Genetics Research Demystifies Fatal Glandular Disease (Cushing’s)

Researchers at Tokyo Institute of Technology have identified genetic mutations responsible for Cushing’s disease, a potentially fatal glandular condition.

Symptoms of Cushing’s disease include weight gain, muscular weakness, mood and reproductive problems, and if untreated patients can die from the resulting infections and cardiovascular problems. Although first described by Harvey Cushing back in 1932, as Martin Reincke and colleagues in Germany and Japan point out in their latest Nature Genetics report, the mechanism causing the disease “has remained obscure since its first description”. Now by sequencing the tissues responsible the researchers have identified clusters of mutations that cause Cushing’s disease as well as how these mutations bring the disease into effect.

The disease arises from benign tumours on glandular pituitary tissue – corticotroph adenomas – which excessively secrete the hormone adrenocorticotropin (ACTH). Previous studies sought to identify mutations that might cause the disease through sequencing candidate genes and microarray studies, but these made little progress. Instead, the researchers applied a particular type of DNA sequencing known as ‘exome sequencing’ to the pituitary corticotroph adenoma.

The collaboration included researchers from Ludwig-Maximilians-Universität Munich, the University of Würzburg, the Max Planck Institute, the Helmholtz-Center Munich, Universität Hamburg , Universität Erlangen in Germany and Tokyo Institute of Technology in Japan. The research team exome-sequenced samples from 10 patients with Cushing’s disease and noticed a small number of protein altering mutations in the adenoma tissue. The researchers further identified the gene harbouring the mutations as ubiquitin-specific protease 8 (USP8), and were able to pinpoint the region of USP8 prone to mutation in Cushing’s disease.

Previous research observations of Cushing’s disease have highlighted strong expression of another gene, epidermal growth factor receptor (EGFR). By examining EGFR in HeLa cells expressing USP8, the researchers behind this latest research demonstrated that this was the result of USP8 mutations inhibiting downregulation of EGFR.

The researchers conclude that their results “not only identify the first of so far enigmatic driver mutations in corticotroph adenomas but also elucidate a novel mechanism by which the EGFR pathway is constitutively activated in human tumours.” Further research will be required for a more detailed understanding of genetic onset of the disease.

Reference

Martin Reincke etal, Nature Genetics, Advance Online Publication 9 December 2014

Background

Cushing’s disease adenomas

The adenomas that cause Cushing’s disease are benign tumours of epithelial tissue that grow on the pituitary gland. The tumours comprise corticotroph cells, a hormone producing cell that secretes asdrenocorticotropin (ACTH). While the pathological role of ACTH hypersecretion was already known, previous studies had been unable to identify the molecular mechanisms behind these hormone processes that lead to Cushing’s disease.

Exome sequencing

When RNA is processed by splicing, parts of the RNA – the introns – are removed. The remaining RNA, the exons, are collectively referred to as the exome.

While DNA sequencing finds the sequence of proteins for the whole DNA, by focusing on the exons, exome sequencing provides information specifically on the protein-coding genes. Changes to these genes are more likely to have significant ramifications on the organism.

Ubiquitination and USP8

Ubiquitination is a reversible protein modification process that occurs by means of a small protein called ubitquitin, which is found in all eukaryotic cells (cells containing a nucleus and other structures enclosed within a membrane). Ubiquitination regulates the fate and function of proteins.

USP8 is a ubiquitin-specific protease enzyme that can remove ubitquitin molecules from target proteins. The discovery of a high number of mutations in the USP8 gene in Cushing’s disease prompted the researchers to make further investigations on the mutant USP8 enzymes at biochemical and cellular levels. From these studies they could identify the mechanisms behind the mutations and the effect on epidermal growth factor receptor (EGFR), a gene that mediates the synthesis of an ACTH precursor.

Figure (click to view larger)

corticotroph

Figure caption: Schematic representation showing the proposed mechanisms how USP8 mutations lead to increased ACTH secretion and tumorigenesis in corticotroph.

Further information

Yukiko Tokida, Asuka Suzuki

Center for Public Affairs and Communications, Tokyo Institute of Technology

2-12-1, Ookayama, Meguro-ku, Tokyo 152-8550, Japan

E-mail: media@jim.titech.ac.jp

URL: http://www.titech.ac.jp/english/

Tel: +81-3-5734-2975     Fax: +81-3-5734-3661

About Tokyo Institute of Technology

As one of Japan’s top universities, Tokyo Institute of Technology seeks to contribute to civilization, peace and prosperity in the world, and aims at developing global human capabilities par excellence through pioneering research and education in science and technology, including industrial and social management. To achieve this mission, we have an eye on educating highly moral students to acquire not only scientific expertise but also expertise in the liberal arts, and a balanced knowledge of the social sciences and humanities, all while researching deeply from basics to practice with academic mastery. Through these activities, we wish to contribute to global sustainability of the natural world and the support of human life.

 

Source: Tokyo Institute of Technology, Center for Public Affairs and Communications: http://www.healthcanal.com/genetics-birth-defects/58155-tokyo-institute-of-technology-research-genetics-research-demystifies-fatal-glandular-disease.html

Cushings Syndrome/Disease can be healed or cured through change in diet or exercise

Myth: Cushing’s Syndrome/Disease can be healed or cured through change in diet or exercise.

myth-busted

Fact: NO! Caloric intake or lack of exercise has NO impact on weight gain and/ or loss in persons with Cushing’s.

Saying that someone “cheated” on their diet may seem reasonable to some as a reason for weight gain but I assure you that a candy bar or a piece of pie does not make a person with Cushing’s gain weight or get sick. Excess cortisol is the reason for Cushing’s symptoms. Treating the disease is the only way to alleviate symptoms.

The first line of treatment with the highest rate of remission is currently surgery to remove the tumor (s) from the pituitary, adrenal gland, or ectopic source.

Cushing’s Myths and Facts

Dr. Karen Thames has been sharing these on her Facebook Page, Battleground Diagnosis: The War to Survive Cushing’s Disease.

She has graciously given me permission to share them here and in the CushieWiki and on the Cushing’s Help message boards.

Find these pages here, under the Myths and Facts category.

Thanks, Karen!

EU Looks to Okay Ketoconazole for Use in Cushing’s Syndrome

The Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) has recommended granting a marketing authorization for ketoconazole (Ketoconazole HRA; Laboratoire HRA Pharma) for the treatment of Cushing’s syndrome, a rare hormonal disorder sometimes called hypercortisolism.

Cushing’s syndrome is characterized by an excess of the hormone cortisol in the blood, which may be caused by a tumor. Treatment options currently available in the European Union include surgery to remove the tumor responsible for the high cortisol levels and radiotherapy, as well as several medicines that reduce the production of cortisol.

But pharmacological options remain very limited, and there is an unmet medical need for additional treatments, especially when surgery fails or for patients who cannot undergo surgery or take other medications. For this reason, the EMA’s CHMP evaluated the medicine under expedited review.

The opinion adopted by the CHMP at its September 2014 meeting is an intermediary step on Ketoconazole HRA’s path to patient access.

The CHMP opinion will now be sent to the European Commission for the adoption of a decision on an EU-wide marketing authorization. Once a marketing authorization has been granted, decisions about price and reimbursement will then take place at the level of each member state considering the potential role/use of this medicine in the context of the national health system of that country.

The recommendation is that Ketoconazole HRA is to be prescribed only by physicians specialized in treating Cushing’s syndrome, as the dosing needs to be individualized for each patient.

This is because oral ketoconazole was previously suspended in the European Union for the indication it was first approved for, fungal infections, due to risk for liver injury. The US Food and Drug Administration (FDA) also decreed, at the same time, that doctors should no longer prescribe ketoconazole tablets as a first-line therapy for any fungal infection, for the same reason.

Information will be sent to healthcare professionals to allow them to advise patients and prescribe the medicine safely and effectively.

A Medicine Used Off-Label for More than 30 Years

Doctors have used ketoconazole to treat Cushing’s syndrome for more than 30 years, although it has never been authorized for this indication in the European Union. The drug is also frequently used off-label in the United States and elsewhere for this purpose.

The CHMP’s recommendation builds on information from published literature and documented off-label use in clinical practice.

At the time of the suspension of ketoconazole for fungal infections, healthcare professionals and patients were concerned that ketoconazole would no longer be available for patients with Cushing’s syndrome.

The CHMP therefore reviewed Ketoconazole HRA through accelerated assessment to facilitate patients’ access to a fully authorized medicine as soon as possible with evidence-based information for patients and doctors.

When assessing Ketoconazole HRA for the treatment of Cushing’s syndrome, the CHMP considered that “in this rare and potentially life-threatening condition, the medicine’s benefits are greater than its risks, which can be manageable in clinical practice by specific measures mitigating the risk of liver toxicity, including close monitoring of the patients’ liver function.”

In 2012, it was estimated that the disease affected approximately 46,000 people in the European Union. Cushing’s syndrome is a long-lasting condition that can be life-threatening because of its complications, including diabetes, high blood pressure, and depression.

From http://www.medscape.com/viewarticle/832399?src=rss

Etomidate drip quickly curbs severe hypercortisolism


AT ICE/ENDO 2014


VITALS  Key clinical point: The anesthetic induction agent etomidate is a potent suppressor of cortisol synthesis in the adrenal cortex at subhypnotic doses, making it a safe and effective agent for management of severe hypercortisolism in Cushing’s syndrome.

Major finding: Continuous infusion of etomidate using a standardized protocol resulted in a reduction in serum cortisol from a mean of 138 mcg/dL to a goal range of 10-20 mcg/dL in an average of 64 hours.

Data source: This was a retrospective case series involving six patients with severe hypercortisolism caused by adrenocorticotropic hormone–dependent Cushing’s syndrome.

Disclosures: The study was carried out with institutional funds. The presenter reported having no financial conflicts.

Continuous intravenous infusion of etomidate safely and swiftly gains control of severe hypercortisolism in patients with adrenocorticotropic hormone–dependent Cushing’s syndrome when conventional presurgical oral treatment is problematic.

“From our cumulative experience, we have now developed a standardized titrated etomidate infusion protocol, which should provide clinicians with a simple, safe, and effective means to lower serum cortisol in patients with severe clinical, metabolic, and neuropsychiatric consequences of prodigious hypercortisolism as a bridge to definitive medical or surgical therapy,” explained Dr. Katarzyna G. Zarnecki at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

Etomidate (Amidate) is a sedative hypnotic agent with an excellent cardiovascular safety profile. It is widely used in emergency settings, such as reduction of dislocated joints and cardioversion. It suppresses adrenal steroidogenesis by potently inhibiting 11-beta hydroxylase. Fortunately for endocrinologic purposes, etomidate suppresses cortisol synthesis even at subhypnotic doses. In using it off label for management of severe hypercortisolism, it’s essential to keep the drug at subhypnotic doses, meaning not more than 0.3 mg/kg per hour, emphasized Dr. Zarnecki of the University of Wisconsin, Milwaukee.

Dr. Zarnecki and her coworkers utilize as their standard etomidate infusion protocol an initial 5-mg bolus followed by an infusion at 0.02 mg/kg per hour, with dose titration in increments of 0.01-0.02 mg/kg per hour every 4-6 hours based on changes in serum cortisol level. The goal is to bring the cortisol down to a target range of 10-20 mcg/dL.

She presented an illustrative six-patient series in which she and her colleagues turned to continuous infusion of etomidate because conventional oral therapy would have taken too long to rein in the severe hypercortisolism or because medication side effects were intolerable.

Mean baseline pretreatment serum cortisol was 138 mcg/dL, with an adrenocorticotropic hormone level of 419 pg/mL. Five of the six patients reached the goal of 10-20 mcg/dL in an average time of 64 hours. The mean rate of serum cortisol reduction was 1.93 mcg/dL per hour. The average etomidate infusion rate at the time the target level was reached was 0.07 mg/kg per hour, with a maximum rate of 0.1 mg/kg per hour. Monitoring via the Richmond Agitation Sedation Scale confirmed that none of the patients experienced sedative effects.

In the sole patient who didn’t reach goal, etomidate therapy was suspended because the patient entered palliative care because of extensive tumor progression.

Dr. Zarnecki reported having no financial conflicts of interest.

From Clinical Endocrinology News