Experts recommend tumor removal as first-line treatment for Cushing’s syndrome

Posted on July 30, 2015 by MaryO

The Endocrine Society today issued a Clinical Practice Guideline (CPG) on strategies for treating Cushing’s syndrome, a condition caused by overexposure to the hormone cortisol.

The CPG, entitled “Treatment of Cushing’s Syndrome: An Endocrine Society Clinical Practice Guideline,” was published online and will appear in the August 2015 print issue of the Journal of Clinical Endocrinology and Metabolism (JCEM), a publication of the Endocrine Society.

Cushing’s syndrome occurs when a person has excess cortisol in the blood for an extended period, according to the Hormone Health Network. When it is present in normal amounts, cortisol is involved in the body’s response to stress, maintains blood pressure and cardiovascular function, keeps the immune system in check, and converts fat, carbohydrates and proteins into energy. Chronic overexposure to the hormone can contribute to the development of cardiovascular disease, infections and blood clots in veins.

People who take cortisol-like medications such as prednisone to treat inflammatory conditions, including asthma and rheumatoid arthritis, can develop Cushing’s syndrome. The high cortisol levels return to normal when they stop taking the medication. This is called exogenous Cushing’s syndrome.

In other cases, tumors found on the adrenal or pituitary glands or elsewhere in the body cause the overproduction of cortisol and lead to the development of Cushing’s syndrome. The Clinical Practice Guidelines focus on this form of the condition, known as endogenous Cushing’s syndrome.

“People who have active Cushing’s syndrome face a greater risk of death – anywhere from nearly twice as high to nearly five times higher – than the general population,” said Lynnette K. Nieman, MD, of the National Institutes of Health’s Eunice Kennedy Shriver National Institute of Child Health and Human Development in Bethesda, MD, and chair of the task force that authored the guideline. “To reduce the risk of fatal cardiovascular disease, infections or blood clots, it is critical to identify the cause of the Cushing’s syndrome and restore cortisol levels to the normal range.”

In the CPG, the Endocrine Society recommends that the first-line treatment for endogenous Cushing’s syndrome be the removal of the tumor unless surgery is not possible or unlikely to address the excess cortisol. Surgical removal of the tumor is optimal because it leaves intact the hypothalamic-pituitary-adrenal axis, which is integral to the body’s central stress response.

Other recommendations from the CPG include:

  • Tumors should be removed by experienced surgeons in the following situations:— A tumor has formed on one or both of the two adrenal glands.— A tumor that secretes adrenocorticotropic hormone (ACTH) – the hormone that signals the adrenal glands to produce cortisol – has formed somewhere in the body other than the adrenal or pituitary gland.

    — A tumor has formed on the pituitary gland itself.

  • Patients who continue to have high levels of cortisol in the blood after surgery should undergo additional treatment.
  • People who had an ACTH-producing tumor should be screened regularly for the rest of their lives for high cortisol levels to spot recurrences.
  • If patients’ cortisol levels are too low following surgery, they should receive glucocorticoid replacement medications and be educated about adrenal insufficiency, a condition where the adrenal glands produce too little cortisol. This condition often resolves in 1-2 years.
  • Morning cortisol and/or ACTH stimulation tests, or insulin-induced hypoglycemia, can be used to test for the recovery of the hypothalamic-pituitary-adrenal axis in people who have low cortisol levels after surgery. Once the tests results return to normal, glucocorticoid replacement can be stopped.
  • People who have undergone pituitary surgery should be re-evaluated for other pituitary hormone deficiencies during the post-operative period.
  • Patients who have a pituitary tumor and have undergone surgery to remove both adrenal glands should be regularly evaluated for tumor progression using pituitary MRIs and tests for ACTH levels.
  • Radiation therapy may be used to treat a pituitary tumor, especially if it is growing. While awaiting the effect of radiation, which may take months to years, treatment with medication is advised.
  • To assess the effect of radiation therapy, the patient’s cortisol levels should be measured at 6- to 12-month intervals.
  • Medications may be used to control cortisol levels as a second-line treatment after surgery for a pituitary gland tumor, as a primary treatment for ACTH-secreting tumors that have spread to other parts of the body or suspected ACTH-secreting tumors that cannot be detected on scans. Medications also can be used as adjunctive treatment to reduce cortisol levels in people with adrenal cortical carcinoma, a rare condition where a cancerous growth develops in the adrenal gland.
  • People with Cushing’s syndrome should be treated for conditions associated with the disease, such as cardiovascular disease risk factors, osteoporosis and psychiatric symptoms.
  • Patients should be tested for recurrence throughout their lives except in cases where the person had a benign adrenal tumor removed.
  • Patients should undergo urgent treatment within 24 to 72 hours of detecting excess cortisol if life-threatening complications such as serious infection, pulmonary thromboembolism, cardiovascular complications and acute psychosis are present.

More information: The Hormone Health Network offers resources on Cushing’s syndrome at www.hormone.org/questions-and-answers/2012/cushing-syndrome

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Hydrocortisone Replacement Patient Information

Posted on July 26, 2015 by MaryO

steroids
Patient Information

What is Hydrocortisone?
Hydrocortisone is a steriod hormone produced by the adrenal gland.  It regulates many of the bodies functions and is essential for life.
Hydrocortisone is taken as a replacement for the natural hormone where this is deficient, either because of pituitary deficieny of ACTH (the hormone that stimulates the production of hydrocortisone by the adrenal gland) or failure of hydrocortisone production by the adrenal gland.

How do I take it?
A common dose is 15-20mg orally split over two or three times daily, and depending on your individual Endocrinologist’s recommendations, e.g., 10mg before rising, 5mg at mid-day and 5mg at 4 p.m.

When would I need to take more hydrocortisone?

If you become ill then the body would naturally increase the output of steroid from your adrenals.  Therefore if you are taking replacement steroid (hydrocortisone) it is essential to mimic the natural response by increasing your dose appropriately.

How can I let others know I take replacement hydrocortisone?
When you are prescribed your medication you will be given a ‘blue steroid card’ from the hospital to carry.  You should also purchase and wear a medical necklace or bracelet, such as MedicAlert, to show your Cortisol replacement therapy.

Emergency Injections – should I have these at home?
It is advisable for all patients on hydrocortisone replacement to have a 100mg injection pack at home and for them or their partners to be taught how to administer it.  If you don’t have one of these already, you can ask your GP or endocrinologist if they will prescribe this for you.  Please check regularly that these preparations are not expired.  Some endocrine clinics will help to show you how to inject in an emergency.

When do I know that I would need an emergency injection?

If you cannot absorb your tablets, or your usual replacement wasn’t sufficient for an acute shock or illness, then gradually or perhaps quite quickly you would feel weak, sickly and light-headed.

Recommendations for changes in oral dose ‘The Sick Rules’
If you become unwell you should take additional hydrocortisone. The amount depends on how unwell you are and the type of illness. The pituitary foundation provides some sensible examples:

If a patient is unwell they should take additional hydrocortisone. The amount depends on how unwell they are and the type of illness. Some examples:

Situtation  Increase in dose Duration  Emergency?
Cold without fever   none
Fever, flu, infection         double dose duration of illness see GP after 48 hours
Vomiting > once, diarrhoea and severe illness Emergency 100mg injection if extra dose of 10-20mg cannot be kept down restart usual dose once stable Phone GP or go to A&E. Administer injection prior to this if emergency pack available (but still seek help)
Minor surgical procedure e.g. tooth extraction     20mg hydrocortisone before procedure resume on usual dose immediately afterward
Minor operation e.g. hernia repair  100mg im every 6 hours for 24 hours  resume on usual dose immediately afterward
Major operation e.g. abdomen or chest 100mg im injection every 6 hours for 24 -72 hours and eating and drinking reduce rapidly to usual dose tell the surgeon and anaesthetist before the operation
Endoscopy Double the dose the day before during bowel prep. For colonoscopy 100mg im before procedure take usual dose on the morning of the procedure drink lots of water to prevent dehydration. Inform your doctor.
Cystoscopy Double dose on the day of procedure. resume as normal inform your doctor.
Severe shock e.g. bereavment or road traffic accident 20mg as tablet or 100mg intramuscular injection See GP or hospital for further advice Sudden and severe shock may be classed as an emergency – seek advice
Long haul flight > 12 hours double dose on the day of the flight extra dose every 6-8 hours when the day is legnthened. Usual regimen in timing with sleep / wake cycle when day is shortened. Speak to your consultant before travel.
General stress, exams etc  not usually required ask GP if concerned

How do I cope if I’m travelling away from home?

You should travel with a 100mg injection kit  in case of emergency.  This injection should be placed in a small cool bag, labelled with your name and kept with you at all times during your journey. You should ask your GP or endocrinologist for a letter about your injection kit, medication and your doses prescribed.  This letter is essential to travel through security checks and will be helpful should you become unwell and have to see a doctor. It is wise to take an extra two weeks supply of hydrocortisone tablets with you in case you need to increase your usual dose whilst away.  All medication should be kept in your hand luggage.

Printable patient information

From http://www.imperialendo.com/for-doctors/hydrocortisone-replacement/hydrocortisone-replacement-patient-information

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Crooke’s changes common in patients with Cushing’s syndrome, high cortisol production

Posted on July 9, 2015 by MaryO
Oldfield EH, et al. J Clin Endocrinol Metab. 2015;doi:10.1210/JC.2015-2493.
July 8, 2015

 

Evidence of Crooke hyaline changes in the pituitary gland points to a higher likelihood of Cushing’s syndrome in adults, with the changes in basophil cells occurring in 75% to 80% of patients with the hormonal disorder, according to research in The Journal of Clinical Endocrinology & Metabolism.

In a retrospective review of hospital patient records from adults with Cushing’s syndrome who underwent pituitary surgery, researchers also found that a higher degree of cortisol production, as well as exposure to excess glucocorticoids, are often associated with Crooke’s changes in adults.

“The presence of Crooke’s changes is a clear indication of the presence of Cushing’s syndrome, although the absence of Crooke’s changes does not exclude it,” the researchers wrote.

Edward H. Oldfield, MD, FACS, of the department of neurological surgery at University of Virginia Health System, and colleagues analyzed electronic hospital data from 213 consecutive patients with Cushing’s syndrome who received pituitary surgery between 2008 and March 2014. Researchers reviewed analysis of the normal pituitary tissue included with the specimens obtained at surgery, as well as cortisol production measured by 24-hour urine.

Within the cohort, Crooke’s changes occurred in 74% of patients; Crooke’s changes occurred in 81% of patients with an adrenocorticotropic hormone tumor.

Researchers also found that 91% of patients with an adrenocorticotropic hormone-producing tumor and a urinary free cortisol test at least fourfold the upper limit of normal had evidence of Crooke’s changes vs. 74% of patients with a urine cortisol amount that was less than fourfold the upper limit of normal (P = .008).

“Our results clearly demonstrate a correlation between the degree of cortisol production and the presence of Crooke’s changes,” the researchers wrote. “Patients with cortisol production exceeding fourfold upper limit almost all had Crooke’s changes.”

Researchers said study results indicate that the presence of Crooke’s changes may be used to indicate that a patient has Cushing’s syndrome following a pituitary surgery in which no tumor is found.

“However, the absence of Crooke’s changes does not reliably indicate the absence of Cushing’s syndrome, as 19% of patients with a proven [adrenocorticotropic hormone-producing tumor] did not have Crooke’s changes,” the researchers wrote. – by Regina Schaffer

Disclosure: The researchers report no relevant financial disclosures.

From http://www.healio.com/endocrinology/adrenal/news/online/%7B838a3557-f284-4fda-b93d-73dbb4823667%7D/crookes-changes-common-in-patients-with-cushings-syndrome-high-cortisol-production

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First Patient Dosed in IST of CDK Inhibitor Seliciclib in Cushing’s Disease, a Serious Endocrine Disorder

Posted on July 2, 2015 by MaryO
Source:Cyclacel Pharmaceuticals, Inc.

BERKELEY HEIGHTS, N.J., July 2, 2015 (GLOBE NEWSWIRE) — Cyclacel Pharmaceuticals, Inc. (NASDAQ:CYCC) (NASDAQ:CYCCP) (Cyclacel or the Company), a biopharmaceutical company developing oral therapies that target the various phases of cell cycle control for the treatment of cancer and other serious disorders today announced that the first patient has been dosed in an investigator sponsored trial (IST) of the Company’s oral cyclin dependent kinase (CDK) inhibitor seliciclib in Cushing’s disease (CD)1. Clinicians at Cedars-Sinai, Los Angeles, were awarded a grant from The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) to evaluate seliciclib, a CDK2/9 inhibitor currently in clinical development to treat certain cancers, as a potential therapy for CD.

“Cushing’s disease is a serious debilitating endocrine disorder with limited treatment options for patients,” said Shlomo Melmed, M.D., Director of the Burns and Allen Research Institute, Principal Investigator and Dean of the Medical Faculty at Cedars-Sinai, Los Angeles. “We believe that seliciclib is unique among clinical stage CDK inhibitors in its potential effectiveness to treat this disease. Its mechanism of action has a dual effect as it impacts tumor growth by decreasing the levels and activity of cyclin E, as well as inhibiting ACTH production. If our trial with seliciclib proves successful, it could lead to dramatically improved treatment outcomes for patients with Cushing’s disease.”

CD is an endocrine disorder caused by adrenocorticotropin (ACTH)-producing pituitary tumors, often leading to obesity, diabetes, hypertension, osteoporosis and increased risk of death if inadequately controlled. Cell cycle dysregulation is a common feature of pituitary tumors, including upregulation of cyclin E, specifically seen in tumors of the corticotroph lineage, such as in CD. Dr. Melmed and Dr. Ning-Ai Liu have previously published preclinical proof-of-concept data showing that seliciclib is uniquely effective amongst CDK inhibitors in resolving the disease, with dual effects on pituitary growth and ACTH production2.

The trial is a Phase 2 proof-of-concept, open-label, single arm study to assess the safety and efficacy of seliciclib in CD. Sixteen patients with de novo, persistent or recurrent CD will receive seliciclib for 4 weeks prior to standard-of-care treatment. The primary objective is to establish the efficacy of seliciclib on normalizing urinary free cortisol levels in patients with CD.

About Cushing’s disease

CD is a rare endocrine, orphan disorder with estimated US prevalence of approximately 20,000. It is the most common cause of endogenous hypercortisolism, which predisposes patients to central obesity, diabetes, hypertension, osteoporosis and substantially increases their risk of infection, thrombosis and psychiatric disorders. If inadequately controlled, CD is fatal with mortality rate four-fold-higher than that of age- and sex-matched controls and median survival of 4.6 years. The leading cause of death in CD is cardiovascular disease. CD remains an unmet medical need despite available therapies.

About seliciclib and its mechanism of action in Cushing’s disease

Seliciclib, an orally-available CDK2/9 inhibitor, has been evaluated to date in approximately 450 patients and is currently being explored in combination with Cyclacel’s orally-available sapacitabine in patients with solid tumors.

Seliciclib has been shown in preclinical models to be uniquely effective amongst other CDK inhibitors. Seliciclib was subsequently shown, in mouse corticotroph tumor cells in vitro, to cause cell cycle arrest, accompanied by decreases in cyclin E levels, increased p27Kip1, p57Kip2 and p21Cip1 expression, and reduced Thr821 phosphorylation of the retinoblastoma (Rb) protein. Rb is reportedly a site phosphorylated by CDK2. In addition, ACTH concentrations in cell supernatant were also decreased by seliciclib, suggesting a dual impact of the compound on corticotroph tumorigenesis. In vivo, oral administration of seliciclib led to a 50% reduction in tumor weight, and consistent with in vitro observations, reduced plasma ACTH levels, serum cortisol levels and tumor PCNA staining.

1. ClinicalTrials.gov (NCT02160730).

2. Liu, N-A., Jiang, H., Ben-Shlomo, A., Wawrowsky, K. Fan, X-M., Lin, S. and Melmed, S. (2011) Targeting zebrafish and murine pituitary corticotroph tumours with a cyclin-dependent kinase (CDK) inhibitor. PNAS doi: 10.1073/pnas.1018091108

About Cyclacel Pharmaceuticals, Inc.

Cyclacel is a biopharmaceutical company developing oral therapies that target the various phases of cell cycle control for the treatment of cancer and other serious diseases. Sapacitabine, Cyclacel’s most advanced product candidate, is the subject of SEAMLESS, a Phase 3 trial, which has completed enrollment and is being conducted under an SPA with the FDA as front-line treatment for acute myeloid leukemia (AML) in the elderly, and other indications including myelodysplastic syndromes (MDS). Cyclacel’s pipeline includes an oral regimen of seliciclib in combination with sapacitabine in a Phase 1 study of patients with Homologous Recombination (HR) repair-deficient breast, ovarian and pancreatic cancers, including gBRCA positive tumors, and CYC065, a novel CDK2/9 inhibitor, with potential utility in both hematological malignancies and solid tumors. Cyclacel’s strategy is to build a diversified biopharmaceutical business focused in hematology and oncology based on a development pipeline of novel drug candidates. Please visit www.cyclacel.com for more information.

Forward-looking Statements

This news release contains certain forward-looking statements that involve risks and uncertainties that could cause actual results to be materially different from historical results or from any future results expressed or implied by such forward-looking statements. Such forward-looking statements include statements regarding, among other things, the efficacy, safety and intended utilization of Cyclacel’s product candidates, the conduct and results of future clinical trials, plans regarding regulatory filings, future research and clinical trials and plans regarding partnering activities. Factors that may cause actual results to differ materially include the risk that product candidates that appeared promising in early research and clinical trials do not demonstrate safety and/or efficacy in larger-scale or later clinical trials, trials may have difficulty enrolling, Cyclacel may not obtain approval to market its product candidates, the risks associated with reliance on outside financing to meet capital requirements, and the risks associated with reliance on collaborative partners for further clinical trials, development and commercialization of product candidates. You are urged to consider statements that include the words “may,” “will,” “would,” “could,” “should,” “believes,” “estimates,” “projects,” “potential,” “expects,” “plans,” “anticipates,” “intends,” “continues,” “forecast,” “designed,” “goal,” or the negative of those words or other comparable words to be uncertain and forward-looking. For a further list and description of the risks and uncertainties the Company faces, please refer to the Company’s most recent Annual Report on Form 10-K and other periodic and other filings Cyclacel files with the Securities and Exchange Commission and are available at www.sec.gov. Such forward-looking statements are current only as of the date they are made, and Cyclacel assumes no obligation to update any forward-looking statements, whether as a result of new information, future events or otherwise.

© Copyright 2015 Cyclacel Pharmaceuticals, Inc. All Rights Reserved. The Cyclacel logo and Cyclacel® are trademarks of Cyclacel Pharmaceuticals, Inc.

Cyclacel Pharmaceuticals, Inc.

Company:
Paul McBarron, (908) 517-7330, 
Investor Relations:
Russo Partners LLC, Robert Flamm, (212) 845-4226

– See more at: http://globenewswire.com/news-release/2015/07/02/749361/10140470/en/First-Patient-Dosed-in-IST-of-CDK-Inhibitor-Seliciclib-in-Cushing-s-Disease-a-Serious-Endocrine-Disorder.html#sthash.KgdD65N9.dpuf

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ALD403 (migraine drug) and ALD1613 (for Cushing’s disease)

Posted on July 2, 2015 by MaryO

As it moves into crucial Phase 3 drug trials for its flagship migraine treatment, Bothell-based Alder Biopharmaceuticals (Nasdaq: ALDR) is looking to raise a lot of cash.

Alder is offering up to $200 million shares of its common stock, according to SEC filings.

The company plans to use the money to develop its drugs ALD403 (its migraine drug) and ALD1613 (for Cushing’s disease), conduct clinical trials and commercialize these drugs. Funds will also go toward “general corporate purposes,” which might include the acquisition or licensing of other products, businesses or technologies, according to those filings.

From http://www.bizjournals.com/seattle/blog/health-care-inc/2015/06/alder-biopharmaceuticals-sets-out-to-raise-200m-to.html

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