Etomidate in the Treatment Of Cushing Syndrome

Posted on September 25, 2023 by MaryO

Cushing syndrome is a metabolic disease caused by chronic exposure to high levels of glucocorticoids. It can present as an endocrine emergency due to a rapid increase in circulating cortisol leading to increased risk of cardiovascular disease and infection. Etomidate rapidly reduces plasma cortisol levels by inhibiting the action of 11β-hidroxilase. We report the case of a patient with severe hypercortisolaemia accompanied by metabolic and psychiatric disorders in whom administration of etomidate reduced preoperative levels of cortisol.

Introduction

Cushing’s syndrome is a metabolic disease caused by chronic exposure to high levels of glucocorticoids. The main causes are ectopic ACTH secretion, adrenal tumours (adenomas or carcinomas), adrenal hyperplasia, and administration of exognous glucocorticoids—the latter being the most common aetiology.1

In most cases, Cushing’s syndrome presents an indolent course for years before diagnosis is made, although it can sometime present as an endocrine emergency due to a rapid increase in circulating cortisol levels.2 In these cases, treatment to control hypercortisolaemia must be started quickly due to the high morbidity and mortality associated with the potentially life-threatening metabolic, infectious, and neuropsychiatric alterations that occur in this syndrome.1, 2, 3, 4

The options for treating Cushing’s syndrome include surgery, radiotherapy, and pharmacological treatment. The most commonly used drugs are adrenal steroidogenesis inhibitors (ketoconazole, metyrapone),3 but this treatment is not always well tolerated and its efficacy is limited.2 Etomidate is a drug from the imidazole family that inhibits the enzyme 11β-hydroxylase, and can reduce cortisol secretion within 48−72 h.2

Section snippets

Case report

Our patient was a 27-year-old woman with no known drug allergies or personal history of interest. She was studied in April 2021 for anxious-depressive symptoms with rapidly evolving paranoid ideation and hirsutism. A Nugent test was performed, which was positive (46.1 mcg/dl), and cortisol in urine was measured (2715 mcg/24 h), leading to a diagnosis of Cushing’s syndrome.

A CT scan showed a large mass on the right adrenal gland, compatible with a primary adrenal gland tumour (Fig. 1).

Discussion

Endogenous Cushing’s syndrome is characterized by over-production of cortisol. In patients such as ours, the syndrome presents in its most serious form, with very high hypercortisolaemia and metabolic, cardiovascular, and neuropsychiatric disorders. Cushing’s syndrome is a medical emergency due to its association with several comorbidities and its high rate of mortality.5 The first therapeutic option is surgical resection of the underlying tumour; however, the accompanying hypercortisolaemia

Conclusion

In its severe form, Cushing’s syndrome is a medical emergency that must be rapidly controlled.

Etomidate is both safe and effective, and has shown promising results in the treatment of severe hypercortisolaemia.

We believe that these patients should be admitted to the Anaesthesia Intensive Care Unit during etomidate therapy in order to monitor their level of consciousness, lung function, and haemodynamics, and to closely monitor cortisol and electrolyte levels.

Ethical considerations

Informed consent was obtained for the use of patient information for teaching and research purposes in accordance with our hospital protocol.

Conflict of interests

None.

Funding

The authors have not received any funding for this manuscript.

References (8)

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    Cushing’s syndrome: Treatment and new therapeutic approaches

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    Continuous Etomidate Infusion for the Management of Severe Cushing Syndrome: Validation of a Standard Protocol

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    Etomidate in the management of hypercortisolaemia in Cushing’s syndrome: a review

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There are more references available in the full text version of this article.

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© 2023 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España, S.L.U. All rights reserved.

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Froedtert and MCW researchers investigate Cushing syndrome incidence in bariatric surgery patients

Posted on January 26, 2016 by MaryO

Researchers at the Medical College of Wisconsin determined that Cushing syndrome, an endocrine disorder, may be the potential cause for weight gain and metabolic complications for patients who have undergone bariatric surgery for obesity. The study, published in the journal Obesity Surgery, was conducted by Ty B. Carroll, MD, assistant professor of endocrinology; James W. Findling, MD, FACP, professor of endocrinology ; and Bradley R. Javorsky, MD, assistant professor of endocrinology. The physicians practice at Froedtert Hospital in Wauwatosa and Community Memorial Hospital in Menomonee Falls.

Cushing syndrome can occur when the human body is exposed to high levels of cortisol for an extended period of time. Cortisol is a hormone in the body which affects blood pressure regulation and cardiovascular system functions. Cortisol also helps regulate the body’s conversion of proteins, carbohydrates and fats from diet into usable energy. However, when the level of cortisol becomes too high, Cushing syndrome can develop.

Cushing syndrome is associated with a variety of symptoms including weight gain and fatty tissue deposits in the body. According to the American Association of Neurological Surgeons, 10 to 15 million people are affected each year by Cushing syndrome.

Bariatric surgery is a procedure performed to help with extreme cases of obesity. Weight loss is achieved by reducing the size of the stomach with a gastric band, removal of a portion of the stomach or resecting and rerouting the small intestine to a small stomach pouch. Bariatric surgery is often used as an option for individuals unable to lose weight through diet and exercise, or have serious health problems caused by obesity.

According to the American Society for Metabolic and Bariatric Surgery, 179,000 bariatric surgeries were performed in the U.S. in 2013. However, despite successes in normal weight loss cases, bariatric surgery does not provide long term weight loss for individuals diagnosed with Cushing syndrome. Cushing syndrome often goes undiagnosed as a potential cause for weight gain and metabolic complications until after the surgery is performed.

MCW researchers in this study analyzed the incidence of Cushing syndrome in patients who underwent bariatric surgery for weight loss. During the investigation, the researchers performed a retrospective chart review on a series of 16 patients diagnosed with Cushing syndrome from five tertiary care centers in the U.S. who underwent bariatric surgery. The results from the study found 12 of the analyzed patients were not diagnosed with Cushing syndrome prior to their bariatric surgery. The remaining four patients had Cushing syndrome surgery prior to bariatric surgery, without recognition that their Cushing syndrome was persistent until after the weight loss surgery. The findings from the research indicate that Cushing syndrome may be often overlooked in patients undergoing bariatric surgery.

According to the researchers, testing for Cushing syndrome should be performed prior to bariatric surgery in patients with persistent hypertension, diabetes mellitus or excessive weight regain.

From http://www.lakecountrynow.com/usersubmittedstories/366480371.html

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