1
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Detomas M, Deutschbein T, Altieri B. Medical Therapy of Endogenous Cushing's Syndrome with Steroidogenesis Inhibitors: Treatment Rationale, Available Drugs, and Therapeutic Effects. Exp Clin Endocrinol Diabetes 2024. [PMID: 38688315 DOI: 10.1055/a-2317-0801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Endogenous Cushing's syndrome (CS) is a rare disease characterized by a glucocorticoid excess. If inadequately treated, hypercortisolism can lead to increased morbidity and mortality. Surgical removal of the underlying tumor is the first-line treatment but is sometimes not feasible or even contraindicated. Additionally, in cases with severe CS, rapid control of hypercortisolism may be required. In these scenarios, steroidogenesis inhibitors represent a therapeutic alternative to surgery. Over the last years, the knowledge of the broad therapeutic effects of steroidogenesis inhibitors per se and the number of available drugs have increased. However, large comparative studies are still lacking. Accordingly, the decision on which drug to be used in a certain patient or clinical setting may be difficult. This review aims to summarize the main characteristics of steroidogenesis inhibitors.
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Affiliation(s)
- Mario Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - Barbara Altieri
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
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2
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Capatina C, Hanzu FA, Hinojosa-Amaya JM, Fleseriu M. Medical treatment of functional pituitary adenomas, trials and tribulations. J Neurooncol 2024; 168:197-213. [PMID: 38760632 DOI: 10.1007/s11060-024-04670-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/27/2024] [Indexed: 05/19/2024]
Abstract
CONTEXT Functioning pituitary adenomas (FPAs) include most frequently prolactinomas, somatotroph or corticotroph adenomas, while thyrotroph and gonadotroph adenomas are very rare. Despite their benign histological nature (aggressive tumors are rare and malignant ones exceptional), FPAs could cause significant morbidity and increased mortality due to complications associated with hormonal excess syndromes and/or mass effect leading to compression of adjacent structures. This mini review will focus on the increasing role of medical therapy in the multimodal treatment, which also includes transsphenoidal surgery (TSS) and radiotherapy. EVIDENCE SYNTHESIS Most patients with prolactinomas are treated only with medications, but surgery could be considered for some patients in a specialized pituitary center, if higher chances of cure. Dopamine agonists, especially cabergoline, are efficient in reducing tumor size and normalizing prolactin. TSS is the first-line treatment for all other FPAs, but most patients require complex adjuvant treatment, including a combination of therapeutic approaches. Medical therapy is the cornerstone of treatment in all patients after unsuccessful surgery or when surgery cannot be offered and includes somatostatin receptor ligands and dopamine agonists (almost all FPAs), growth hormone receptor antagonists (acromegaly), adrenal steroidogenesis inhibitors and glucocorticoid receptor blockers (Cushing's disease). Novel medical treatments, especially for acromegaly and Cushing's disease are under research. CONCLUSIONS An enlarged panel of effective drugs available with increased knowledge of predictive factors for response and/or adverse effects will enhance the possibility to offer a more individualized treatment. This would not only improve disease control and prognosis, but also quality of life.
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Affiliation(s)
- Cristina Capatina
- Department of Endocrinology, University of Medicine and Pharmacy "Carol Davila" Bucharest, and Department of Pituitary and Neuroendocrine Pathology, C.I. Parhon National Institute of Endocrinology, Bucharest, Romania
| | - Felicia Alexandra Hanzu
- Endocrinology Department, Hospital Clínic de Barcelona, Spain, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José Miguel Hinojosa-Amaya
- Endocrinology Division and Department of Medicine, Pituitary Clinic, Hospital Universitario U.A.N.L, Monterrey, Mexico
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health and Science University, Portland, OR, USA.
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3
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Pivonello R, Simeoli C, Paola ND, Larocca A, Crescenzo EM, Colao A. Osilodrostat: A Novel Potent Inhibitor of 11-Beta-Hydroxylase for the Treatment of Cushing's Syndrome. TOUCHREVIEWS IN ENDOCRINOLOGY 2024; 20:43-51. [PMID: 38812665 PMCID: PMC11132648 DOI: 10.17925/ee.2024.20.1.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 07/31/2023] [Indexed: 05/31/2024]
Abstract
Osilodrostat is a novel potent oral steroidogenesis inhibitor with a non-steroidal chemical structure, recently approved for the treatment of adult patients with endogenous Cushing's syndrome, and Cushing's disease not cured bytab pituitary surgery or in whom pituitary surgery is not an option. Osilodrostat has been evaluated in different multicentre phase II and III clinical studies, and has shown to have notable effects, such as significant reductions in cortisol secretion, associated with significant improvement in body weight, blood pressure, glucose metabolism, lipid profile, psychological status and quality of life. The favourable safety profile, combined with the relevant efficacy, could make osilodrostat suitable as medical treatment in several phases of the Cushing's syndrome treatment journey: before surgery, as preoperative treatment, or instead of surgery, in cases where surgery is not an option or refused, as first-line treatment; after surgery, in cases of persistent or recurrent disease, as second-line treatment; after second surgery or radiotherapy following pituitary surgery as bridging treatment waiting for the definitive disease control, as third-line treatment. Further real-world clinical experience data are needed to confirm the current knowledge.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinicae Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologiae Nutrizione, Università “Federico II” di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, University Federico II, Naples, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinicae Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologiae Nutrizione, Università “Federico II” di Napoli, Naples, Italy
| | - Nicola Di Paola
- Dipartimento di Medicina Clinicae Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologiae Nutrizione, Università “Federico II” di Napoli, Naples, Italy
| | - Angelica Larocca
- Dipartimento di Medicina Clinicae Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologiae Nutrizione, Università “Federico II” di Napoli, Naples, Italy
| | - Erminio Massimo Crescenzo
- Dipartimento di Medicina Clinicae Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologiae Nutrizione, Università “Federico II” di Napoli, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinicae Chirurgia, Sezione di Endocrinologia, Diabetologia, Andrologiae Nutrizione, Università “Federico II” di Napoli, Naples, Italy
- UNESCO Chair for Health Education and Sustainable Development, University Federico II, Naples, Italy
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4
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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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Laguillier-Morizot C, Bonnet-Serrano F, Leguy MC, Simeonovic M, Sée C, Zientek C, Soussan M, Bouys L, Bertherat J, Guibourdenche J. Diagnostic performance of an automated immunoassay for salivary cortisol. ANNALES D'ENDOCRINOLOGIE 2024; 85:20-26. [PMID: 37926277 DOI: 10.1016/j.ando.2023.10.007] [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: 09/01/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 11/07/2023]
Abstract
Automated immunoanalysis (AI) is an interesting alternative for measuring salivary cortisol, as the gold standard HPLC-MS/MS method is not yet readily available. The aim of this study was to evaluate the diagnostic performance of salivary cortisol immunoassay on the iSYS immunoanalyzer in adrenal dynamic tests. Cortisol was measured on iSYS and on HPLC-MS/MS in saliva samples collected after 1mg-dexamethasone suppression test (DST) in 115 patients suspected of Cushing syndrome, and during Synacthen® stimulation test (SST) in 108 patients suspected of adrenal insufficiency. Concentrations on AI correlated well with HPLC-MS/MS (Spearman r=0.9496; P<0.0001), but with a significant positive bias. ROC analysis of salivary cortisol identified optimal cut-off values on AI and HPLC-MS/MS of respectively 3.5 and 0.77nmol/L for DST and 32.6 and 13.8nmol/L at T60 after SST. Automated immunoassays for salivary cortisol are suitable in daily practice but require determination of specific cut-off and reference values.
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Affiliation(s)
- Christelle Laguillier-Morizot
- Department of Hormonology, bâtiment J. Dausset, 2(e) étage, CHU Cochin, 27, rue du Fg-St-Jacques, 75014 Paris, France; Faculté de santé, université Paris Cité, 2, rue Valette, 75005 Paris, France.
| | - Fidéline Bonnet-Serrano
- Department of Hormonology, bâtiment J. Dausset, 2(e) étage, CHU Cochin, 27, rue du Fg-St-Jacques, 75014 Paris, France; Faculté de santé, université Paris Cité, 2, rue Valette, 75005 Paris, France
| | - Marie-Clémence Leguy
- Department of Hormonology, bâtiment J. Dausset, 2(e) étage, CHU Cochin, 27, rue du Fg-St-Jacques, 75014 Paris, France
| | - Miliça Simeonovic
- Department of Hormonology, bâtiment J. Dausset, 2(e) étage, CHU Cochin, 27, rue du Fg-St-Jacques, 75014 Paris, France; Université Paris-Est Créteil Val-de-Marne, 61, avenue du Général-de-Gaulle, 94010 Créteil cedex, France
| | - Catherine Sée
- Department of Hormonology, bâtiment J. Dausset, 2(e) étage, CHU Cochin, 27, rue du Fg-St-Jacques, 75014 Paris, France
| | - Corinne Zientek
- Department of Hormonology, bâtiment J. Dausset, 2(e) étage, CHU Cochin, 27, rue du Fg-St-Jacques, 75014 Paris, France
| | - Mickael Soussan
- Department of Hormonology, bâtiment J. Dausset, 2(e) étage, CHU Cochin, 27, rue du Fg-St-Jacques, 75014 Paris, France; Faculté de santé, université Paris Cité, 2, rue Valette, 75005 Paris, France
| | - Lucas Bouys
- Faculté de santé, université Paris Cité, 2, rue Valette, 75005 Paris, France; Department of Endocrinology, CHU Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France; Reference Center for Rare Adrenal Diseases, CHU Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Jérôme Bertherat
- Faculté de santé, université Paris Cité, 2, rue Valette, 75005 Paris, France; Department of Endocrinology, CHU Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France; Reference Center for Rare Adrenal Diseases, CHU Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Jean Guibourdenche
- Department of Hormonology, bâtiment J. Dausset, 2(e) étage, CHU Cochin, 27, rue du Fg-St-Jacques, 75014 Paris, France; Faculté de santé, université Paris Cité, 2, rue Valette, 75005 Paris, France
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Divaris E, Kostopoulos G, Efstathiadou ZA. Current and Emerging Pharmacological Therapies for Cushing's Disease. Curr Pharm Des 2024; 30:757-777. [PMID: 38424426 DOI: 10.2174/0113816128290025240216110928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/09/2024] [Accepted: 01/31/2024] [Indexed: 03/02/2024]
Abstract
Cushing's Disease (CD), hypercortisolism due to pituitary ACTH secreting neuroendocrine neoplasm, is associated with increased morbidity and, if untreated, mortality in about half of the affected individuals. Consequently, the timely initiation of effective treatment is mandatory. Neurosurgery is the first line and the only potentially curative treatment; however, 30% of patients will have persistent disease post-surgery. Furthermore, a small percentage of those initially controlled will develop hypercortisolism during long-term follow- up. Therefore, patients with persistent or recurrent disease, as well as those considered non-eligible for surgery, will need a second-line therapeutic approach, i.e., pharmacotherapy. Radiation therapy is reserved as a third-line therapeutic option due to its slower onset of action and its unfavorable profile regarding complications. During the past few years, the understanding of molecular mechanisms implicated in the physiology of the hypothalamus-pituitary-adrenal axis has evolved, and new therapeutic targets for CD have emerged. In the present review, currently available treatments, compounds currently tested in ongoing clinical trials, and interesting, potentially new targets emerging from unraveling molecular mechanisms involved in the pathophysiology of Cushing's disease are discussed.
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Affiliation(s)
- Efstathios Divaris
- Department of Endocrinology, "Hippokration" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Georgios Kostopoulos
- Department of Endocrinology, "Hippokration" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Zoe A Efstathiadou
- Department of Endocrinology, "Hippokration" General Hospital of Thessaloniki, Thessaloniki, Greece
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7
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Dzialach L, Sobolewska J, Respondek W, Szamotulska K, Witek P. Cushing's Disease: Long-Term Effectiveness and Safety of Osilodrostat in a Polish Group of Patients with Persistent Hypercortisolemia in the Experience of a Single Center. Biomedicines 2023; 11:3227. [PMID: 38137448 PMCID: PMC10741245 DOI: 10.3390/biomedicines11123227] [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: 11/02/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Osilodrostat is a potent oral steroidogenesis inhibitor that has emerged as the new medical agent for patients with Cushing's disease (CD) requiring long-term medical therapy for hypercortisolemia control. Its efficacy and safety have been assessed in clinical trials; however, real-world evidence is still scarce. This study aimed to investigate the long-term treatment (156 weeks) clinical and biochemical effect of osilodrostat in six patients with CD at a single center in Poland, initially participating in the LINC4 study. At week 36, all six patients met the key secondary endpoint of the LINC4 trial, achieving normalization of median urinary free cortisol. Osilodrostat treatment allowed for complete disease control in all patients and none of the patients was excluded due to the lack of treatment effectiveness in 156 weeks of follow-up. All patients demonstrated significant improvement from baseline on most metabolic and cardiovascular parameters, which was most evident at week 36 and sustained throughout the study period. This study supports and strengthens the role of osilodrostat as an effective long-term medical treatment in patients with CD. We also present three patient case histories in detail to highlight the clinical situations that endocrinologists might face during osilodrostat therapy.
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Affiliation(s)
- Lukasz Dzialach
- Department of Internal Medicine Endocrinology and Diabetes, Medical University of Warsaw, 03-242 Warsaw, Poland (P.W.)
| | - Joanna Sobolewska
- Department of Internal Medicine Endocrinology and Diabetes, Medical University of Warsaw, 03-242 Warsaw, Poland (P.W.)
| | - Wioleta Respondek
- Department of Internal Medicine Endocrinology and Diabetes, Mazovian Brodnowski Hospital, 03-242 Warsaw, Poland
| | - Katarzyna Szamotulska
- Department of Epidemiology and Biostatistics, Institute of Mother and Child, 01-211 Warsaw, Poland;
| | - Przemysław Witek
- Department of Internal Medicine Endocrinology and Diabetes, Medical University of Warsaw, 03-242 Warsaw, Poland (P.W.)
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8
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Fleseriu M, Varlamov EV, Hinojosa-Amaya JM, Langlois F, Melmed S. An individualized approach to the management of Cushing disease. Nat Rev Endocrinol 2023; 19:581-599. [PMID: 37537306 DOI: 10.1038/s41574-023-00868-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 08/05/2023]
Abstract
Cushing disease caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary corticotroph adenoma leads to hypercortisolaemia with high mortality due to metabolic, cardiovascular, immunological, neurocognitive, haematological and infectious conditions. The disorder is challenging to diagnose because of its common and heterogenous presenting features and the biochemical pitfalls of testing levels of hormones in the hypothalamic-pituitary-adrenal axis. Several late-night salivary cortisol and 24-h urinary free cortisol tests are usually required as well as serum levels of cortisol after a dexamethasone suppression test. MRI might only identify an adenoma in 60-75% of patients and many adenomas are small. Therefore, inferior petrosal sinus sampling remains the gold standard for confirmation of ACTH secretion from a pituitary source. Initial treatment is usually transsphenoidal adenoma resection, but preoperative medical therapy is increasingly being used in some countries and regions. Other management approaches are required if Cushing disease persists or recurs following surgery, including medications to modulate ACTH or block cortisol secretion or actions, pituitary radiation, and/or bilateral adrenalectomy. All patients require lifelong surveillance for persistent comorbidities, clinical and biochemical recurrence, and treatment-related adverse effects (including development of treatment-associated hypopituitarism). In this Review, we discuss challenges in the management of Cushing disease in adults and provide information to guide clinicians when planning an integrated and individualized approach for each patient.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA.
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
| | - Elena V Varlamov
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
| | - Jose M Hinojosa-Amaya
- Division of Endocrinology, Department of Medicine, Hospital Universitario "Dr. José E. González", Autonomous University of Nuevo León, Monterrey, Mexico
| | - Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Shlomo Melmed
- Department of Medicine and Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Valentín-Goyco J, Liu J, Peng HM, Oommen J, Auchus RJ. Selectivity of osilodrostat as an inhibitor of human steroidogenic cytochromes P450. J Steroid Biochem Mol Biol 2023; 231:106316. [PMID: 37098354 PMCID: PMC10757358 DOI: 10.1016/j.jsbmb.2023.106316] [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: 02/01/2023] [Revised: 04/20/2023] [Accepted: 04/22/2023] [Indexed: 04/27/2023]
Abstract
Osilodrostat (LCI699) is a potent inhibitor of the human steroidogenic cytochromes P450 11β-hydroxylase (CYP11B1) and aldosterone synthase (CYP11B2). LCI699 is FDA-approved for the treatment of Cushing disease, which is characterized by chronic overproduction of cortisol. While phase II and III clinical studies have proven the clinical efficacy and tolerability of LCI699 for treating Cushing disease, few studies have attempted to fully assess the effects of LCI699 on adrenal steroidogenesis. To this end, we first comprehensively analyzed LCI699-mediated inhibition of steroid synthesis in the NCI-H295R human adrenocortical cancer cell line. We then studied LCI699 inhibition using HEK-293 or V79 cells stably expressing individual human steroidogenic P450 enzymes. Our studies using intact cells confirm the potent inhibition of CYP11B1 and CYP11B2 with negligible inhibition of 17-hydroxylase/17,20-lyase (CYP17A1) and 21-hydroxylase (CYP21A2). Furthermore, partial inhibition of the cholesterol side-chain cleavage enzyme (CYP11A1) was observed. To calculate the dissociation constant (Kd) of LCI699 with the adrenal mitochondrial P450 enzymes, we successfully incorporated P450s into lipid nanodiscs and carried out spectrophotometric equilibrium and competition binding assays. Our binding experiments confirm the high affinity of LCI699 to CYP11B1 and CYP11B2 (Kd ≈ 1 nM or less) and much weaker binding for CYP11A1 (Kd = 18.8 μM). Our results confirm the selectivity of LCI699 for CYP11B1 and CYP11B2 and demonstrate partial inhibition of CYP11A1 but not CYP17A1 and CYP21A2.
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Affiliation(s)
- Juan Valentín-Goyco
- Division of Metabolism, Endocrinology, & Diabetes, Department of Internal Medicine, United States; Department of Pharmacology, University of Michigan, Ann Arbor, MI 48109, United States; Veterans Affairs Medical Center, 2215 Fuller Road, Building 31, Room 225, Ann Arbor, MI 48105, United States
| | - Jiayan Liu
- Division of Metabolism, Endocrinology, & Diabetes, Department of Internal Medicine, United States
| | - Hwei-Ming Peng
- Division of Metabolism, Endocrinology, & Diabetes, Department of Internal Medicine, United States
| | - Jerry Oommen
- Department of Pharmacology, University of Michigan, Ann Arbor, MI 48109, United States
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, & Diabetes, Department of Internal Medicine, United States; Department of Pharmacology, University of Michigan, Ann Arbor, MI 48109, United States; Veterans Affairs Medical Center, 2215 Fuller Road, Building 31, Room 225, Ann Arbor, MI 48105, United States.
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10
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Poirier J, Bonnet-Serrano F, Thomeret L, Bouys L, Bertherat J. Prolonged adrenocortical blockade following discontinuation of Osilodrostat. Eur J Endocrinol 2023; 188:K29-K32. [PMID: 37300549 DOI: 10.1093/ejendo/lvad060] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/19/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Osilodrostat is the newest approved steroidogenic inhibitor drug for the treatment of hypercortisolism. In this article, we describe 3 patients who experienced a previously undescribed adverse event: a prolonged adrenocortical blockade following treatment cessation. METHODS Patient records showing a history of successful hypercortisolism control with Osilodrostat followed by at least 4 weeks of treatment interruption were reviewed. Patient characteristics and hormonal dosage were analyzed. RESULTS Persistence of adrenocortical blockade was found in 3 patients and lasted from 6 weeks to 9 months depending on patients. This phenomenon manifested in patients regardless of lower or higher daily Osilodrostat doses (2-10 mg) and total treatment duration did not seem to predict the severity of the blockade. CONCLUSION The finding of this previously undescribed side effect highlights the importance of continuing adrenal function monitoring after Osilodrostat interruption to prevent adrenal crisis in patients at risk.
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Affiliation(s)
- Jonathan Poirier
- Assistance Publique-Hôpitaux de Paris, Service d'Endocrinologie et Maladies Métaboliques -Hôpitaux universitaires Paris-Centre, Paris F-75014, France
| | - Fidéline Bonnet-Serrano
- Assistance Publique-Hôpitaux de Paris, UF d'hormonologie-Hôpitaux universitaires Paris-Centre, Paris F-75014, France
- Institut Cochin, Inserm U1016-CNRS UMR8104-Université Paris-Cité, Paris F-75014, France
| | - Louis Thomeret
- Institut Cochin, Inserm U1016-CNRS UMR8104-Université Paris-Cité, Paris F-75014, France
| | - Lucas Bouys
- Assistance Publique-Hôpitaux de Paris, Service d'Endocrinologie et Maladies Métaboliques -Hôpitaux universitaires Paris-Centre, Paris F-75014, France
- Assistance Publique-Hôpitaux de Paris, UF d'hormonologie-Hôpitaux universitaires Paris-Centre, Paris F-75014, France
- Institut Cochin, Inserm U1016-CNRS UMR8104-Université Paris-Cité, Paris F-75014, France
| | - Jérôme Bertherat
- Assistance Publique-Hôpitaux de Paris, Service d'Endocrinologie et Maladies Métaboliques -Hôpitaux universitaires Paris-Centre, Paris F-75014, France
- Assistance Publique-Hôpitaux de Paris, UF d'hormonologie-Hôpitaux universitaires Paris-Centre, Paris F-75014, France
- Institut Cochin, Inserm U1016-CNRS UMR8104-Université Paris-Cité, Paris F-75014, France
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Balakirouchenane D, Vasseur A, Bonnet-Serrano F, Choi M, Khoudour N, Puszkiel A, Groussin L, Vidal M, Declèves X, Bertherat J, Blanchet B. LC-MS/MS method for simultaneous quantification of osilodrostat and metyrapone in human plasma from patients treated for Cushing's Syndrome. J Pharm Biomed Anal 2023; 228:115316. [PMID: 36868030 DOI: 10.1016/j.jpba.2023.115316] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/13/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023]
Abstract
Steroidogenesis inhibitors such as metyrapone (MTP) and osilodrostat (ODT) have a key role in the medical treatment of endogenous Cushing's Syndrome (ECS). Both drugs are characterized by a high inter-individual variability of response and require a dose-titration period to achieve optimal control of cortisol excess. However, PK/PD data remain scarce for both molecules and a pharmacokinetically guided approach could help reaching eucortisolism more rapidly. We aimed to develop and validate a liquid chromatography tandem mass spectrometry (LC-MS/MS) method for the simultaneous quantification of ODT and MTP in human plasma. After addition of isotopically labeled internal standard (IS), plasma pretreatment consisted in protein precipitation with acetonitrile including 1% formic acid (v/v). Chromatographic separation was performed on Kinetex® HILIC (4.6 × 50 mm; 2.6 µm) analytical column with an isocratic elution during the 2.0-min run time. The method was linear from 0.5 to 250 ng/mL for ODT and from 2.5 to 1250 ng/mL for MTP. Intra- and inter-assay precisions were < 7.2%, with an accuracy ranging from 95.9% to 114.9%. The IS-normalized matrix effect ranged from 106.0% to 123.0% (ODT) and from 107.0% to 123.0% (MTP) and the range of the IS-normalized extraction recovery was 84.0-101.0% for ODT and 87.0-101.0% for MTP. The LC-MS/MS method was successfully applied in patients' plasma samples (n = 36), trough concentration of ODT and MTP ranged from 2.7 ng/mL to 8.2 ng/mL and from 10.8 ng/mL to 27.8 ng/mL, respectively. Incurred sample reanalysis exhibits less than 14% difference between the first and the second analysis for both drugs. This accurate and precise method, meeting all validation criteria, can therefore be used for plasma drug monitoring of ODT and MTP within the dose-titration period.
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Affiliation(s)
- David Balakirouchenane
- Department of Pharmacokinetics and Pharmacochemistry, Cochin Hospital, AP-HP, CARPEM, 75014 Paris, France; Université Paris Cité, UMR8038 CNRS, U1268 INSERM, Faculty of Pharmacy, CARPEM, 75006 Paris, France.
| | - Axelle Vasseur
- Department of Pharmacokinetics and Pharmacochemistry, Cochin Hospital, AP-HP, CARPEM, 75014 Paris, France
| | - Fidéline Bonnet-Serrano
- Hormonal Biology Laboratory, Cochin Hospital, AP-HP, 75014 Paris, France; Université Paris Cité, Institut Cochin, INSERM U1016, CNRS UMR8104, 75006 Paris, France
| | - Minna Choi
- Department of Pharmacokinetics and Pharmacochemistry, Cochin Hospital, AP-HP, CARPEM, 75014 Paris, France
| | - Nihel Khoudour
- Department of Pharmacokinetics and Pharmacochemistry, Cochin Hospital, AP-HP, CARPEM, 75014 Paris, France
| | - Alicja Puszkiel
- Department of Pharmacokinetics and Pharmacochemistry, Cochin Hospital, AP-HP, CARPEM, 75014 Paris, France; Université Paris Cité, INSERM UMR-S1144, Faculty of Pharmacy, 75006 Paris, France
| | - Lionel Groussin
- Université Paris Cité, Institut Cochin, INSERM U1016, CNRS UMR8104, 75006 Paris, France; Department of Endocrinology, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Michel Vidal
- Department of Pharmacokinetics and Pharmacochemistry, Cochin Hospital, AP-HP, CARPEM, 75014 Paris, France; Université Paris Cité, UMR8038 CNRS, U1268 INSERM, Faculty of Pharmacy, CARPEM, 75006 Paris, France
| | - Xavier Declèves
- Department of Pharmacokinetics and Pharmacochemistry, Cochin Hospital, AP-HP, CARPEM, 75014 Paris, France; Université Paris Cité, INSERM UMR-S1144, Faculty of Pharmacy, 75006 Paris, France
| | - Jérôme Bertherat
- Université Paris Cité, Institut Cochin, INSERM U1016, CNRS UMR8104, 75006 Paris, France; Department of Endocrinology, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Benoit Blanchet
- Department of Pharmacokinetics and Pharmacochemistry, Cochin Hospital, AP-HP, CARPEM, 75014 Paris, France; Université Paris Cité, UMR8038 CNRS, U1268 INSERM, Faculty of Pharmacy, CARPEM, 75006 Paris, France
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Castinetti F. How best to monitor the specific side effects of medical treatments of Cushing's disease. Best Pract Res Clin Endocrinol Metab 2022; 36:101718. [PMID: 36435719 DOI: 10.1016/j.beem.2022.101718] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The first-line treatment of Cushing's disease is transsphenoidal surgery. Medical treatment of Cushing's disease can be considered in several situations: as a presurgical treatment in patients with severe comorbidities, when surgery fails, or while waiting for the maximal efficacy of radiation techniques. Several modalities of medical treatment are possible, from adrenal-targeting drugs (steroidogenesis inhibitors) to pituitary-targeting drugs (somatostatin receptor ligand pasireotide or the dopamine agonist cabergoline), or even drugs that antagonize the glucocorticoid receptor (mifepristone). Given the morbidities associated with hypercortisolism, and the fact that medical treatment can be delivered on a long-term basis, it is important to obtain eucortisolism and to monitor the drug effectively. The efficacy of these drugs will not be detailed in this review, nor their roles in the therapeutic algorithm of Cushing's disease. This review will rather focus specifically on adverse events associated with these drugs (ketoconazole, levoketoconazole, metyrapone, osilodrostat, pasireotide, cabergoline and mifepristone), and the way in which to monitor and treat them, based on retrospective studies and the most recently published prospective studies.
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Affiliation(s)
- Frederic Castinetti
- Aix Marseille University, Marseille Medical Genetics, INSERM U1251, MarMaRa Institute, Department of endocrinology, La Conception Hospital, Assistance Publique Hopitaux de Marseille, Marseille, France.
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Nowotny HF, Braun L, Vogel F, Bidlingmaier M, Reincke M, Tschaidse L, Auer MK, Lottspeich C, Wudy SA, Hartmann MF, Hawley J, Adaway JE, Keevil B, Schilbach K, Reisch N. 11-Oxygenated C19 steroids are the predominant androgens responsible for hyperandrogenemia in Cushing's disease. Eur J Endocrinol 2022; 187:663-673. [PMID: 36074938 PMCID: PMC9578081 DOI: 10.1530/eje-22-0320] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/08/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Symptoms of hyperandrogenism are common in patients with Cushing's disease (CD), yet they are not sufficiently explained by androgen concentrations. In this study, we analyzed the contribution of 11-oxygenated C19 steroids (11oxC19) to hyperandrogenemia in female patients with CD. METHODS We assessed saliva day profiles in females with CD pre (n = 23) and post (n = 13) successful transsphenoidal surgery, 26 female controls, 5 females with CD treated with metyrapone and 5 treated with osilodrostat for cortisol, cortisone, androstenedione (A4), 11-hydroxyandrostenedione (11OHA4), testosterone (TS), 11-ketotestosterone (11KT), as well as metabolites of classic and 11-oxygenated androgens in 24-h urine. In addition, morning baseline levels of gonadotropins and estradiol, sex hormone-binding globulin, cortisol and dehydroepiandrosterone sulfate (DHEAS) in serum and adrenocorticotrophic hormone in plasma in patients and controls were investigated. RESULTS Treatment-naïve females with CD showed a significantly elevated area under the curve of 11OHA4 and 11KT in saliva throughout the day compared to controls (11OHA4 mean rank difference (mrd) 18.13, P = 0.0002; 11KT mrd 17.42; P = 0.0005), whereas A4, TS and DHEAS were comparable to controls. Gonadotropin concentrations were normal in all patients with CD. After transsphenoidal surgery, 11oxC19 and their metabolites dropped significantly in saliva (11OHA4 P < 0.0001; 11KT P = 0.0010) and urine (11-oxo-androsterone P = 0.0011; 11-hydroxy-androsterone P < 0.0001), treatment with osilodrostat and metyrapone efficaciously blocked 11oxC19 synthesis. CONCLUSION Hyperandrogenemia in CD is predominantly caused by excess of 11oxC19 steroids.
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Affiliation(s)
- Hanna F Nowotny
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Leah Braun
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Frederick Vogel
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Martin Bidlingmaier
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Lea Tschaidse
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Matthias K Auer
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Christian Lottspeich
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Stefan A Wudy
- Division of Pediatric Endocrinology & Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus-Liebig-University, Giessen, Germany
| | - Michaela F Hartmann
- Division of Pediatric Endocrinology & Diabetology, Laboratory for Translational Hormone Analysis in Pediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus-Liebig-University, Giessen, Germany
| | - James Hawley
- Department of Clinical Biochemistry, Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Joanne E Adaway
- Department of Clinical Biochemistry, Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Brian Keevil
- Department of Clinical Biochemistry, Manchester University Foundation NHS Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Katharina Schilbach
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
| | - Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, Munich, Germany
- Correspondence should be addressed to N Reisch;
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Gilis-Januszewska A, Bogusławska A, Rzepka E, Ziaja W, Hubalewska-Dydejczyk A. Individualized medical treatment options in Cushing disease. Front Endocrinol (Lausanne) 2022; 13:1060884. [PMID: 36531477 PMCID: PMC9755355 DOI: 10.3389/fendo.2022.1060884] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/17/2022] [Indexed: 12/05/2022] Open
Abstract
Cushing disease (CD) is caused by a pituitary tumor which oversecretes adrenocorticotropic hormone (ACTH). It is a serious endocrine disease associated with increased mortality and impaired quality of life. The management of CD remains challenging. Although transsphenoidal surgery is the treatment of choice in most cases, in approximately half of CD patients, second or third-line treatment options are needed. Currently, new medical therapies are available which target adrenal steroidogenesis, pituitary somatostatin and dopamine receptors, and glucocorticoid receptors. Selection of which medication to use should be individualized and is determined by many factors including severity of the disease, possible side effects, patients preferences and local availability. The aim of this article is to describe currently available medical therapy to help clinicians individualize the treatment options in the context of recently updated Pituitary Society recommendations.
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