Long-acting Signifor Has Similar Safety Profiles as Twice-daily Treatment in Cushing’s Patients, Trial Showed

A long-acting, once-a-month treatment of Signifor (pasireotide) normalized cortisol levels in 40% of patients with Cushing’s disease whose disease had recurred after surgery, or who were not candidates for surgery, according to new data from a Phase 3 trial.

The safety profiles of the once-monthly regimen proved to be similar to standard twice-daily Signifor treatments, researchers found.

The study, “Efficacy and safety of once-monthly pasireotide in Cushing’s disease: a 12 month clinical trial,” was published in the journal The Lancet Diabetes & Endocrinology.

Novartis‘ Signifor in its twice-daily injection formulation has already been approved for treating Cushing’s in the U.S. and elsewhere.

The 12-month, Phase 3 trial (NCT01374906) was conducted at 57 sites in 19 countries. The study included 150 patients with Cushing’s whose cortisol levels had risen or not dropped at all after surgery, or who were unable to undergo surgery.

Between Dec. 28, 2011, and Dec. 9, 2014, participants were randomized to receive either 10 mg or 30 mg of Signifor every four weeks, via an injection to the muscle. If, after four months of therapy, cortisol urinary levels (mUFC) were 50% greater than the upper normal limit, the dose could be increased from 10 mg to 30 mg, or from 30 mg to 40 mg. It could also be increased after seven, nine, or 12 months if the mUFC concentration was greater than normal.

The goal was to normalize average concentrations of free cortisol in the urine to less than or equal to the upper normal limit at month seven. It was met by 31 of the 74 patients in the 10 mg group (41.9%) and 31 of the 76 patients in the 30 mg group (40.8%).

The most common adverse events were hyperglycemia (high concentration of blood sugar), diarrhea, cholelithiasis (gall stones), diabetes, and nausea.

The researchers consider this treatment to be a good option for patients whose disease has returned after surgery, or who cannot undergo surgery. The long-lasting treatment schedule of one injection per month is more convenient for patients than the twice-daily subcutaneous injection, making it more likely that they would not discontinue treatment.

“Surgical resection of the causative pituitary adenoma is the first-line treatment of choice for most patients with Cushing’s disease, which leads to remission in greater than 75% of patients if done by an expert pituitary surgeon,” wrote Dr. Andre Lacroix, MD, a professor in the Department of Medicine at the University of Montreal teaching hospital, and colleagues.

“However, surgery is not always successful, and disease recurrence can occur several years after initial remission, while some patients refuse or are not candidates for surgery. As a result, many patients require additional treatment options.”

“Long-acting pasireotide normalized mUFC concentration in about 40% of patients with Cushing’s disease at month 7 and had a similar safety profile to that of twice-daily subcutaneous pasireotide,” the team wrote in the study.

“Long-acting pasireotide is an efficacious treatment option for some patients with Cushing’s disease who have persistent or recurrent disease after initial surgery or are not surgical candidates, and provides a convenient monthly administration schedule,” researchers concluded.

From https://cushingsdiseasenews.com/2017/10/31/long-acting-signifor-for-cushings-disease-has-similar-efficacy-and-safety-as-twice-daily-treatment/

Study Highlights Importance of Clinical Follow-Up in Cushing’s Patients After Adenoma Removal

A rare case of Cushing’s syndrome (CS) in a 17-year-old patient with multiple pituitary adenomas highlights the importance of clinical follow-up in order to determine the best treatment options for patients.

The study, “A rare case of multiple pituitary adenomas in an adolescent Cushing disease presenting as a vertebral compression fracture,” was published in the journal Annals of Pediatric Endocrinology and Metabolism

CS is a very rare disease with an incidence of 0.7-2.4 cases per million, per year. It is caused by exposure to very high levels of the hormone cortisol. In children, the most common symptom is weight gain without height gain. In some rare cases, tumors known as multiple pituitary adenomas (MPAs) appear, and patients have elevated levels of adrenocorticotropic hormone (ACTH). Surgical removal through transsphenoidal surgery (TSS) is considered the best treatment, and the first TSS has a success rate of more than 90%.

However, since 15% of patients have a recurrence, ongoing monitoring and follow-up after TSS are important. The importance of this follow-up care is highlighted in a recent case report.

The study described the case of a 17-year-old male adolescent who was 149.5 cm tall (4’9″) and weighed 63.6 kg (140 lbs). The patient was referred to a hospital for the evaluation of a vertebral compression fracture and obesity. Over four years, the patient gained 23 kg (51 lbs) without an increase in height. Despite showing many of the features of CS, this patient had not been previously diagnosed with CS.

He had high levels of ACTH and cortisol, and an MRI suggested the presence of an 8-mm (0.8 cm) micro-adenoma. After TSS, the patient’s morning ACTH and cortisol levels were reduced, and a persistent headache had improved. But there was no reduction in weight.

Three months after the TSS, the patient’s body mass index did not show improvement, and both cortisol and ACTH levels were elevated again. MRI revealed a new 9 mm (0.9 cm) micro-adenoma, which was removed with a second TSS. However, cortisol and ACHT remained elevated after the second surgery, with no evidence of a pituitary tumor in MRI scans.

Researchers recommended additional options, such as total removal of the pituitary gland, radiotherapy, or removal of both adrenal glands, options that the patient and his family declined. He continued to receive treatment for osteoporosis, hypertension, and increased lipid levels.

“In conclusion, we reported the clinical course of Cushing disease with 2 distinct pituitary adenomas. Since there is no consensus as to the best treatment for relapsing or persistent Cushing disease and since only a few cases of MPA among pediatric Cushing disease have been reported, a close followup of tumor status, severity of hypercortisolism, and patients’ perspectives are the major parameters used to determine the best treatment option for each patient. In addition, early recognition and diagnosis of pediatric Cushing disease would lead to earlier recovery, improved growth, and better quality of life,” the researchers wrote.

From https://cushingsdiseasenews.com/2017/10/27/cushings-disease-rare-case-report-highlights-importance-early-diagnosis-follow-up-care/

Long-acting pasireotide safe, effective for recurrent Cushing’s disease

October 20, 2017

In patients with persistent or recurring Cushing’s disease after surgery, monthly pasireotide was safe and effective, leading to normal urinary free cortisol levels in about 40% of patients after 12 months, according to findings from a phase 3 clinical trial.

“Surgical resection of the causative pituitary adenoma is the first-line treatment of choice for most patients with Cushing’s disease, which leads to remission in greater than 75% of patients if done by an expert pituitary surgeon,” Andre Lacroix, MD, professor in the department of medicine at University of Montreal teaching hospital, and colleagues wrote in the study background. “However, surgery is not always successful, and disease recurrence can occur several years after initial remission, while some patients refuse or are not candidates for surgery. As a result, many patients require additional treatment options.”

Lacroix and colleagues analyzed data from 150 patients with a confirmed diagnosis of persistent, recurrent or new Cushing’s disease with mean urinary free cortisol level concentration 1.5 to five times the upper limit of normal, normal or greater than normal plasma and confirmed pituitary source of Cushing’s disease. Patients were recruited between December 2011 and December 2014; those who received mitotane therapy within 6 months, pituitary irradiation within 10 years or previous pasireotide treatment were excluded. Researchers randomly assigned patients to 10 mg (n = 74) or 30 mg (n = 76) monthly intramuscular pasireotide (Signifor LAR, Novartis) for 12 months, with investigators and patients masked to the group allocation and dose. Pasireotide was up-titrated from 10 mg to 30 mg or from 30 mg to 40 mg at month 4, or at month 7, 9 or 12 if urinary free cortisol concentrations remained greater than 1.5 times the upper limit of normal. At month 12, patients considered to be receiving clinical benefit from the therapy (mean urinary free cortisol concentration at or less than the upper limit of normal) could continue to receive it during an open-ended extension phase. The primary outcome was to assess the proportion of patients achieving mean urinary free cortisol concentration less than or equal to the upper limit of normal by month 7, regardless of dose.

Within the cohort, 41.9% of patients in the 10-mg group and 40.8% of patients in the 40-mg group met the primary endpoint at month 7, whereas 5% of patients in the 10-mg group and 13% of patients in the 40-mg group achieved partial control. Researchers did not observe between-sex differences or differences in response among those who did or did not undergo previous surgery.

The number of patients who achieved the primary endpoint at month 7 without an up-titration in dose was smaller, but not significantly different between the 10-mg and 40-mg dose groups (28.4% and 31.6%, respectively), according to researchers. Among those who received an up-titration in dose in the 10-mg and 40-mg groups (42% and 37%, respectively), 32% and 25%, respectively, were considered responders at month 7.

Researchers also observed improvements in several metabolic parameters during the 12-month course of treatment with both doses, including improvements in systolic and diastolic blood pressure; reductions in waist circumference, BMI and body weight; and improvement in scores for the Cushing’s Quality of Life questionnaire. The most common adverse events were hyperglycemia, diarrhea, cholelithiasis, diabetes and nausea.

The researchers noted that, in both dose groups, the reductions in mean urinary free cortisol concentration were observed within 1 month, with concentrations remaining below baseline levels for the 12-month study period.

“This large phase 3 trial showed that long-acting pasireotide administered for 12 months can reduce [median urinary free cortisol] concentrations, is associated with improvements in clinical signs and [health-related quality of life] and has a similar safety profile to that of twice-daily pasireotide,” the researchers wrote, adding that the long-acting formulation provides a convenient monthly administration schedule. – by Regina Schaffer

Disclosures: Novartis funded this study. Lacroix reports he has received grants and personal fees as a clinical investigator, study steering committee member and advisory board member for Novartis, Stonebridge and UpToDate. Please see the study for all other authors’ relevant financial disclosures.

From https://www.healio.com/endocrinology/adrenal/news/in-the-journals/%7B55988079-312b-478d-8788-036a465b1881%7D/long-acting-pasireotide-safe-effective-for-recurrent-cushings-disease

Kiko Matthews, Pituitary Cushing’s Survivor Solo Rows Atlantic to Raise £100K For Hospital That Saved Her Life

Adapted from an article at http://metro.co.uk/2017/07/24/ex-teacher-is-rowing-across-the-atlantic-solo-to-raise-money-for-hospital-who-cured-her-brain-tumour-6773756/

You’d imagine if you’d never set foot in a rowing boat before, apart from, say, an abortive attempt in a boating lake age 9, that you would set yourself a fairly tame goal for your first challenge when you did finally take up the sport.

Not so Kiko Matthews. The science teacher-turned-paddle board instructor and adventurer, this time last year a total beginner in a rowing boat, set herself the challenge of rowing solo across the Atlantic – before she’d actually picked up an oar.

Not only does she plan to raise £100,000 for King’s College Hospital with the row – after they saved her life when she was struck with a rare disease – but she plans to break the female world record for a solo Atlantic crossing while she’s doing it.

The previous record for a woman rowing solo across the Atlantic is 56 days, the male record is 35.

Kiko plans to do it in 45, taking 11 days off the current female record.

Her determination and dedication indicate that she’ll do it too.

She has been training daily for 7 months since she made the vow (she hadn’t even been drinking when she made it, she tells me) in order to smash the record for the 3,000-mile trip.

On the way she will encounter storms, freezing nights, scorching hot days, sharks – and a whole lot of solitude. ‘I have to be skipper, medic, my own best friend – and, sometimes, no doubt, my own worst enemy,’ she says.

She’ll have an emergency button in case of crisis — and not much else, besides her equipment and her ego.

A rigorous regime of on-land and on-water rowing, circuits, weights and cross-training with cycling and running is preparing her for the 16 hours a day of rowing she’ll have to put in to make the record crossing.

The months of 4am wake-up calls are, as you’ll see from her Facebook and Instagram posts, made somewhat easier by incredible sunrises, sunsets and glass-like oceans, but they are nonetheless gruelling.

However, they will have set her up for what will be six sleep-deprived weeks where she will try to shoehorn what sleep she can – a four-hour chunk and a few cat naps throughout the day – into the eight hours she has to eat and rest when she is not rowing.

No matter how much work she is putting in, the challenge is ambitious — but her chances are improved immeasurably not only by her tenacity (you have to meet her to believe it) but the fact that the boat she is using for the crossing is the same one that was used by the current male solo Atlantic World Record holder, Charlie Pitcher.

He set the new record for solo male crossing in 2013, taking 35 days to row the 3,000 miles in the carbon-hulled, 6.5m ocean rowing boat Soma of Essex.

His boat was the first of its kind to have the rower facing backwards into the waves rather than rowing forward, which made the boat far more aerodynamic and helped him to shave 5 days off the previous 40-day record.

And, as Kiko says, ‘when you’re in the middle of the Atlantic with nothing for miles either side, you don’t really need to see where you’re going anyway.’

Now, Pitcher has not only lent Kiko his record-breaking boat, but he’s helping to train her too. And, having been exposed to the whirlwind that is Kiko Matthews, he is confident she can achieve her goal.

‘I met Kiko at a charity function we were both involved with and we just hit it off immediately, like we had known each other for years,’ he says. ‘I wanted to lend her the boat because I believe she has what it takes to smash this, and not many others do,’ he says.

‘To break a tough world record like this, you need all the right tools in your bag. Kiko has the full house.’

The mammoth physical undertaking is all the more impressive when you understand how far Kiko has come health wise.

The once fit young woman was so rapidly debilitated by this mystery disease she had to drag herself upstairs on her hands and knees, yet doctors could not find out what was wrong.

Unlike most people with Cushing’s, who experience the condition worsening over a long period, sometimes years, the size of Kiko’s tumour meant the symptoms were aggressive and dramatic.

As she deteriorated, she was quickly referred to King’s College Hospital where she lay for a month believing she would die before doctors were able to diagnose Cushing’s.

Even then, her potassium levels were too low for her to survive surgery so she was taken to intensive care unit until she was strong enough for doctors to operate and remove the tumour.

Kiko says now that those were her darkest times. ‘I couldn’t see, I couldn’t speak properly or think. I was too weak to move,’ she says.

Ultimately, the disease could have proved fatal. But with the tumour finally removed, the levels of cortisol in her blood reduced from 3,000 mcg/dL to 30 mcg/dL in three days.

Within five, the brain fluid stopped dripping from her nose, the swelling in her body had gone down, her memory returned and diabetes and other symptoms vanished.

Soon after her recovery, Kiko left her role as a science teacher to set up SupKiko, a company teaching paddle boarding, and a charity, The Big Stand, that gives opportunities to young people and those with mental health problems.

While she still leads paddle boarding groups, most of her time is now spent training for the Atlantic crossing, which sets off from the Canary Islands in January.

….

Ironically, both the challenge and fundraising attempt for KCH has added poignancy now.

A few months into her training, Kiko began to feel ‘strange’ symptoms and, as they developed, she began to suspect the return of Cushing’s.

An MRI detected a 3mm tumour on her pituitary gland, confirming her fears, and she found herself back at King’s where Kiko says that the doctors, who remembered her aggressive and rare case 8 years ago, have been ‘fantastic’.

She is booked for surgery on 1 August when surgeons will go in through her nose to remove the tumour quickly so that she can continue her training.

‘With the help of an amazing team of nurses and doctors, I’ll be 100% fine for my row in January. I’ll make sure I am,’ she says.

‘The tumour returning has only made me even more determined to break the record and raise the money,’ she says.

‘The doctors will have saved my life not once, but twice.’

Read the entire article at http://metro.co.uk/2017/07/24/ex-teacher-is-rowing-across-the-atlantic-solo-to-raise-money-for-hospital-who-cured-her-brain-tumour-6773756/

Grading system may predict recurrence, progression of pituitary neuroendocrine tumors

The risk for recurrence or progression of pituitary neuroendocrine tumors in adults is significantly associated with age and tumor type, according to findings published in The Journal of Clinical Endocrinology & Metabolism.

Gérald Raverot, MD, PhD, of Hospices Civils de Lyon, Federation d’Endocrinologie du Pole Est in France, and colleagues evaluated 374 adults (194 women) who underwent surgery for a pituitary neuroendocrine tumor (mean age at surgery, 51.9 years) between February 2007 and October 2012 to test the value of a new classification system on prognostic relevance.

Tumors were classified using a grading system based on invasion on MRI, immunocytochemical profile, Ki-67 mitotic index and p53 positivity. Noninvasive tumors were classified as grade 1a, noninvasive but proliferative tumors were grade 1b, invasive tumors were grade 2a, invasive and proliferative tumors were grade 2b and metastatic tumors were grade 3.

Macroadenomas were the most common type of tumor based on MRI classification (82.1%), followed by microadenoma (13.6%) and giant adenoma (4.3%).

Information on grade was available for 365 tumors; grade 1a was the most common (51.2%), followed by grades 2a (32.3%), 2b (8.8%) and 1b (7.7%).

The progression-free survival analysis included 213 participants from the original cohort during a mean follow-up of 3.5 years. A recurrent event occurred in 52 participants, and progression occurred in 37 participants. The risk for recurrence and/or progression was associated with age (P = .035), tumor type (P = .028) and grade (P < .001). The risk for recurrence and/or progression was increased with grade 2b tumors compared with grade 1a tumors (HR = 3.72; 95% CI, 1.9-7.26) regardless of tumor type. Invasion was significantly associated with recurrence in grade 2a tumors (HR = 2.98; 95% CI, 1.89-4.7), whereas proliferation was not significantly associated with prognosis for grade 1b (HR = 1.25; 95% CI, 0.73-2.13).

“This prospective study confirms the usefulness of our previously proposed classification and may now allow clinicians to adapt their therapeutic strategies according to prognosis, but may also be used to stratify patients and evaluate therapeutic efficacy in future clinical trials,” the researchers wrote. “Further progress can be expected, in particular if an improved understanding of molecular abnormalities associated with pituitary tumorigenesis generates better biomarkers.” – by Amber Cox

Disclosures: The researchers report no relevant financial disclosures.

From https://www.healio.com/endocrinology/neuroendocrinology/news/in-the-journals/%7B4dbd524c-4534-42e3-a1dc-4e3a0d82a0f1%7D/grading-system-may-predict-recurrence-progression-of-pituitary-neuroendocrine-tumors

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