms were prospectively evaluated weekly for the first 12 weeks following surgical remission of hypercortisolism. Quality of life (CushingQoL and Short-Form-36) and muscle function (hand grip strength and sit-to-stand test) were assessed at the baseline and at 12 weeks after surgery. RESULTS Prevalent symptoms were myalgias and arthralgias (50%), fatigue (45%), weakness (34%), sleep disturbance (29%), and mood changes (19%). Most symptoms persisted, while myalgias, arthralgias, and weakness worsened during weeks 5-12 postoperatively. At 12 weeks after surgery, normative hand grip strength was weaker than at baseline (mean Z-score delta -0.37, P = .009), while normative sit-to-stand test performance improved (mean Z-score delta 0.50, P = .013). Short-Form-36 Physical Component Summary score worsened (mean delta -2.6, P = .015), but CushingQoL score improved (mean delta 7.8, P < .001) at 12 weeks compared to baseline. Cushing syndrome (CS) clinical severity was predictive of postoperative GWS symptomology. CONCLUSION Glucocorticoid withdrawal symptoms are prevalent and persistent following surgical remission of hypercortisolism with baseline CS clinical severity predictive of postoperative GWS symptom burden. Differential changes observed in muscle function and quality of life in the early postoperative period may reflect the competing influences of GWS and recovery from hypercortisolism.
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Affiliation(s)
- Catherine D Zhang
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Sumitabh Singh
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Malavika Suresh
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Department of Internal Medicine, Medstar Health, Baltimore, MD 21237, USA
| | - Karthik Thangamuthu
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Rohit Nathani
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Sara J Achenbach
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | - Elizabeth J Atkinson
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | | | - William F Young
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
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14
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Concepción-Zavaleta MJ, Armas CD, Quiroz-Aldave JE, García-Villasante EJ, Gariza-Solano AC, Durand-Vásquez MDC, Concepción-Urteaga LA, Zavaleta-Gutiérrez FE. Cushing disease in pediatrics: an update. Ann Pediatr Endocrinol Metab 2023; 28:87-97. [PMID: 37401055 DOI: 10.6065/apem.2346074.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/22/2023] [Indexed: 07/05/2023] Open
Abstract
Cushing disease (CD) is the main cause of endogenous Cushing syndrome (CS) and is produced by an adrenocorticotropic hormone (ACTH)-producing pituitary adenoma. Its relevance in pediatrics is due to the retardation of both growth and developmental processes because of hypercortisolism. In childhood, the main features of CS are facial changes, rapid or exaggerated weight gain, hirsutism, virilization, and acne. Endogenous hypercortisolism should be established after exogenous CS has been ruled out based on 24-hour urinary free cortisol, midnight serum or salivary cortisol, and dexamethasone suppression test; after that, ACTH dependence should be established. The diagnosis should be confirmed by pathology. The goal of treatment is to normalize cortisol level and reverse the signs and symptoms. Treatment options include surgery, medication, radiotherapy, or combined therapy. CD represents a challenge for physicians owing to its multiple associated conditions involving growth and pubertal development; thus, it is important to achieve an early diagnosis and treatment in order to control hypercortisolism and improve the prognosis. Its rarity in pediatric patients has led physicians to have limited experience in its management. The objective of this narrative review is to summarize the current knowledge about the pathophysiology, diagnosis, and treatment of CD in the pediatric population.
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15
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Theiler-Schwetz V, Prete A. Glucocorticoid withdrawal syndrome: what to expect and how to manage. Curr Opin Endocrinol Diabetes Obes 2023; 30:167-174. [PMID: 36876715 DOI: 10.1097/med.0000000000000804] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
PURPOSE OF REVIEW Glucocorticoid withdrawal syndrome (GWS) can develop after withdrawing exposure to supraphysiological levels of endogenous or exogenous glucocorticoids due to an established physical dependence. It is characterised by symptoms similar to adrenal insufficiency but needs to be regarded as a separate entity. GWS is often under-recognised in clinical practice and affected patients can experience significant impairment in their quality of life. RECENT FINDINGS A cornerstone in GWS management is adequate patient education and reassurance that symptoms are expected and typically temporary. Patients with endogenous Cushing's syndrome need to be aware that psychopathology may persist into the postoperative period. GWS is more likely to develop in severe Cushing's syndrome and in patients with very low levels of cortisol after surgery. Postoperatively, glucocorticoid replacement should be initiated and tapered in an individualised approach but there is currently no consensus on the best tapering strategy. If symptoms of GWS develop, glucocorticoid replacement ought to be temporarily increased to the previous, well tolerated dose. No randomised studies have thus far compared regimens for withdrawing glucocorticoids after treatment for anti-inflammatory or immunosuppressive causes to determine the best and safest tapering strategy. One open-label, single-arm trial in patients with asthma has recently proposed a personalised glucocorticoid tapering regimen which included the systematic assessment of adrenal function. SUMMARY Awareness of GWS by treating physicians and patient education are essential. Evidence on optimal GWS management after Cushing's syndrome treatment is scarce, but new data are emerging for tapering after long-term glucocorticoid treatment.
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Affiliation(s)
- Verena Theiler-Schwetz
- Institute of Metabolism and Systems Research, University of Birmingham, UK
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners
- Department of Endocrinology, Queen Elizabeth Hospital
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Chen Cardenas SM, Santhanam P, Morris-Wiseman L, Salvatori R, Hamrahian AH. Perioperative Evaluation and Management of Patients on Glucocorticoids. J Endocr Soc 2022; 7:bvac185. [PMID: 36545644 PMCID: PMC9760550 DOI: 10.1210/jendso/bvac185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Indexed: 12/04/2022] Open
Abstract
Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.
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Affiliation(s)
- Stanley M Chen Cardenas
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Prasanna Santhanam
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lilah Morris-Wiseman
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Amir H Hamrahian
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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17
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Guo X, Zhang D, Pang H, Wang Z, Gao L, Wang Y, Ma W, Lian W, Xing B. Safety of Withholding Perioperative Hydrocortisone for Patients With Pituitary Adenomas With an Intact Hypothalamus-Pituitary-Adrenal Axis: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2242221. [PMID: 36383383 PMCID: PMC9669812 DOI: 10.1001/jamanetworkopen.2022.42221] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Pituitary adenoma is the second most common primary brain tumor. Perioperative hydrocortisone has been used for decades to avoid postoperative adrenal insufficiency. Recent studies suggest that withholding perioperative hydrocortisone may be safe for patients with an intact hypothalamus-pituitary-adrenal (HPA) axis. OBJECTIVE To assess the safety of withholding hydrocortisone during the perioperative period of pituitary adenoma surgery for patients with an intact HPA axis. DESIGN, SETTING, AND PARTICIPANTS A parallel-group, triple-masked, noninferiority randomized clinical trial was conducted at Peking Union Medical College Hospital from November 1, 2020, to January 31, 2022, among 436 patients aged 18 to 70 years with an intact HPA axis undergoing surgery for pituitary adenomas. INTERVENTIONS Hydrocortisone supplementation protocol (intravenous and subsequent oral hydrocortisone, using a taper program) or no-hydrocortisone protocol. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of new-onset adrenal insufficiency (morning cortisol level, <5 μg/dL with adrenal insufficiency-related symptoms) during the perioperative period (on the day of operation and the following 2 days). The secondary outcome was the incidence of adrenal insufficiency in postoperative month 3. Analysis was on an intention-to-treat basis. RESULTS Of the 436 eligible patients, 218 were randomly assigned to the hydrocortisone group (136 women [62.4%]; mean [SD] age, 45.4 [13.0] years) and 218 to the no-hydrocortisone group (128 women [58.7%]; mean [SD] age, 44.5 [13.8] years). All patients completed 3-month postoperative follow-up. The incidence of new-onset adrenal insufficiency during the perioperative period was 11.0% (24 of 218; 95% CI, 6.9%-15.2%) in the no-hydrocortisone group and 6.4% (14 of 218; 95% CI, 3.2%-9.7%) in the hydrocortisone group, with a difference of 4.6% (95% CI, -0.7% to 9.9%), meeting the prespecified noninferiority margin of 10 percentage points. The incidence of adrenal insufficiency at the 3-month follow-up was 3.7% (8 of 218) in the no-hydrocortisone group and 3.2% (7 of 218) in the hydrocortisone group (difference, 0.5%; 95% CI, -3.0% to 3.9%). Incidences of new-onset diabetes mellitus (1 of 218 [0.5%] vs 9 of 218 [4.1%]), hypernatremia (9 of 218 [4.1%] vs 21 of 218 [9.6%]), hypokalemia (23 of 218 [10.6%] vs 34 of 218 [15.6%]), and hypocalcemia (6 of 218 [2.8%] vs 19 of 218 [8.7%]) were lower in the no-hydrocortisone group than in the hydrocortisone group. Lower preoperative morning cortisol levels were associated with higher risks of the primary event (<9.3 µg/dL; odds ratio, 3.0; 95% CI, 1.5-5.9) and the secondary event (<8.8 µg/dL; odds ratio, 7.8; 95% CI, 2.6-23.4) events. CONCLUSIONS AND RELEVANCE This study found that withholding hydrocortisone was safe and demonstrated noninferiority to the conventional hydrocortisone supplementation regimen regarding the incidence of new-onset adrenal insufficiency among patients with an intact HPA axis undergoing pituitary adenomectomy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04621565.
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Affiliation(s)
- Xiaopeng Guo
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Duoxing Zhang
- Peking Union Medical College, Tsinghua University, Dongcheng District, Beijing, China
| | - Haiyu Pang
- Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Zihao Wang
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Lu Gao
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Yu Wang
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Wenbin Ma
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Wei Lian
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
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Malik RB, Ben-Shlomo A. Adrenal Cushing’s Syndrome Treated With Preoperative Osilodrostat and Adrenalectomy. AACE Clin Case Rep 2022; 8:267-270. [DOI: 10.1016/j.aace.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022] Open
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