Common Cushing’s Treatment, Somatostatin Analogs, May Sometimes Worsen Disease Course

Doctors often prescribe somatostatin analogs to manage the hormonal imbalance that characterizes Cushing’s syndrome. However, in rare situations these medicines have paradoxically made patients worse than better.

This recently happened with a 48-year-old Spanish woman whose Cushing’s syndrome was caused by an adrenal gland tumor that was producing excess adrenocorticotropic hormone (ACTH). Her case was recently reported in the study “Ectopic Cushing’s syndrome: Paradoxical effect of somatostatin analogs,” and published in the journal Endocrinología, Diabetes y Nutrición.

Cushing’s syndrome occurs when the body produces too much cortisol. This can happen for many reasons, including an oversupply of ACTH, the hormone responsible for cortisol production, due to a tumor in the pituitary gland.

But sometimes, tumors growing elsewhere can also produce ACTH. This feature, known as ectopic ACTH secretion (EAS), may also cause ACTH-dependent Cushing’s syndrome.

Two-thirds of EAS tumors are located in the thorax, and 8 to 15 percent are in the abdominal cavity. Only 5 percent of EAS tumors are located in the adrenal gland, and up to 15 percent of EAS tumors are never detected.

Doctors usually use cortisol synthesis inhibitors such as ketoconazole or Metopirone (metyrapone) to control EAS, due to their efficacy and safety profiles. But somatostatin analogs (SSAs) such as Somatuline (lanreotide) have also been used to treat these tumors. However, these drugs produce mixed results.

The woman in the case study, reported by researchers at the University Hospital Vall d’Hebron in Barcelona, Spain, had an EAS tumor on the adrenal gland. She experienced s life-threatening cortisol and ACTH increase after receiving high-dose Somatuline.

The patient had been recently diagnosed with hypertension, and complained of intense fatigue, muscular weakness, easy bruising and an absence of menstruation. Laboratory analysis revealed that she had triple the normal levels of free cortisol in the urine, elevated levels of plasma cortisol, and high ACTH levels. In addition, her cortisol levels remained unchanged after receiving dexamethasone. The patient was therefore diagnosed with ACTH-dependent Cushing syndrome.

To determine the origin of her high cortisol levels, the team conducted magnetic resonance imaging (MRI). They found no tumors on the most common places, including the pituitary gland, neck, thorax or abdomen. However, additional evaluation detected a small alteration on the left adrenal gland, suggesting that was the source of ectopic ACTH production.

The team initiated treatment with 120 mg of Somatuline, but a week later, her condition had worsened and become life-threatening. Doctors started Ketoconazole treatment immediately, three times daily. The affected adrenal gland was surgically removed, and tissue analysis confirmed the diagnosis. The patient’s clinical condition improved significantly over the follow-up period.

“We highlight the need to be aware of this rare presentation of EAS, and we remark the difficulties of EAS diagnosis and treatment,”  researchers wrote.

The team could not rule out the possibility that the patient’s clinical development was due to the natural course of the disease. However, they believe “she had a paradoxical response on the basis of her dramatical worsening just after the SSAs administration, associated to an important rise in ACTH and UFC levels.”

For that reason, researchers think a new version of SSAs, such as Signifor (pasireotide) — which has improved receptor affinity — could provide better therapeutic response.

From https://cushingsdiseasenews.com/2017/11/09/paradoxical-effects-of-somatostatin-analogs-on-adrenal-ectopic-acth-tumor/

Metopirone effective treatment for hypercortisolemia in Cushing’s syndrome

Hypercortisolemia in Cushing’s syndrome can be controlled with Metopirone therapy, according to recent study findings published in The Journal of Clinical Endocrinology & Metabolism.

John Newell-Price, PhD, FRCP, of the University of Sheffield in the United Kingdom, and colleagues evaluated 195 patients with Cushing’s syndrome to determine the effect of Metopirone (metyrapone, HRA Pharma) on the control of excess cortisol. Cushing’s syndrome was most commonly Cushing’s disease (n = 115), followed by ectopic adrenocorticotropic hormone (ACTH; n = 37), benign adrenal disease (n = 30), adrenocortical carcinoma (n = 10), ACTH-independent macronodular adrenal hyperplasia (n = 2) and primary pigmented nodular adrenal hyperplasia (n = 1).

The biochemical parameters of activity of Cushing’s syndrome were measured by mean serum cortisol day-curve (target, 150-300 nmol/L), early morning serum cortisol and 24-hour urinary free cortisol.

Most participants received monotherapy (n = 164) and had significant improvements in excess cortisol during treatment. Significant improvements were revealed from first to last review for cortisol day-curve, early morning cortisol and 24-hour urinary free cortisol.

At last review, 55% of participants who had cortisol day-curve, 43% who had urinary free cortisol, 46% who had early morning cortisol less than 331 nmol/L and 76% who had early morning cortisol less than the upper limit of normal/600 nmol/L achieved control.

The median final dose of metyrapone was 1,375 mg among those with Cushing’s disease, 1,500 mg among those with ectopic ACTH, 750 mg among those with benign adrenal disease and 1,250 among those with adrenocortical carcinoma.

Twenty-five percent of participants experienced adverse events, with the most common being mild gastrointestinal upset and dizziness. Most of the adverse events occurred within 2 weeks of initiation or dose increase and were reversible.

“Overall more than 80% of patients showed an improvement in levels of circulating cortisol with over 50% achieving biochemical eucortisolemia when on monotherapy when assessed by the stringent criterion of control on a [cortisol day-curve],” the researchers wrote. “It is likely that additional therapies were added because of the severity of disease and clinician preference, but the retrospective and multicenter nature of our study precludes a formal assessment of this. Furthermore, our data support that metyrapone monotherapy is an effective treatment for hypercortisolemia either before or after surgical intervention to the primary cause of [Cushing’s syndrome].” – by Amber Cox

Disclosure: Newell-Price reports various financial ties with HRA Pharma and Novartis. Please see the full study for a list of all other authors’ relevant financial disclosures.

From http://www.healio.com/endocrinology/adrenal/news/online/%7B067ff9a2-dbce-428f-be94-849e1f466150%7D/metopirone-effective-treatment-for-hypercortisolemia-in-cushings-syndrome

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