1
|
Birtolo MF, Armignacco R, Benanteur N, Baussart B, Villa C, De Murat D, Guignat L, Groussin L, Libé R, Zennaro MC, Saidi M, Perlemoine K, Letourneur F, Amar L, Bertherat J, Jouinot A, Assié G. Whole blood transcriptomic signature of Cushing's syndrome. Eur J Endocrinol 2024; 191:55-63. [PMID: 38970559 DOI: 10.1093/ejendo/lvae083] [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: 12/12/2023] [Revised: 04/15/2024] [Accepted: 05/20/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVE Cushing's syndrome is characterized by high morbidity and mortality with high interindividual variability. Easily measurable biomarkers, in addition to the hormone assays currently used for diagnosis, could reflect the individual biological impact of glucocorticoids. The aim of this study is to identify such biomarkers through the analysis of whole blood transcriptome. DESIGN Whole blood transcriptome was evaluated in 57 samples from patients with overt Cushing's syndrome, mild Cushing's syndrome, eucortisolism, and adrenal insufficiency. Samples were randomly split into a training cohort to set up a Cushing's transcriptomic signature and a validation cohort to assess this signature. METHODS Total RNA was obtained from whole blood samples and sequenced on a NovaSeq 6000 System (Illumina). Both unsupervised (principal component analysis) and supervised (Limma) methods were used to explore the transcriptome profile. Ridge regression was used to build a Cushing's transcriptome predictor. RESULTS The transcriptomic profile discriminated samples with overt Cushing's syndrome. Genes mostly associated with overt Cushing's syndrome were enriched in pathways related to immunity, particularly neutrophil activation. A prediction model of 1500 genes built on the training cohort demonstrated its discriminating value in the validation cohort (accuracy .82) and remained significant in a multivariate model including the neutrophil proportion (P = .002). Expression of FKBP5, a single gene both overexpressed in Cushing's syndrome and implied in the glucocorticoid receptor signaling, could also predict Cushing's syndrome (accuracy .76). CONCLUSIONS Whole blood transcriptome reflects the circulating levels of glucocorticoids. FKBP5 expression could be a nonhormonal marker of Cushing's syndrome.
Collapse
Affiliation(s)
- Maria Francesca Birtolo
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele Milan, Italy
| | - Roberta Armignacco
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
| | - Nesrine Benanteur
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
| | - Bertrand Baussart
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Department of Neurosurgery, Hôpital Universitaire Pitié-Salpêtrière, APHP, Sorbonne Université, 75013 Paris, France
| | - Chiara Villa
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Department of Neuropathology, Hôpital Universitaire Pitié-Salpêtrière, APHP, Sorbonne Université, 75013 Paris, France
| | - Daniel De Murat
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
| | - Laurence Guignat
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| | - Lionel Groussin
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| | - Rossella Libé
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| | - Maria-Christina Zennaro
- Université Paris Cité, Inserm, PARCC, F-75015, Paris, France
- Service de Génétique, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
| | - Meriama Saidi
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| | - Karine Perlemoine
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
| | - Franck Letourneur
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
| | - Laurence Amar
- Hypertension Unit, AP-HP, Hôpital Européen Georges Pompidou, F-75015, Paris, France
| | - Jérôme Bertherat
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| | - Anne Jouinot
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| | - Guillaume Assié
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
- Service d'Endocrinologie, Center for Rare Adrenal Diseases, AP-HP, Hôpital Cochin, F-75014 Paris, France
| |
Collapse
|
2
|
Pivonello C, Patalano R, Simeoli C, Montò T, Negri M, Amatrudo F, Di Paola N, Larocca A, Crescenzo EM, Pirchio R, Solari D, de Angelis C, Auriemma RS, Cavallo LM, Colao A, Pivonello R. Circulating myomiRNAs as biomarkers in patients with Cushing's syndrome. J Endocrinol Invest 2024; 47:655-669. [PMID: 37682493 PMCID: PMC10904409 DOI: 10.1007/s40618-023-02184-3] [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: 05/23/2023] [Accepted: 08/22/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE Impairment of skeletal muscle mass and strength affects 40-70% of patients with active Cushing's syndrome (CS). Glucocorticoid excess sustains muscle atrophy and weakness, while muscle-specific microRNAs (myomiRs) level changes were associated with muscle organization and function perturbation. The aim of the current study is to explore changes in circulating myomiRs in CS patients compared to healthy controls and their involvement in IGFI/PI3K/Akt/mTOR pathway regulation in skeletal muscle. METHODS C2C12, mouse myocytes, were exposed to hydrocortisone (HC), and atrophy-related gene expression was investigated by RT-qPCR, WB and IF to assess HC-mediated atrophic signalling. miRNAs were evaluated in HC-treated C2C12 by PCR Arrays. MyomiRs significantly overexpressed in C2C12 were investigated in 37 CS patients and 24 healthy controls serum by RT-qPCR. The anti-anabolic role of circulating miRNAs significantly upregulated in CS patients was explored in C2C12 by investigating the IGFI/PI3K/Akt/mTOR pathway regulation. RESULTS HC induced higher expression of atrophy-related genes, miR-133a-3p, miR-122-5p and miR-200b-3p in C2C12 compared to untreated cells. Conversely, the anabolic IGFI/PI3K/Akt/mTOR signalling was reduced and this effect was mediated by miR-133a-3p. In CS patients miR-133a-3p and miR-200b-3p revealed higher circulating levels (p < 0.0001, respectively) compared to controls. ROC curves for miR-133a-3p (AUC 0.823, p < 0.0001) and miR-200b-3p (AUC 0.850, p < 0.0001) demonstrated that both myomiRs represent potential biomarkers to discriminate between CS and healthy subjects. Pearson's correlation analysis revealed that circulating levels of miR-133a-3p are directly correlated with 24 h urinary-free cortisol level (r = 0.468, p = 0.004) in CS patients. CONCLUSIONS HC induces atrophic signals by miR-133a-3p overexpression in mouse myocytes and humans. Circulating miR-133a-3p is promising biomarkers of hypercortisolism.
Collapse
Affiliation(s)
- C Pivonello
- Department of Public Health, Federico II University, Naples, Italy
| | - R Patalano
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - C Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - T Montò
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - M Negri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - F Amatrudo
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - N Di Paola
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - A Larocca
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - E M Crescenzo
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - R Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - D Solari
- Department of Neuroscience, Division of Neurosurgery, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - C de Angelis
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - R S Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
| | - L M Cavallo
- Department of Neuroscience, Division of Neurosurgery, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - A Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologia e Nutrizione, Università Federico II di Napoli, Naples, Italy.
- UNESCO Chair for Health Education and Sustainable Development, Federico II University, Naples, Italy.
| |
Collapse
|
3
|
Mondin A, Ceccato F, Voltan G, Mazzeo P, Manara R, Denaro L, Scaroni C, Barbot M. Complications and mortality of Cushing's disease: report on data collected over a 20-year period at a referral centre. Pituitary 2023; 26:551-560. [PMID: 37495935 PMCID: PMC10539191 DOI: 10.1007/s11102-023-01343-2] [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] [Accepted: 07/14/2023] [Indexed: 07/28/2023]
Abstract
CONTEXT Cushing's disease (CD) is rare condition burdened by several systemic complications correlated to higher mortality rates. The primary goal of clinicians is to achieve remission, but it is unclear if treatment can also increase life expectancy. AIM To assess the prevalence of cortisol-related complications and mortality in a large cohort of CD patients attending a single referral centre. MATERIALS AND METHODS The clinical charts of CD patients attending a referral hospital between 2001 and 2021 were reviewed. RESULTS 126 CD patients (median age at diagnosis 39 years) were included. At the last examination, 78/126 (61.9%) of the patients were in remission regardless of previous treatment strategies. Patients in remission showed a significant improvement in all the cardiovascular (CV) comorbidities (p < 0.05). The CV events were more frequent in older patients (p = 0.003), smokers and persistent CD groups (p < 0.05). Most of the thromboembolic (TE) and infective events occurred during active stages of the disease. The CV events were the most frequent cause of death. The standardized mortality ratio (SMR) resulted increased in persistent cases at the last follow-up (SMR 4.99, 95%CI [2.15; 9.83], p < 0.001) whilst it was not higher in those in remission (SMR 1.66, 95%CI [0.34; 4.85], p = 0.543) regardless of the timing or number of treatments carried out. A younger age at diagnosis (p = 0.005), a microadenoma (p = 0.002), and remission status at the last follow-up (p = 0.027) all increased survival. Furthermore, an elevated number of comorbidities, in particular arterial hypertension, increased mortality rates. CONCLUSIONS Patients with active CD presented a poor survival outcome. Remission restored the patients' life expectancy regardless of the timing or the types of treatments used to achieve it. Persistent CD-related comorbidities remained major risk factors.
Collapse
Affiliation(s)
- Alessandro Mondin
- Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Giacomo Voltan
- Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Pierluigi Mazzeo
- Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Renzo Manara
- Neuroradiology Unit, University Hospital of Padova, Padua, Italy
| | - Luca Denaro
- Academic Neurosurgery, Department of Neurosciences, University of Padova, Padua, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine-DIMED, University Hospital of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy.
| |
Collapse
|
4
|
Flowers KC, Shipman KE. Pitfalls in the Diagnosis and Management of Hypercortisolism (Cushing Syndrome) in Humans; A Review of the Laboratory Medicine Perspective. Diagnostics (Basel) 2023; 13:diagnostics13081415. [PMID: 37189516 DOI: 10.3390/diagnostics13081415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/28/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Biochemical confirmation of a diagnosis of hypercortisolism (Cushing syndrome) is vital to direct further investigations, especially given the overlap with non-autonomous conditions, such as pseudo-Cushing, and the morbidity associated with missed diagnoses. A limited narrative review was performed focusing on the laboratory perspective of the pitfalls of making a biochemical diagnosis of hypercortisolism in those presenting with presumed Cushing syndrome. Although analytically less specific, immunoassays remain cheap, quick, and reliable in most situations. Understanding cortisol metabolism can help with patient preparation, specimen selection (e.g., consideration of urine or saliva for those with possible elevations of cortisol binding globulin concentration), and method selection (e.g., mass spectrometry if there is a high risk of abnormal metabolites). Although more specific methods may be less sensitive, this can be managed. The reduction in cost and increasing ease of use makes techniques such as urine steroid profiles and salivary cortisone of interest in future pathway development. In conclusion, the limitations of current assays, particularly if well understood, do not impede diagnosis in most cases. However, in complex or borderline cases, there are other techniques to consider to aid in the confirmation of hypercortisolism.
Collapse
Affiliation(s)
- Kade C Flowers
- Department of Clinical Chemistry, University Hospitals Sussex NHS Trust, Worthing BN11 2DH, UK
| | - Kate E Shipman
- Department of Clinical Chemistry, University Hospitals Sussex NHS Trust, Worthing BN11 2DH, UK
- Department of Medical Education, Brighton and Sussex Medical School, University of Sussex, Falmer Campus, Brighton BN1 9PX, UK
| |
Collapse
|
5
|
Lugat A, Lasolle H, François M, Benhenda N, Bricaire L, Cornu E, Cristante J, Gitton A, Hadoux J, Kerlan V, Le Bras M, Mezzaroba V, Puerto M, Storey C, Ouzounian S, Donadille B, Raverot G, Drui D, Haissaguerre M. Pneumocystis pneumonia in patients with Cushing's syndrome: A French multicenter retrospective study. ANNALES D'ENDOCRINOLOGIE 2023; 84:37-44. [PMID: 36183804 DOI: 10.1016/j.ando.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Pneumocystis pneumonia (PcP) is an opportunistic infection occurring in immunocompromised patients. Cushing's syndrome (CS) impairs the immune system, and several authors have reported PcP in patients with CS. The present study aimed to characterize PcP occurring in a CS context and its management in French tertiary centers, in order to highlight the similarities in clinical presentation and treatment according to whether prophylaxis is implemented or not. METHODS This was a multicenter retrospective study conducted in several French University Hospitals and Cancer Centers. Patients with PcP and confirmed CS regardless of etiology were included. We excluded patients with other known causes of acquired immunodeficiency with increased risk of PcP. RESULTS Twenty-five patients were included. CS etiology was neoplastic in 84.0% of cases. CS clinical presentation associated predominant catabolic signs (76.0%), hypokalemia (91.7%) and lymphopenia (89.5%). CS was intense in most patients, with mean plasma cortisol levels at diagnosis of 2.424±1.102nmol/L and urinary free cortisol>10× the upper limit of normal in 85.0%. In all patients, PcP onset followed introduction of cortisol blockers, at a median 5.5 days. Patients were treated with 1 to 3 cortisol blockers, mainly metyrapone (88%), which significatively lowered plasma cortisol levels to 667±541nmol/L at the onset of PcP (P<0.001). PcP occurred in 7 patients despite prophylaxis. Finally, 60.0% patients were admitted to intensive care, and 20.0% died of PcP. CONCLUSION High mortality in patients with PcP implies that clinicians should be better informed about this rare infectious complication. Prophylaxis remains controversial, requiring comparative studies.
Collapse
Affiliation(s)
- Alexandre Lugat
- Medical Oncology Department, CHU de Nantes, 44000 Nantes, France; Nantes Université, Inserm 1307, CNRS 6075, Université d'Angers, CRCI2NA, Nantes, France
| | - Hélène Lasolle
- Endocrinology Department, Reference Centre for Rare Pituitary Diseases HYPO, "Groupement Hospitalier Est", Hospices Civils de Lyon, Bron, France; Lyon 1 University, Villeurbanne, France; INSERM U1052, CNRC UMR5286, Cancer Research Centre of Lyon (CRLC), Lyon, France
| | - Maud François
- Endocrinology, Diabetology and Nutrition, Centre Hospitalier Universitaire de Reims, Reims, France
| | | | - Léopoldine Bricaire
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance publique-Hôpitaux de Paris, 75014 Paris, France
| | - Erika Cornu
- Hypertension Unit, Hôpital Européen George-Pompidou, Paris, France
| | | | - Anne Gitton
- Endocrinology, Diabetology and Nutrition, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Julien Hadoux
- Department of Endocrine Oncology and Nuclear Medicine, Gustave-Roussy and University Paris-Saclay, Villejuif, France
| | - Véronique Kerlan
- Department of Endocrinology, Diabetes and Metabolic Diseases, Hôpital de la Cavale-Blanche, Brest, France
| | - Maëlle Le Bras
- Department of Endocrinology, Diabetology and Nutrition, l'institut du thorax, CHU Nantes, Nantes, France
| | - Vincent Mezzaroba
- Endocrinology Department, Reference Centre for Rare Pituitary Diseases HYPO, "Groupement Hospitalier Est", Hospices Civils de Lyon, Bron, France; Lyon 1 University, Villeurbanne, France; INSERM U1052, CNRC UMR5286, Cancer Research Centre of Lyon (CRLC), Lyon, France
| | - Marie Puerto
- Department of Endocrinology, Haut Levêque University Hospital, Bordeaux, France
| | - Caroline Storey
- Department of Paediatric Endocrinology and Diabetology, Robert-Debré Teaching Hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Sophie Ouzounian
- Endocrinology Department, Saint-Antoine Hospital, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Bruno Donadille
- Endocrinology Department, Saint-Antoine Hospital, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Gérald Raverot
- Endocrinology Department, Reference Centre for Rare Pituitary Diseases HYPO, "Groupement Hospitalier Est", Hospices Civils de Lyon, Bron, France; Lyon 1 University, Villeurbanne, France; INSERM U1052, CNRC UMR5286, Cancer Research Centre of Lyon (CRLC), Lyon, France
| | - Delphine Drui
- Department of Endocrinology, Diabetology and Nutrition, l'institut du thorax, CHU Nantes, Nantes, France
| | - Magalie Haissaguerre
- Department of Endocrinology, Haut Levêque University Hospital, Bordeaux, France.
| |
Collapse
|
6
|
Tabarin A, Assié G, Barat P, Bonnet F, Bonneville JF, Borson-Chazot F, Bouligand J, Boulin A, Brue T, Caron P, Castinetti F, Chabre O, Chanson P, Corcuff JB, Cortet C, Coutant R, Dohan A, Drui D, Espiard S, Gaye D, Grunenwald S, Guignat L, Hindie E, Illouz F, Kamenicky P, Lefebvre H, Linglart A, Martinerie L, North MO, Raffin-Samson ML, Raingeard I, Raverot G, Raverot V, Reznik Y, Taieb D, Vezzosi D, Young J, Bertherat J. Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome. ANNALES D'ENDOCRINOLOGIE 2022; 83:119-141. [PMID: 35192845 DOI: 10.1016/j.ando.2022.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.
Collapse
Affiliation(s)
- Antoine Tabarin
- Service Endocrinologie, Diabète et Nutrition, Université, Hôpital Haut-Leveque CHU de Bordeaux, 33604 Pessac, France.
| | - Guillaume Assié
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Pascal Barat
- Unité d'Endocrinologie-Diabétologie-Gynécologie-Obésité Pédiatrique, Hôpital des Enfants CHU Bordeaux, Bordeaux, France
| | - Fidéline Bonnet
- UF d'Hormonologie Hôpital Cochin, Université de Paris, Institut Cochin Inserm U1016, CNRS UMR8104, Paris, France
| | | | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis-Pradel, Hospices Civils de Lyon, INSERM U1290, Université Lyon1, 69002 Lyon, France
| | - Jérôme Bouligand
- Faculté de Médecine Paris-Saclay, Unité Inserm UMRS1185 Physiologie et Physiopathologie Endocriniennes, Paris, France
| | - Anne Boulin
- Service de Neuroradiologie, Hôpital Foch, 92151 Suresnes, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies Métaboliques, Pôle Cardiovasculaire et Métabolique, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France
| | - Frédéric Castinetti
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Olivier Chabre
- Université Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Le Kremlin-Bicêtre, France
| | - Jean Benoit Corcuff
- Laboratoire d'Hormonologie, Service de Médecine Nucléaire, CHU Bordeaux, Laboratoire NutriNeuro, UMR 1286 INRAE, Université de Bordeaux, Bordeaux, France
| | - Christine Cortet
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, CHU de Lille, Lille, France
| | - Régis Coutant
- Service d'Endocrinologie Pédiatrique, CHU Angers, Centre de Référence, Centre Constitutif des Maladies Rares de l'Hypophyse, CHU Angers, Angers, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Delphine Drui
- Service Endocrinologie-Diabétologie et Nutrition, l'institut du Thorax, CHU Nantes, 44092 Nantes cedex, France
| | - Stéphanie Espiard
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, INSERM U1190, Laboratoire de Recherche Translationnelle sur le Diabète, 59000 Lille, France
| | - Delphine Gaye
- Service de Radiologie, Hôpital Haut-Lêveque, CHU de Bordeaux, 33604 Pessac, France
| | - Solenge Grunenwald
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Laurence Guignat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Elif Hindie
- Service de Médecine Nucléaire, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frédéric Illouz
- Centre de Référence Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Service Endocrinologie-Diabétologie-Nutrition, CHU Angers, 49933 Angers cedex 9, France
| | - Peter Kamenicky
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Service d'Endocrinologie, Diabète et Maladies Métaboliques, CHU de Rouen, Rouen, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, and Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, CHU Robert-Debré, AP-HP, Paris, France; Université de Paris, Paris, France
| | - Marie Odile North
- Service de Génétique et Biologie Moléculaire, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Marie Laure Raffin-Samson
- Service d'Endocrinologie Nutrition, Hôpital Ambroise-Paré, GHU Paris-Saclay, AP-HP Boulogne, EA4340, Université de Versailles-Saint-Quentin, Paris, France
| | - Isabelle Raingeard
- Maladies Endocriniennes, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires, "Groupement Hospitalier Est", Hospices Civils de Lyon, Lyon, France
| | - Véronique Raverot
- Hospices Civils de Lyon, LBMMS, Centre de Biologie Est, Service de Biochimie et Biologie Moléculaire, 69677 Bron cedex, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte-de-Nacre, 14033 Caen cedex, France; University of Caen Basse-Normandie, Medical School, 14032 Caen cedex, France
| | - David Taieb
- Aix-Marseille Université, CHU La Timone, AP-HM, Marseille, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Jacques Young
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Jérôme Bertherat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| |
Collapse
|
7
|
Guarnotta V, Di Gaudio F, Giordano C. Vitamin D Deficiency in Cushing's Disease: Before and After Its Supplementation. Nutrients 2022; 14:nu14050973. [PMID: 35267948 PMCID: PMC8912655 DOI: 10.3390/nu14050973] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 11/27/2022] Open
Abstract
Background: The primary objective of the study was to assess serum 25-hydroxyvitamin D [25(OH)D] values in patients with Cushing’s disease (CD), compared to controls. The secondary objective was to assess the response to a load of 150,000 U of cholecalciferol. Methods: In 50 patients with active CD and 48 controls, we evaluated the anthropometric and biochemical parameters, including insulin sensitivity estimation by the homeostatic model of insulin resistance, Matsuda Index and oral disposition index at baseline and in patients with CD also after 6 weeks of cholecalciferol supplementation. Results: At baseline, patients with CD showed a higher frequency of hypovitaminosis deficiency (p = 0.001) and lower serum 25(OH)D (p < 0.001) than the controls. Six weeks after cholecalciferol treatment, patients with CD had increased serum calcium (p = 0.017), 25(OH)D (p < 0.001), ISI-Matsuda (p = 0.035), oral disposition index (p = 0.045) and decreased serum PTH (p = 0.004) and total cholesterol (p = 0.017) values than at baseline. Multivariate analysis showed that mean urinary free cortisol (mUFC) was independently negatively correlated with serum 25(OH)D in CD. Conclusions: Serum 25(OH)D levels are lower in patients with CD compared to the controls. Vitamin D deficiency is correlated with mUFC and values of mUFC > 240 nmol/24 h are associated with hypovitaminosis D. Cholecalciferol supplementation had a positive impact on insulin sensitivity and lipids.
Collapse
Affiliation(s)
- Valentina Guarnotta
- Department of Health Promotion, Maternal-Infantile Care, Excellence Internal and Specialist Medicine “G. D’Alessandro” [PROMISE], Section of Endocrine Disease and Nutrition, University of Palermo, 90127 Palermo, Italy;
| | - Francesca Di Gaudio
- Biochemistry Head CQRC Division (Quality Control and Biochemical Risk), Department of Health Promotion, Maternal-Infantile Care, Excellence Internal and Specialist Medicine “G. D’Alessandro” [PROMISE], University of Palermo, 90127 Palermo, Italy;
| | - Carla Giordano
- Department of Health Promotion, Maternal-Infantile Care, Excellence Internal and Specialist Medicine “G. D’Alessandro” [PROMISE], Section of Endocrine Disease and Nutrition, University of Palermo, 90127 Palermo, Italy;
- Correspondence: ; Tel.: +39-0916552110; Fax: +39-0916552123
| |
Collapse
|
8
|
Irisin and Secondary Osteoporosis in Humans. Int J Mol Sci 2022; 23:ijms23020690. [PMID: 35054874 PMCID: PMC8775753 DOI: 10.3390/ijms23020690] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/31/2021] [Accepted: 01/05/2022] [Indexed: 02/06/2023] Open
Abstract
Irisin is a peptide secreted by skeletal muscle following exercise that plays an important role in bone metabolism. Numerous experiments in vitro and in mouse models have shown that the administration of recombinant irisin promotes osteogenesis, protects osteocytes from dexamethasone-induced apoptosis, prevents disuse-induced loss of bone and muscle mass, and accelerates fracture healing. Although some aspects still need to be elucidated, such as the dose- and frequency-dependent effects of irisin in cell cultures and mouse models, ample clinical evidence is emerging to support its physiological relevance on bone in humans. A reduction in serum irisin levels, associated with an increased risk of osteoporosis and bone fractures, was observed in postmenopausal women and in both men and women during aging, Recently, cohort studies of subjects with secondary osteoporosis showed that these patients have lower circulating levels of irisin, suggesting that this myokine could be a novel marker to monitor bone quality in this disease. Although there are still few studies, this review discusses the emerging data that are highlighting the involvement of irisin in some diseases that cause secondary osteoporosis.
Collapse
|
9
|
Guarnotta V, Ferrigno R, Martino M, Barbot M, Isidori AM, Scaroni C, Ferrante A, Arnaldi G, Pivonello R, Giordano C. Glucocorticoid excess and COVID-19 disease. Rev Endocr Metab Disord 2021; 22:703-714. [PMID: 33025384 PMCID: PMC7538187 DOI: 10.1007/s11154-020-09598-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 12/15/2022]
Abstract
The pandemic of coronavirus disease (COVID-19), a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is causing high and rapid morbidity and mortality. Immune system response plays a crucial role in controlling and resolving the viral infection. Exogenous or endogenous glucocorticoid excess is characterized by increased susceptibility to infections, due to impairment of the innate and adaptive immune system. In addition, diabetes, hypertension, obesity and thromboembolism are conditions overrepresented in patients with hypercortisolism. Thus patients with chronic glucocorticoid (GC) excess may be at high risk of developing COVID-19 infection with a severe clinical course. Care and control of all comorbidities should be one of the primary goals in patients with hypercortisolism requiring immediate and aggressive treatment. The European Society of Endocrinology (ESE), has recently commissioned an urgent clinical guidance document on management of Cushing's syndrome in a COVID-19 period. In this review, we aim to discuss and expand some clinical points related to GC excess that may have an impact on COVID-19 infection, in terms of both contagion risk and clinical outcome. This document is addressed to all specialists who approach patients with endogenous or exogenous GC excess and COVID-19 infection.
Collapse
Affiliation(s)
- Valentina Guarnotta
- Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", UOC di Malattie endocrine, del Ricambio e della Nutrizione, Università degli studi di Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Marianna Martino
- Clinica di Endocrinologia e Malattie del Metabolismo, Dipartimento di Scienze Cliniche e Molecolari (DISCLIMO), Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Via Conca 71, 60126, Ancona, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine, DIME University-Hospital of Padova, Padua, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Policlinico Umberto I, COVID Hospital, Sapienza University of Rome, 00161, Rome, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine, DIME University-Hospital of Padova, Padua, Italy
| | - Angelo Ferrante
- Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", UO di Reumatologia, Università degli studi di Palermo, Palermo, Italy
| | - Giorgio Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Dipartimento di Scienze Cliniche e Molecolari (DISCLIMO), Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Via Conca 71, 60126, Ancona, Italy.
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy.
| | - Carla Giordano
- Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", UOC di Malattie endocrine, del Ricambio e della Nutrizione, Università degli studi di Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy.
| |
Collapse
|
10
|
Guarnotta V, Amodei R, Giordano C. Metabolic comorbidities of adrenal insufficiency: Focus on steroid replacement therapy and chronopharmacology. Curr Opin Pharmacol 2021; 60:123-132. [PMID: 34416524 DOI: 10.1016/j.coph.2021.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/16/2021] [Accepted: 07/09/2021] [Indexed: 02/08/2023]
Abstract
Adrenal insufficiency (AI) is characterized by higher mortality and morbidity compared with the general population. Conventional replacement steroid therapy, currently recommended for the treatment of AI, is associated with increased frequency of metabolic comorbidities due to daily overexposure. By contrast, dual-release hydrocortisone is associated with a decreased risk of metabolic comorbidities, providing an adequate release of hydrocortisone and mimicking the physiological profile of cortisol. These favorable effects are due to a reduced daily steroid exposure that does not affect the expression of the clock genes which are involved in metabolic pathways and are regulated by the normal physiological circadian rhythm of endogenous cortisol. This narrative review focuses on the possible metabolic comorbidities of AI due to steroid replacement therapy, which evaluates the effects of conventional and novel drugs with attention to chronopharmacology.
Collapse
Affiliation(s)
- Valentina Guarnotta
- Dipartimento di Promozione della Salute Materno-Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - Roberta Amodei
- Dipartimento di Promozione della Salute Materno-Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - Carla Giordano
- Dipartimento di Promozione della Salute Materno-Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy.
| |
Collapse
|
11
|
Bancos I, Hatipoglu BA, Yuen KCJ, Chandramohan L, Chaudhari S, Moraitis AG. Evaluation of FKBP5 as a cortisol activity biomarker in patients with ACTH-dependent Cushing syndrome. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2021; 24:100256. [PMID: 34258233 PMCID: PMC8260880 DOI: 10.1016/j.jcte.2021.100256] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 12/04/2022]
Abstract
Purpose To evaluate the performance of FKBP5 as a cortisol activity biomarker in patients with ACTH-dependent Cushing syndrome (CS). Methods This was a prospective, multicenter, nonrandomized, noninterventional study of a cortisol activity biomarker in adult patients (≥18 years) with documented ACTH-dependent, endogenous CS. The impact of surgery on FKBP5 mRNA expression levels in these patients and the difference in expression levels between these patients and healthy controls were evaluated. Cortisol and biomarker samples were collected before and immediately after surgery. A custom NanoString assay was used to quantify FKBP5 mRNA expression levels. The same method was used to analyze healthy volunteer samples collected from a different study. Results Surgery was considered successful in 14/24 patients (58.3%) and changes from baseline in serum cortisol were −92.6% (P = 0.0005) and −43.8% (not significant) in patients with successful and unsuccessful surgeries, respectively. A strong positive correlation between FKBP5 and cortisol levels was observed (before surgery: r = 0.72, P = 0.0002; after surgery: r = 0.85, P < 0.0001). After successful surgery, FKBP5 expression levels were similar to those of healthy subjects. In patients without surgical success, FKBP5 levels remained unchanged from baseline and distinct from healthy subjects (P = 0.0025). Conclusions Our findings confirm that FKBP5 levels are higher in the presence of excess cortisol exposure in patients with CS and decrease to normal baseline levels after successful surgery. These findings suggest that FKBP5 can serve as a measure of biological cortisol activity and set the stage for the development of an FKBP5 mRNA expression assay as a biomarker of cortisol activity.
Collapse
Affiliation(s)
- Irina Bancos
- Division of Endocrinology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Betul Ayse Hatipoglu
- Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, F20, Cleveland, OH 44195, USA
| | - Kevin C J Yuen
- Swedish Neuroscience Institute, Swedish Pituitary Center, 550 17th Avenue, Suite 400, Seattle, WA 98122, USA
| | - Lakshmi Chandramohan
- NeoGenomics Laboratories, Inc., 7256 South Sam Houston Parkway West, Suite 300, Houston, TX 77085, USA
| | - Sandeep Chaudhari
- Advance Research Associates, 2350 Mission College Blvd #825, Santa Clara, CA 95054, USA
| | | |
Collapse
|
12
|
Schernthaner-Reiter MH, Siess C, Micko A, Zauner C, Wolfsberger S, Scheuba C, Riss P, Knosp E, Kautzky-Willer A, Luger A, Vila G. Acute and Life-threatening Complications in Cushing Syndrome: Prevalence, Predictors, and Mortality. J Clin Endocrinol Metab 2021; 106:e2035-e2046. [PMID: 33517433 DOI: 10.1210/clinem/dgab058] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Cushing syndrome (CS) results in significant morbidity and mortality. OBJECTIVE To study acute and life-threatening complications in patients with active CS. METHODS We performed a retrospective cohort study using inpatient and outpatient records of patients with CS in a tertiary center. A total of 242 patients with CS were included, including 213 with benign CS (pituitary n = 101, adrenal n = 99, ectopic n = 13), and 29 with malignant disease. We collected acute complications necessitating hospitalization, from appearance of first symptoms of hypercortisolism until 1 year after biochemical remission. Mortality data were obtained from the national registry. Baseline factors relating to and predicting acute complications were tested using uni- and multivariate analysis. RESULTS The prevalence of acute complications was 62% in patients with benign pituitary CS, 40% in patients with benign adrenal CS, and 100% in patients with ectopic CS. Complications observed in patients with benign CS included infections (25%), thromboembolic events (17%), hypokalemia (13%), hypertensive crises (9%), cardiac arrhythmias (5%), and acute coronary events (3%). Among these patients, 23% had already been hospitalized for acute complications before CS was suspected, and half of complications occurred after the first surgery. Glycated hemoglobin (HbA1c) and 24-hour urinary free cortisol positively correlated with the number of acute complications per patient. Patients with malignant disease had significantly higher rates of acute complications. Mortality during the observation period was 2.8% and 59% in benign and malignant CS, respectively. CONCLUSIONS This analysis highlights the whole spectrum of acute and life-threatening complications in CS, and their high prevalence even before disease diagnosis and after successful surgery.
Collapse
Affiliation(s)
- Marie Helene Schernthaner-Reiter
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Christina Siess
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Christian Zauner
- Clinical Division of Gastroenterology and Hepatology, Intensive Care Unit, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna; Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Christian Scheuba
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Philipp Riss
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Alexandra Kautzky-Willer
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Anton Luger
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Greisa Vila
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| |
Collapse
|
13
|
Abstract
Severe hypercortisolism is characterized as a life-threatening endocrine condition in patients with Cushing syndrome, usually related to the concomitant onset of one or more comorbidities, requiring rapid normalization of cortisol concentrations and aggressive treatment of associated complications. It is mainly, but not exclusively, caused by ectopic ACTH syndrome, and the diagnosis of severity is more accurate when is based on simultaneous evaluation of the clinical course and manifestations of the disease, cortisol levels and systematic search of comorbidities. Once the severity and imminent risk to life are established, urgent therapeutic measures must be taken and etiological investigation postponed until the patient is stabilized. Adrenal steroidogenesis inhibitors (mainly etomidate, ketoconazole, and metyrapone), alone or in combined therapy, are commonly the first-line treatment for severe hypercortisolemia due to their rapid action, good efficacy and safety profile. The new drug osilodrostat is a future potential candidate to be included in the list. The glucocorticoid receptor antagonist mifepristone has also a rapid action, but its use has been limited due to difficulties to monitor its efficacy and safety. Other slow-acting cortisol-lowering drugs (mainly mitotane, cabergoline, and pasireotide) might be included in the therapeutic scheme to synergize and overcome a possible escape phenomenon frequently observed with the fast-acting drugs in the prolonged follow-up. When medical therapies fail, are unavailable or contra-indicated, bilateral adrenalectomy should be indicated as a life-saving measure. Adrenal arterial embolization is rarely encountered in routine clinical practice, being a last alternative in specialized centers when all other options fail or are contra-indicated.
Collapse
Affiliation(s)
- Júlia Vieira Oberger Marques
- SEMPR, Serviço de Endocrinologia e Metabologia, Departamento de Clínica Médica, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil.
| | - Cesar Luiz Boguszewski
- SEMPR, Serviço de Endocrinologia e Metabologia, Departamento de Clínica Médica, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil.
| |
Collapse
|
14
|
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.
Collapse
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.
| |
Collapse
|
15
|
Barbot M, Regazzo D, Mondin A, Zilio M, Lizzul L, Zaninotto M, Plebani M, Arnaldi G, Ceccato F, Scaroni C. Is pasireotide-induced diabetes mellitus predictable? A pilot study on the effect of a single dose of pasireotide on glucose homeostasis. Pituitary 2020; 23:534-542. [PMID: 32524277 DOI: 10.1007/s11102-020-01055-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Pasireotide (PAS) is an effective treatment for Cushing's disease (CD) but its use is burdened by an associated high incidence of diabetes mellitus (DM). The aim of this study was to examine the effect of a single subcutaneous injection of PAS on glucose metabolism in CD, and to identify predictors of DM onset. METHODS Fifteen patients with CD (13 females, 2 males; median age 43 years [IQR 34-50]) were submitted to an acute PAS test (600 µg s.c.), measuring glucose, insulin, C-peptide, GIP, glucagon, GLP-1, ACTH, and cortisol at the baseline and every 30 min for 2 h. Then they were treated twice daily with PAS 600 µg, and followed up with clinical and hormone assessments for a median of 6 months [2-13]. RESULTS PAS prompted a significant decrease in all hormonal parameters considered except for glycemia, which increased (as expected), reaching the highest value at 120' (p < 0.0001). Overall, 9/15 patients developed DM within 2 months of starting PAS therapy. There were no differences in age, weight, visceral adiposity, HOMA index, fasting glucose or severity of CD between patients who developed DM and those who did not. Baseline fasting glucagon levels were higher in the DM patients (17.95 [12.45-20.54] vs. 10.53 [8.11-12.33] pmol/L, p = 0.0256), and so were GIP and HbA1c levels (37 [5.5-39.5] vs. 29 [27-31.8] mmol/mol, p = 0.0008). Glucose at 120' was also significantly higher in the DM patients (9.5 [8.65-11.95] vs. 6.85 [4.48-9] mmol/L, p = 0.012). CONCLUSIONS PAS was rapidly able to suppress insulin and incretin secretion, with a subsequent rise in glucose levels into the diabetic range. It also induced a significant inhibition of glucagon production. The patients at higher risk of DM during PAS therapy were those with higher glucagon levels, HbA1c > 34.5 mmol/mol, and a glucose peak after PAS administration > 9 mmol/L. CD patients with these features given PAS therapy should therefore be monitored more carefully.
Collapse
Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy.
| | - Daniela Regazzo
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy
| | - Alessandro Mondin
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy
| | - Marialuisa Zilio
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy
| | - Laura Lizzul
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy
| | - Martina Zaninotto
- Laboratory Medicine Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Laboratory Medicine Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Giorgio Arnaldi
- Endocrinology Division, Department of Clinical and Molecular Sciences (DISCLIMO), Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile 105, 35128, Padova, Italy
| |
Collapse
|
16
|
Guarnotta V, Prinzi A, Pitrone M, Pizzolanti G, Giordano C. Circulating Irisin Levels as a Marker of Osteosarcopenic-Obesity in Cushing's Disease. Diabetes Metab Syndr Obes 2020; 13:1565-1574. [PMID: 32494173 PMCID: PMC7227819 DOI: 10.2147/dmso.s249090] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/26/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To evaluate circulating irisin levels in patients with active and controlled Cushing's disease (CD). DESIGN Forty-four patients with CD evaluated during the active phase and after 12 months of biochemical remission and 40 controls were recruited. METHODS Phenotypic, anthropometric, hormonal and metabolic parameters, including insulin sensitivity estimation by homeostatic model of insulin resistance, Matsuda index and oral disposition index and circulating irisin levels were evaluated. RESULTS Patients with active CD showed lower irisin levels compared to controls (p<0.001) and controlled CD (p<0.001). The independent variables significantly associated with irisin were waist circumference (WC) (p=0.025), body fat percentage (BF%) (p=0.009), PTH (p=0.007) and chair rising test (CRT) (p<0.001) in active CD and WC (p=0.013), BF% (p=0.014), PTH (p=0.038), CRT (p=0.029) and urinary-free cortisol (p<0.001) in controlled CD. CONCLUSION Circulating irisin levels tend to be lower in patients with active CD compared to those with controlled CD and controls. They are strongly associated with osteosarcopenia and central obesity in CD and therefore may be a possible marker of diagnosis.
Collapse
Affiliation(s)
- Valentina Guarnotta
- Dipartimento di Promozione Della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - Antonio Prinzi
- Dipartimento di Promozione Della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - Maria Pitrone
- Dipartimento di Promozione Della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - Giuseppe Pizzolanti
- Dipartimento di Promozione Della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - Carla Giordano
- Dipartimento di Promozione Della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
- Correspondence: Carla Giordano; Giuseppe Pizzolanti Piazza Delle Cliniche 2, Palermo90127, ItalyTel +39 0916552110; +39 0916552138Fax +39 0916552123 Email ;
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Guarnotta V, Di Stefano C, Santoro A, Ciresi A, Coppola A, Giordano C. Dual-release hydrocortisone vs conventional glucocorticoids in adrenal insufficiency. Endocr Connect 2019; 8:853-862. [PMID: 31252397 PMCID: PMC6599082 DOI: 10.1530/ec-19-0176] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/04/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Dual-release hydrocortisone (DR-HC) improves metabolism in patients with adrenal insufficiency. The aims of this study were to compare the cardiovascular and metabolic effects of conventional glucocorticoids (GCs) vs. DR-HC and of high vs. low doses of GCs, after 48 months of observation. METHODS We selected 27 patients on hydrocortisone (mean dose 17.5 ± 4.2 mg/day) and 20 patients on cortisone acetate (mean dose 37.5 ± 12.1 mg/day) who maintained this treatment (group A) and 53 patients switched to DR-HC (mean dose 22 ± 4.8 mg/day) (group B). At baseline and after 48 months, clinical and metabolic parameters and Framingham Risk Score (FRS) were obtained. RESULTS After 48 months, patients in group A had a significant increase from baseline in BMI (P < 0.001), waist circumference (P = 0.001), systolic blood pressure (P = 0.001), LDL cholesterol (P = 0.018), HbA1c (P = 0.020) and FRS (P = 0.002). By contrast, patients in group B had a significant decrease in BMI (P = 0.002), waist circumference (P = 0.015), diastolic blood pressure (P = 0.031), total (P = 0.006) and LDL cholesterol (P = 0.005), HbA1c (P < 0.001) and FRS (P = 0.015) compared to baseline. No significant differences between high and low doses of both conventional GCs and DR-HC were observed. CONCLUSIONS DR-HC is associated with an improvement of metabolic parameters and cardiovascular risk compared to conventional GCs, which are associated with a worsening of these parameters, regardless of the dose used.
Collapse
Affiliation(s)
- V Guarnotta
- Dipartimento di Promozione della Salute, Materno – Infantile, Medicina Interna e Specialistica di Eccellenza ‘G. D’Alessandro’ (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - C Di Stefano
- Dipartimento di Promozione della Salute, Materno – Infantile, Medicina Interna e Specialistica di Eccellenza ‘G. D’Alessandro’ (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - A Santoro
- Dipartimento di Promozione della Salute, Materno – Infantile, Medicina Interna e Specialistica di Eccellenza ‘G. D’Alessandro’ (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - A Ciresi
- Dipartimento di Promozione della Salute, Materno – Infantile, Medicina Interna e Specialistica di Eccellenza ‘G. D’Alessandro’ (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - A Coppola
- Dipartimento di Promozione della Salute, Materno – Infantile, Medicina Interna e Specialistica di Eccellenza ‘G. D’Alessandro’ (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
| | - C Giordano
- Dipartimento di Promozione della Salute, Materno – Infantile, Medicina Interna e Specialistica di Eccellenza ‘G. D’Alessandro’ (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Palermo, Italy
- Correspondence should be addressed to C Giordano:
| |
Collapse
|
19
|
Pivonello R, Arnaldi G, Scaroni C, Giordano C, Cannavò S, Iacuaniello D, Trementino L, Zilio M, Guarnotta V, Albani A, Cozzolino A, Michetti G, Boscaro M, Colao A. The medical treatment with pasireotide in Cushing's disease: an Italian multicentre experience based on "real-world evidence". Endocrine 2019; 64:657-672. [PMID: 30968338 PMCID: PMC6551343 DOI: 10.1007/s12020-018-1818-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/12/2018] [Indexed: 12/20/2022]
Abstract
A phase III study has demonstrated that 6-month pasireotide treatment induced disease control with good safety in 15-26% of patients with Cushing's disease (CD). The aim of the current study was to evaluate the 6-month efficacy and safety of pasireotide treatment according to the real-world evidence. Thirty-two CD patients started pasireotide at the dose of 600 µg twice a day (bid) and with the chance of up-titration to 900 µg bid, or down-titration to 450 or 300 µg bid, on the basis of urinary cortisol (UC) levels or safety. Hormonal, clinical and metabolic parameters were measured at baseline and at 3-month and 6-month follow-up, whereas tumour size was evaluated at baseline and at 6-month follow-up. At baseline, 31 patients had very mild to moderate disease and 1 patient had very severe disease. Five (15.6%) patients discontinued treatment for adverse events; the remaining 27 patients (26 with very mild to moderate disease and 1 with very severe disease), reached 6-month follow-up. Considering the group of patients with very mild to moderate disease, responsiveness, defined by the normalization (<1 the upper limit of normal range, ULN) or near normalization (>1 and ≤1.1 ULN) of UC levels, was registered in 21 patients (full control in 19 and near control in 2), corresponding to 67.7% and 80.8% according to an "intention-to-treat" or "per-protocol" methodological approach, respectively. Weight, body mass index, waist circumference, as well as total and LDL-cholesterol significantly decreased, whereas fasting plasma glucose and glycated haemoglobin significantly increased. Hyperglycaemia was documented in 81.2%, whereas gastrointestinal disturbances in 40.6% of patients. In conclusion, in the real-life clinical practice, pasireotide treatment normalizes or nearly normalizes UC in at least 68% of patients with very mild to moderate disease, with consequent improvement in weight, visceral adiposity and lipid profile, despite the occurrence or deterioration of diabetes in the majority of cases, confirming the usefulness of this treatment in patients with milder disease and without uncontrolled diabetes.
Collapse
Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy.
| | - Giorgio Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Carla Scaroni
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Carla Giordano
- Dipartimento Biomedico di Medicina Interna e Specialistica Di.Bi.MI.S, sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, A.O.U.P. "Paolo Giaccone", Palermo, Italy
| | - Salvo Cannavò
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italy
| | - Davide Iacuaniello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Laura Trementino
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Marialuisa Zilio
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Valentina Guarnotta
- Dipartimento Biomedico di Medicina Interna e Specialistica Di.Bi.MI.S, sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, A.O.U.P. "Paolo Giaccone", Palermo, Italy
| | - Adriana Albani
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italy
| | - Alessia Cozzolino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Dipartimento di Medicina Sperimentale, Università "La Sapienza", Roma, Italy
| | - Grazia Michetti
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Marco Boscaro
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| |
Collapse
|
20
|
Barbot M, Ceccato F, Scaroni C. The Pathophysiology and Treatment of Hypertension in Patients With Cushing's Syndrome. Front Endocrinol (Lausanne) 2019; 10:321. [PMID: 31164868 PMCID: PMC6536607 DOI: 10.3389/fendo.2019.00321] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/02/2019] [Indexed: 12/19/2022] Open
Abstract
When hypertension, a pathology that is frequently found in the general population, presents in a young patient, secondary causes such as Cushing's syndrome (CS), a rare disease characterized by long-term elevated cortisol levels, should be considered. Present in ~80% of CS patients independently of their age and sex, hypertension is one of the pathology's most prevalent, alarming features. Its severity is principally associated with the duration and intensity of elevated cortisol levels. Prompt diagnosis and rapid initiation of treatment are important for reducing/delaying the consequences of hypercortisolism. Glucocorticoid excess leads to hypertension via a variety of mechanisms including mineralocorticoid mimetic activity, alterations in peripheral and renovascular resistance, and vascular remodeling. As hypertension in CS patients is caused by cortisol excess, treating the underlying pathology generally contributes to reducing blood pressure (BP) levels, although hypertension tends to persist in approximately 30% of cured patients. Surgical removal of the pituitary tumor remains the first-line treatment for both adrenocorticotropin hormone (ACTH) dependent and independent forms of the syndrome. In light of the fact that surgery is not always successful in curing the underlying disease, it is essential that other treatments be considered and prescribed as needed. This article discusses the mechanisms involved in the pathogenesis of CS and the pros and the cons of the various antihypertensive agents that are presently available to treat these patients.
Collapse
Affiliation(s)
- Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| |
Collapse
|
21
|
Schernthaner-Reiter MH, Siess C, Gessl A, Scheuba C, Wolfsberger S, Riss P, Knosp E, Luger A, Vila G. Factors predicting long-term comorbidities in patients with Cushing's syndrome in remission. Endocrine 2019; 64:157-168. [PMID: 30467627 PMCID: PMC6453862 DOI: 10.1007/s12020-018-1819-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/12/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE In Cushing's syndrome, comorbidities often persist after remission of glucocorticoid excess. Here, we aim to identify factors predicting long-term comorbidities in patients with Cushing's syndrome in remission. METHODS In a retrospective cross-sectional study, 118 patients with Cushing's syndrome in remission (52 pituitary, 58 adrenal, 8 ectopic) were followed for a median of 7.9 years (range 2-38) after the last surgery. Associations between baseline anthropometric, metabolic, hormonal parameters at diagnosis, and comorbidities (obesity, diabetes, hyperlipidemia, hypertension, osteoporosis, depression) at last follow-up, were tested by uni- and multivariate regression analysis. RESULTS In patients with manifest comorbidities at diagnosis, remission of Cushing's syndrome resolved diabetes in 56% of cases, hypertension in 36% of cases, hyperlipidaemia in 23%, and depression in 52% of cases. In a multivariate regression analysis, age, fasting glucose, BMI, and the number of comorbidities at diagnosis were positive predictors of the number of long-term comorbidities, while baseline 24-h urinary free cortisol (UFC) negatively correlated with the persistence of long-term comorbidities. The negative relationship between baseline UFC and long-term comorbidities was also found when pituitary and adrenal Cushing's cases were analyzed separately. Baseline UFC was negatively related to the time of exposure to excess glucocorticoids. CONCLUSIONS Long-term comorbidities after remission of Cushing's syndrome depend not only on the presence of classic cardiovascular risk factors (age, hyperglycemia, BMI), but also on the extent of glucocorticoid excess. Lower baseline UFC is associated with a higher number of long-term comorbidities, possibly due to the longer exposure to excess glucocorticoids in milder Cushing's syndrome.
Collapse
Affiliation(s)
- Marie Helene Schernthaner-Reiter
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christina Siess
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alois Gessl
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christian Scheuba
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Riss
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Anton Luger
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Greisa Vila
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
22
|
Guarnotta V, Mineo MI, Radellini S, Pizzolanti G, Giordano C. Dual-release hydrocortisone improves hepatic steatosis in patients with secondary adrenal insufficiency: a real-life study. Ther Adv Endocrinol Metab 2019; 10:2042018819871169. [PMID: 31489172 PMCID: PMC6713956 DOI: 10.1177/2042018819871169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 07/31/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Conventional glucocorticoid treatment has a significant impact on liver in patients with adrenal insufficiency. Dual-release hydrocortisone (DR-HC) provides physiological cortisol exposure, leading to an improvement in anthropometric and metabolic parameters. We aimed to evaluate the effects of 12-month DR-HC treatment on the hepatic steatosis index (HSI), a validated surrogate index of hepatic steatosis, in patients with secondary adrenal insufficiency (SAI). METHODS A total of 45 patients with hypopituitarism, 22 with hypogonadism, hypothyroidism, ACTH, and GH deficiencies, and 23 with hypogonadism, hypothyroidism, and ACTH deficiency, on replacement therapy for all the pituitary deficiencies, were switched from conventional hydrocortisone to DR-HC. At baseline and after 12 months, glucose and insulin levels, surrogate estimates of insulin sensitivity, and hepatic steatosis were evaluated through ultrasonography and HSI. RESULTS At diagnosis, ultrasonography documented steatosis in 31 patients (68.8%) while 33 (73.3%) showed high HSI. Hydrocortisone (HC) dose (β = 1.231, p = 0.010), insulin resistance index (HOMA-IR) (β = 1.431, p = 0.002), and insulin sensitivity index (ISI)-Matsuda (β = -1.389, p = 0.034) were predictors of HSI at baseline. After 12 months of DR-HC, a significant decrease in body mass index (BMI) (p = 0.008), waist circumference (WC) (p = 0.010), fasting insulin (p = 0.041), HOMA-IR (p = 0.047), HSI (p < 0.001) and number of patients with HSI ⩾36 (p = 0.003), and a significant increase in sodium (p < 0.001) and ISI-Matsuda (p = 0.031) were observed. HOMA-IR (β = 1.431, p = 0.002) and ISI-Matsuda (β = -9.489, p < 0.001) were identified as independent predictors of HSI at 12 months. CONCLUSIONS In adults with SAI, DR-HC is associated with an improvement in HSI, regardless of the dose used, mainly related to an improvement in insulin sensitivity.
Collapse
Affiliation(s)
- Valentina Guarnotta
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Sicilia, Italy
| | - Mariagrazia Irene Mineo
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Sicilia, Italy
| | - Stefano Radellini
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Sicilia, Italy
| | - Giuseppe Pizzolanti
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro” (PROMISE), Sezione di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Sicilia, Italy
| | | |
Collapse
|
23
|
Guarnotta V, Pizzolanti G, Ciresi A, Giordano C. Insulin sensitivity and secretion and adipokine profile in patients with Cushing's disease treated with pasireotide. J Endocrinol Invest 2018; 41:1137-1147. [PMID: 29396758 DOI: 10.1007/s40618-018-0839-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 01/22/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE To evaluate the effect of pasireotide on β-cell and adipose function in patients with Cushing's disease (CD). METHODS Clinical and hormonal parameters, insulin secretion evaluated by HOMA-β and by the area under the curve (AUC2h) of C-peptide during a mixed meal tolerance test and insulin sensitivity, evaluated by the euglycaemic hyperinsulinaemic clamp, were evaluated in 12 patients with active CD, before and after 6 and 12 months of pasireotide. In addition, a panel of adipokines including leptin (Ob), leptin/leptin receptor ratio (Ob/Ob-R ratio), adiponectin, resistin, visfatin, adipocyte fatty acid binding protein (AFABP) and non-esterified fatty acids (NEFAs) was evaluated at baseline and after 12 months of pasireotide. RESULTS During 12 months of pasireotide treatment, a significant decrease in weight (p = 0.004), BMI (p = 0.008), waist circumference (p = 0.009), urinary free cortisol (p = 0.007), fasting insulinaemia (p = 0.007), HOMA-β (p = 0.015) and AUC2h c-peptide (p = 0.017), concomitance with an increase in fasting glycaemia (p = 0.015) and HbA1c (p = 0.030), was found. With regard to adipokines, a significant decrease in Ob (p = 0.039), Ob/Ob-R ratio (p = 0.017) and AFABP (p = 0.036) was observed concomitant with a significant increase in Ob-R (p = 0.028) after 12 months of pasireotide. CONCLUSIONS 12 months of treatment with pasireotide in CD is associated with an impairment of insulin secretion and an improvement of adipose function without any interference in insulin sensitivity.
Collapse
Affiliation(s)
- V Guarnotta
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - G Pizzolanti
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - A Ciresi
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - C Giordano
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy.
| |
Collapse
|
24
|
Bertagna X. MANAGEMENT OF ENDOCRINE DISEASE: Can we cure Cushing's disease? A personal view. Eur J Endocrinol 2018; 178:R183-R200. [PMID: 29467229 DOI: 10.1530/eje-18-0062] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 02/20/2018] [Indexed: 12/21/2022]
Abstract
One of today's challenges in endocrinology is the treatment of Cushing's disease: Although pituitary surgery has the potential to 'cure' the patient and restore a completely normal pituitary adrenal axis, there are immediate failures and late recurrences that will ultimately require alternate therapeutic approaches. Their high number is in direct correlation with their serious limitations and they all appear to be 'default options'. This 'personal view' tries to shed some light on the inescapable difficulties of the current treatments of Cushing's disease and to provide some optimistic view for the future where the pituitary adenoma should be the 'reasonable obsession' of a successful therapeutist.
Collapse
Affiliation(s)
- X Bertagna
- Service des Maladies Endocriniennes et MétaboliquesCentre de Référence des Maladies Rares de la Surrénale, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris 5, Paris, France
| |
Collapse
|
25
|
Abstract
Treatment of Cushing's disease remains a challenge. Whereas pituitary surgery can "cure" the patient and restore a completely normal pituitary adrenal axis, there are immediate failures and late recurrences which ultimately require alternate therapeutic approaches. These are numerous, but so are their drawbacks, and all appear to be "default options". For the future, pituitary adenoma has to remain the "reasonable obsession" of efficient and optimistic therapists….
Collapse
Affiliation(s)
- Xavier Bertagna
- Service des maladies endocriniennes et métaboliques, centre de référence des maladies rares de la surrénale, hôpital Cochin, faculté de médecine Paris-Descartes, université Paris 5, 24, rue du Faubourg-St-Jacques, 75014 Paris, France.
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Sheriff N, McCormack AI. How useful is urinary-free cortisol in the clinic? Biomark Med 2017; 11:1009-1016. [DOI: 10.2217/bmm-2016-0311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Measurement of 24-h urine-free cortisol is frequently employed as a first-line screening and disease-monitoring test in Cushing's syndrome (CS). The quest for ‘cortisol specificity’ has seen the emergence of mass spectrometry (MS) based assays, particularly liquid chromatography/tandem mass spectrometry. In contrast to traditional immunoassays, liquid chromatography/tandem mass spectrometry ‘free cortisol’ measurement is less susceptible to ‘interference’ from cortisol precursors and metabolites. However, detection of these conjugates is important in mild CS and therefore, missed by MS if cortisol alone is measured. MS assays nevertheless are capable of measuring broad steroid profiles, including the potential to distinguish benign from malignant adrenal-based CS and detection of exogenous glucocorticoids. Until this is routine practice, we recommend against abandoning immunoassays measurement of urine-free cortisol.
Collapse
Affiliation(s)
- Nisa Sheriff
- Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, Australia
| | - Ann I McCormack
- Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, Australia
| |
Collapse
|
28
|
Kennedy L, Recinos PF. Cushing Disease: Are We Making Progress? J Clin Endocrinol Metab 2017; 102:2133-2135. [PMID: 28899077 DOI: 10.1210/jc.2017-00775] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 04/21/2017] [Indexed: 11/19/2022]
Abstract
This paper comments on how we can assess the success of transsphenoidal surgery for patients with Cushing disease.
Collapse
Affiliation(s)
- Laurence Kennedy
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, Ohio 44195
| | - Pablo F Recinos
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio 44195
| |
Collapse
|
29
|
Pappachan JM, Hariman C, Edavalath M, Waldron J, Hanna FW. Cushing's syndrome: a practical approach to diagnosis and differential diagnoses. J Clin Pathol 2017; 70:350-359. [PMID: 28069628 DOI: 10.1136/jclinpath-2016-203933] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/01/2016] [Accepted: 12/08/2016] [Indexed: 02/05/2023]
Abstract
Diagnosis of Cushing's syndrome (CS) and identification of the aetiology of hypercortisolism can be challenging. The Endocrine Society clinical practice guidelines recommends one of the four tests for initial screening of CS, namely, urinary-free cortisol, late night salivary cortisol, overnight dexamethasone suppression test or a longer low-dose dexamethasone suppression test, for 48 hours. Confirmation and localisation of CS requires additional biochemical and radiological tests. Radiological evaluation involves different imaging modalities including MRI with or without different radio-nuclear imaging techniques. Invasive testing such as bilateral inferior petrosal sinus sampling may be necessary in some patients for accurate localisation of the cause for hypercortisolism. This best practice review discusses a practical approach for the diagnostic evaluation of CS with a brief discussion on differential diagnoses, and cyclical CS, to enhance the skills of clinicians and laboratory personnel.
Collapse
Affiliation(s)
- Joseph M Pappachan
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Christian Hariman
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Mahamood Edavalath
- Department of Endocrinology & Diabetes, Imperial College London Diabetes Centre, Abu Dhabi, UAE
| | - Julian Waldron
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Fahmy W Hanna
- Department of Endocrinology & Diabetes, University Hospitals of North Midlands NHS Trust & North Staffordshire University, Stoke-on-Trent, UK
| |
Collapse
|