Cushing's disease is a rare subtype of Cushing’s syndrome caused by a benign pituitary tumor that overproduces adrenocorticotropic hormone (ACTH), causing excessive cortisol production by the adrenal glands. This condition disrupts normal cortisol rhythms and can cause serious complications and early death if left untreated.
Surgery is often the primary treatment for Cushing's disease because it directly addresses the root cause of the condition. However, medications can also be an important part of treatment for Cushing’s disease.
Medication is used for patients with persistent or recurrent disease after surgery, for those who are not candidates for surgery, or in cases where rapid cortisol control is needed due to severe hypercortisolism or life-threatening complications.
In this article we’ll cover the medications available for treating Cushing's Disease including a discussion of their uses, how they work, and what patients can expect from medication use as they heal from Cushing’s disease.
[signup]
Understanding the Role of Cortisol in Cushing’s Disease
Excessive cortisol levels, or cortisolemia, is the cause of the disease process seen in Cushing’s.
What is Cortisol?
Cortisol, a glucocorticoid hormone, is often called a stress hormone because it is foundational to our stress response. However, cortisol has many roles in normal human physiology.
Cortisol:
- Regulates metabolism (promoting gluconeogenesis and reducing glucose uptake)
- Supports the stress response (mobilizing energy and increasing alertness through neuroendocrine signaling pathways)
- Increases blood pressure (enhancing vasoconstriction and increasing blood volume)
- Supports fetal lung and nervous system development
- Maintains bone health by balancing bone formation and resorption
How Cushing’s Disease Affects Cortisol Production
Cushing’s syndrome is the general condition that refers to the condition of hypercortisolism, while Cushing’s disease specifically refers to hypercortisolism due to an ACTH-secreting pituitary tumor.
The pathophysiology of Cushing's syndrome involves prolonged exposure to high levels of cortisol.
In Cushing’s disease, the pituitary adenoma secretes excessive ACTH which stimulates the adrenal cortex to over-produce cortisol.
Elevated cortisol leads to increased gluconeogenesis, protein catabolism, insulin resistance, and immune suppression, manifesting in various symptoms like weight gain, muscle weakness, osteoporosis, hypertension, and susceptibility to infections.
Why Managing Cortisol is Critical
Chronic excessive cortisol exposure has disastrous long-term health consequences. The mortality rate of Cushing disease is estimated to be 10-11%. Successful recovery from Cushing disease may still leave the patient with other chronic health conditions such as diabetes, cardiovascular disease, osteoporosis, or chronic mental health conditions.
Common symptoms of Cushing’s disease include central obesity, with fat accumulation in the abdomen, face ("moon face"), and upper back ("buffalo hump").
Skin changes, such as thinning, slow wound healing, and purple stretch marks, also occur due to disrupted collagen production. Patients may experience acne and altered hair growth, especially women and prepubertal children.
Muscle weakness in the limbs creates a contrast between a large abdomen and thin extremities.
Elevated cortisol can also cause mood disturbances including depression, anxiety, and cognitive impairment, as well as high blood pressure due to fluid retention.
Metabolic issues like insulin resistance, hyperglycemia, and hyperlipidemia are common, along with bone health problems such as osteoporosis, resulting in fragile bones and back pain.
Reproductive health may also be affected, with women facing menstrual irregularities and men experiencing decreased libido or erectile dysfunction.
Other symptoms include increased thirst and urination, headaches, visual disturbances, and decreased immunity, which can mimic conditions like diabetes or cardiovascular disease.
Types of Medications for Cushing’s Disease
Medical management of Cushing's Disease requires careful selection and monitoring of therapies to balance efficacy and side effects, considering patient-specific factors and disease severity.
Here we’ll discuss the different classes of medications used including their mechanism of action, clinical indications, potential side effects and monitoring requirements.
Adrenal Steroidogenesis Inhibitors
Ketoconazole, metyrapone, mitotane, etomidate, and osilodrostat are steroidogenesis inhibitors that block adrenal enzymes to reduce cortisol production.
Ketoconazole is effective but can cause liver toxicity and male hypogonadism, requiring regular liver function monitoring. It may also lead to gastrointestinal issues.
Metyrapone and osilodrostat provide rapid cortisol control but can cause adrenal insufficiency, androgenic effects, hypertension, gastrointestinal upset, and hypokalemia.
Mitotane is less commonly used due to slower action and neurological side effects. It can cause gastrointestinal disturbances, CNS effects, and teratogenicity. Mitotane also accelerates the metabolism of other steroids, complicating glucocorticoid replacement.
Etomidate is used for rapid cortisol reduction in severe hypercortisolism cases, typically in hospitalized patients.
Monitoring for all steroidogenesis inhibitors includes watching for symptoms of adrenal insufficiency (fatigue, nausea, vomiting, hypotension, electrolyte imbalances), regular checks of blood glucose, lipid levels, and other metabolic parameters, and monitoring blood pressure, especially with metyrapone, due to hypertension risk.
Pituitary-Directed Treatments
The primary pituitary-directed treatments for Cushing's disease (CD) are cabergoline and pasireotide, which both inhibit ACTH production in pituitary corticotroph tumors to lower cortisol levels.
Pasireotide targets somatostatin receptors, reducing cortisol and tumor size but often causes hyperglycemia, requiring careful management. Common side effects include gastrointestinal issues, hyperglycemia, gallstones, and elevated liver function tests, necessitating monitoring for glucose intolerance and metabolic disturbances.
Cabergoline, a dopamine agonist targeting D2 receptors, moderately lowers cortisol and tumor size but may cause impulse control problems and potential cardiac effects. Side effects include nausea, dizziness, and asthenia, with some concerns about long-term use leading to heart valve disease, though evidence is not definitive.
Glucocorticoid Receptor Antagonist
Mifepristone blocks cortisol effects, improving hyperglycemia and weight gain without reducing cortisol levels.
Mifepristone can cause symptoms of cortisol insufficiency, hypokalemia, hypertension, and endometrial thickening. Monitoring response is based on clinical symptoms rather than biochemical markers due to the nature of receptor blockade.
Monitoring for adrenal insufficiency is complex, and it should only be used by experienced clinicians due to its side effects and lack of biochemical markers to monitor efficacy.
Combination Therapy
Combination therapy is often used when monotherapy is insufficient. Common combinations include ketoconazole with metyrapone, or ketoconazole with cabergoline, to maximize cortisol suppression while potentially minimizing side effects. More aggressive combinations are used for severe hypercortisolism.
General Practice for Medication Selection and Monitoring
Clinicians keep the following themes in mind when selecting and monitoring an appropriate medication regimen:
Determining When to Use Medications
Medications may be used in the following situations:
Second-Line Therapy: medications are used when surgery is not possible, has failed, or when rapid cortisol control is needed. This applies to ACTH-dependent CS patients with noncurative or inoperable conditions, guided by patient preferences, CS cause, and urgency.
Primary Treatment for Ectopic ACTH Syndrome: if the tumor can't be localized, resected, or in cases of metastasis, use steroidogenesis inhibitors or glucocorticoid receptor antagonists.
Adjunctive Treatment: medications may lower cortisol in adrenocortical carcinoma or supplement radiation therapy.
Emergency Situations: for life-threatening hypercortisolism (e.g., severe infections, cardiovascular issues, psychosis), use steroidogenesis inhibitors or glucocorticoid receptor antagonists immediately to reduce cortisol levels.
Selection Criteria for Medication
Factors such as disease severity, need for rapid cortisol reduction, tumor presence, comorbidities (e.g., diabetes, hypertension), patient preferences, and potential side effects influence the choice of medication.
Specific drugs may be preferred based on patient characteristics, such as gender or pregnancy plans.
Overview of Medication Monitoring and Adjustments
Regular monitoring of cortisol levels, symptoms, and comorbidities is essential. Adjustments are made based on efficacy and side effects. Annual imaging is recommended to monitor tumor growth, particularly with long-term use of steroidogenesis inhibitors or mifepristone.
Preoperative and Long-term Use
Medication may be used preoperatively to control severe hypercortisolism or when surgery is delayed. Long-term use is generally for patients with persistent disease post-surgery or those not eligible for surgery.
Combination therapy may be necessary for chronic management.
What to Expect During Treatment
Patients with Cushing's syndrome typically begin to see a reduction in cortisol levels soon after starting medication, often within days to a few weeks. This is particularly true for steroidogenesis inhibitors, which have a rapid onset and high efficacy in reducing cortisol.
Regular monitoring of cortisol levels is essential to gauge the initial response and adjust the dosage accordingly.
Long-Term Management
Patients may need long-term, sometimes indefinite, medication use if surgery is not an option or was not fully curative. Management involves adjusting drug types and dosages to control cortisol and minimize side effects, with regular follow-ups for optimization.
Ketoconazole, metyrapone, and mitotane are used to inhibit adrenal steroidogenesis, reducing cortisol levels and managing Cushing’s Disease symptoms. However, efficacy can vary, and treatment escape is common.
Regular monitoring of cortisol, liver function (especially with ketoconazole due to hepatotoxicity), and blood levels is essential.
Mitotane requires monitoring for neurological side effects and adrenal insufficiency. Blood pressure, electrolytes (potassium), and glucose levels should be checked due to risks like hypokalemia and hypertension.
Mifepristone requires monitoring clinical symptoms and metabolic parameters (blood glucose, weight, blood pressure) to assess treatment response. Vigilance for adrenal insufficiency symptoms, such as weakness and fatigue, is crucial. Periodic imaging may be needed to monitor for potential tumor growth, particularly in the pituitary.
Cabergoline and pasireotide require regular monitoring of cortisol and ACTH levels. Cabergoline needs blood pressure and heart function checks due to risks of hypotension and cardiac issues. Pasireotide monitoring includes blood glucose, liver function, and thyroid function due to risks of hyperglycemia, liver enzyme elevation, and hypothyroidism.
Regular imaging may be necessary to track tumor size with long-term use of these medications.
Impact on Quality of Life
Medications for Cushing's Disease can greatly enhance quality of life by alleviating symptoms like fatigue, weight gain, high blood pressure, and mood disturbances. Drugs such as ketoconazole, metyrapone, mitotane, mifepristone, cabergoline, and pasireotide reduce cortisol production or its effects, leading to symptom relief.
This can result in increased energy levels, improved weight management, better blood pressure control, and enhanced mood and cognitive function. Effective treatment can improve both physical and mental health, significantly boosting overall well-being.
Regular monitoring and individualized therapy adjustments are crucial to maintaining these benefits and minimizing side effects.
When to Consult Your Doctor
Patients in recovery from Cushing’s disease may have questions regarding the efficacy of their treatments. Patients should always feel comfortable reaching out to their doctor with questions.
Signs That Medications Are Working
Effective treatment for Cushing's disease can be indicated by a noticeable reduction in symptoms such as fatigue, weight gain, high blood pressure, and mood disturbances. Additionally, laboratory tests showing normalized cortisol levels are a key marker of treatment success.
When to Report Side Effects
Some side effects may require immediate medical attention including severe headaches, significant changes in blood pressure, muscle weakness, unusual fatigue, hypokalemia (low potassium levels), jaundice (which may be due to liver damage from ketoconazole), or signs of adrenal insufficiency like dizziness and fainting.
It's important to promptly report these symptoms to a healthcare provider.
Adjusting Treatment Plans
Regular consultations with healthcare providers are crucial to monitor the effectiveness of the treatment and make necessary adjustments. This may involve altering dosages or switching medications to better manage symptoms, minimize side effects, and ensure optimal control of cortisol levels.
Alternative and Complementary Treatments
Treatment plans for Cushing’s disease may include the following:
Surgical Options
Surgery is often the first-line treatment for Cushing's disease, aiming to remove the pituitary tumor responsible for excess cortisol production. Transsphenoidal resection of the ACTH-secreting tumor can effectively normalize cortisol levels and alleviate symptoms.
Successful surgery, especially when performed by experienced surgeons, offers the best chance for long-term remission.
It is typically recommended after confirming the diagnosis and tumor localization via imaging, like MRI. The primary goals are to restore normal cortisol levels, improve symptoms, and reduce the risk of severe complications such as cardiovascular disease and diabetes.
Radiation Therapy
Radiation therapy (RT), including external-beam radiation and stereotactic radiosurgery (SRS), is used when surgery is insufficient or tumors are aggressive.
RT can achieve biochemical remission and control tumor growth but often leads to hypopituitarism, requiring lifelong monitoring for tumor recurrence and hormone deficiencies.
Lifestyle Modifications
Diet and lifestyle are foundational for recovery, with a focus on a healthy diet, regular exercise, good sleep, and stress management to support overall well-being and HPA axis function.
A balanced diet plays a crucial role in managing weight, blood sugar, and bone health, while regular exercise improves cardiovascular health, muscle strength, and mood.
Stress management is essential, as reducing stress helps prevent cortisol fluctuations and aids in recovery.
Ongoing medical monitoring is important for the early detection and management of complications such as hypertension, diabetes, osteoporosis, and psychological issues. Regular follow-ups are vital to ensure prompt treatment of emerging problems, supporting long-term health and quality of life.
[signup]
Conclusion
- Recap of Medication Options
- Adrenal Steroidogenesis Inhibitors: medications like ketoconazole, metyrapone, and osilodrostat are used to reduce cortisol production by blocking adrenal enzymes. They offer rapid cortisol control but require monitoring for side effects like liver toxicity and hypokalemia.
- Pituitary-Directed Treatments: cabergoline and pasireotide target the pituitary gland to reduce ACTH production, thus lowering cortisol levels. They can be effective but may cause side effects such as hyperglycemia and potential cardiac issues.
- Glucocorticoid Receptor Antagonist: mifepristone blocks the effects of cortisol on tissues, helping to manage hyperglycemia and weight gain. It requires careful monitoring for symptoms of adrenal insufficiency and other metabolic disturbances.
- Regularly communicate with healthcare providers to monitor cortisol levels, manage side effects, report symptom changes, and adjust treatment plans for optimal health outcomes.
- A comprehensive treatment plan, including medication, lifestyle changes, and monitoring, helps manage symptoms effectively. Appropriate treatment improves energy, mood, and physical health, enhancing quality of life.
Cushing's disease is a rare subtype of Cushing’s syndrome caused by a benign pituitary tumor that overproduces adrenocorticotropic hormone (ACTH), leading to increased cortisol production by the adrenal glands. This condition can disrupt normal cortisol rhythms and may contribute to serious complications if not managed appropriately. It is important to consult with a healthcare provider for diagnosis and treatment options.
Surgery is often the primary approach for addressing Cushing's disease because it targets the underlying cause. However, medications can also play a significant role in managing Cushing’s disease.
Medication may be used for individuals with persistent or recurrent symptoms after surgery, for those who are not candidates for surgery, or in situations where rapid cortisol management is needed due to severe hypercortisolism or potential complications.
In this article, we’ll explore the medications available for managing Cushing's Disease, including a discussion of their uses, how they work, and what individuals can expect from medication use as they manage Cushing’s disease.
[signup]
Understanding the Role of Cortisol in Cushing’s Disease
Excessive cortisol levels, or cortisolemia, are a key factor in the disease process seen in Cushing’s.
What is Cortisol?
Cortisol, a glucocorticoid hormone, is often called a stress hormone because it is foundational to our stress response. However, cortisol has many roles in normal human physiology.
Cortisol:
How Cushing’s Disease Affects Cortisol Production
Cushing’s syndrome is the general condition that refers to the condition of hypercortisolism, while Cushing’s disease specifically refers to hypercortisolism due to an ACTH-secreting pituitary tumor.
The pathophysiology of Cushing's syndrome involves prolonged exposure to high levels of cortisol.
In Cushing’s disease, the pituitary adenoma secretes excessive ACTH which stimulates the adrenal cortex to over-produce cortisol.
Elevated cortisol may contribute to increased gluconeogenesis, protein catabolism, insulin resistance, and immune suppression, which can manifest in various symptoms like weight gain, muscle weakness, osteoporosis, hypertension, and increased susceptibility to infections.
Why Managing Cortisol is Important
Chronic excessive cortisol exposure can have significant long-term health impacts. Studies suggest that the mortality rate of Cushing disease is estimated to be 10-11%. Successful management of Cushing disease may still leave the individual with other chronic health conditions such as diabetes, cardiovascular disease, osteoporosis, or chronic mental health conditions.
Common symptoms of Cushing’s disease may include central obesity, with fat accumulation in the abdomen, face ("moon face"), and upper back ("buffalo hump").
Skin changes, such as thinning, slow wound healing, and purple stretch marks, may also occur due to disrupted collagen production. Individuals may experience acne and altered hair growth, especially women and prepubertal children.
Muscle weakness in the limbs can create a contrast between a large abdomen and thin extremities.
Elevated cortisol may also contribute to mood disturbances including depression, anxiety, and cognitive impairment, as well as high blood pressure due to fluid retention.
Metabolic issues like insulin resistance, hyperglycemia, and hyperlipidemia are common, along with bone health problems such as osteoporosis, resulting in fragile bones and back pain.
Reproductive health may also be affected, with women facing menstrual irregularities and men experiencing decreased libido or erectile dysfunction.
Other symptoms may include increased thirst and urination, headaches, visual disturbances, and decreased immunity, which can mimic conditions like diabetes or cardiovascular disease.
Types of Medications for Cushing’s Disease
Medical management of Cushing's Disease requires careful selection and monitoring of therapies to balance efficacy and side effects, considering individual-specific factors and disease severity.
Here we’ll discuss the different classes of medications used including their mechanism of action, clinical indications, potential side effects, and monitoring requirements.
Adrenal Steroidogenesis Inhibitors
Ketoconazole, metyrapone, mitotane, etomidate, and osilodrostat are steroidogenesis inhibitors that may help manage cortisol production by blocking adrenal enzymes.
Ketoconazole is effective but can cause liver toxicity and male hypogonadism, requiring regular liver function monitoring. It may also lead to gastrointestinal issues.
Metyrapone and osilodrostat provide rapid cortisol management but can cause adrenal insufficiency, androgenic effects, hypertension, gastrointestinal upset, and hypokalemia.
Mitotane is less commonly used due to slower action and neurological side effects. It can cause gastrointestinal disturbances, CNS effects, and teratogenicity. Mitotane also accelerates the metabolism of other steroids, complicating glucocorticoid replacement.
Etomidate is used for rapid cortisol management in severe hypercortisolism cases, typically in hospitalized patients.
Monitoring for all steroidogenesis inhibitors includes watching for symptoms of adrenal insufficiency (fatigue, nausea, vomiting, hypotension, electrolyte imbalances), regular checks of blood glucose, lipid levels, and other metabolic parameters, and monitoring blood pressure, especially with metyrapone, due to hypertension risk.
Pituitary-Directed Treatments
The primary pituitary-directed treatments for Cushing's disease (CD) are cabergoline and pasireotide, which both aim to manage ACTH production in pituitary corticotroph tumors to help lower cortisol levels.
Pasireotide targets somatostatin receptors, potentially reducing cortisol and tumor size but often causes hyperglycemia, requiring careful management. Common side effects include gastrointestinal issues, hyperglycemia, gallstones, and elevated liver function tests, necessitating monitoring for glucose intolerance and metabolic disturbances.
Cabergoline, a dopamine agonist targeting D2 receptors, may help lower cortisol and tumor size but may cause impulse control problems and potential cardiac effects. Side effects include nausea, dizziness, and asthenia, with some concerns about long-term use leading to heart valve disease, though evidence is not definitive.
Glucocorticoid Receptor Antagonist
Mifepristone blocks cortisol effects, which may help manage hyperglycemia and weight gain without reducing cortisol levels.
Mifepristone can cause symptoms of cortisol insufficiency, hypokalemia, hypertension, and endometrial thickening. Monitoring response is based on clinical symptoms rather than biochemical markers due to the nature of receptor blockade.
Monitoring for adrenal insufficiency is complex, and it should only be used by experienced clinicians due to its side effects and lack of biochemical markers to monitor efficacy.
Combination Therapy
Combination therapy is often considered when monotherapy is insufficient. Common combinations include ketoconazole with metyrapone, or ketoconazole with cabergoline, to maximize cortisol management while potentially minimizing side effects. More aggressive combinations are used for severe hypercortisolism.
General Practice for Medication Selection and Monitoring
Clinicians keep the following themes in mind when selecting and monitoring an appropriate medication regimen:
Determining When to Use Medications
Medications may be used in the following situations:
Second-Line Therapy: medications are used when surgery is not possible, has failed, or when rapid cortisol management is needed. This applies to ACTH-dependent CS patients with noncurative or inoperable conditions, guided by individual preferences, CS cause, and urgency.
Primary Treatment for Ectopic ACTH Syndrome: if the tumor can't be localized, resected, or in cases of metastasis, use steroidogenesis inhibitors or glucocorticoid receptor antagonists.
Adjunctive Treatment: medications may help manage cortisol in adrenocortical carcinoma or supplement radiation therapy.
Emergency Situations: for life-threatening hypercortisolism (e.g., severe infections, cardiovascular issues, psychosis), use steroidogenesis inhibitors or glucocorticoid receptor antagonists immediately to help manage cortisol levels.
Selection Criteria for Medication
Factors such as disease severity, need for rapid cortisol management, tumor presence, comorbidities (e.g., diabetes, hypertension), individual preferences, and potential side effects influence the choice of medication.
Specific drugs may be preferred based on individual characteristics, such as gender or pregnancy plans.
Overview of Medication Monitoring and Adjustments
Regular monitoring of cortisol levels, symptoms, and comorbidities is essential. Adjustments are made based on efficacy and side effects. Annual imaging is recommended to monitor tumor growth, particularly with long-term use of steroidogenesis inhibitors or mifepristone.
Preoperative and Long-term Use
Medication may be used preoperatively to help manage severe hypercortisolism or when surgery is delayed. Long-term use is generally for individuals with persistent symptoms post-surgery or those not eligible for surgery.
Combination therapy may be necessary for chronic management.
What to Expect During Treatment
Individuals with Cushing's syndrome may begin to see a reduction in cortisol levels soon after starting medication, often within days to a few weeks. This is particularly true for steroidogenesis inhibitors, which have a rapid onset and high efficacy in managing cortisol.
Regular monitoring of cortisol levels is essential to gauge the initial response and adjust the dosage accordingly.
Long-Term Management
Individuals may need long-term, sometimes indefinite, medication use if surgery is not an option or was not fully curative. Management involves adjusting drug types and dosages to help manage cortisol and minimize side effects, with regular follow-ups for optimization.
Ketoconazole, metyrapone, and mitotane are used to inhibit adrenal steroidogenesis, potentially reducing cortisol levels and managing Cushing’s Disease symptoms. However, efficacy can vary, and treatment escape is common.
Regular monitoring of cortisol, liver function (especially with ketoconazole due to hepatotoxicity), and blood levels is essential.
Mitotane requires monitoring for neurological side effects and adrenal insufficiency. Blood pressure, electrolytes (potassium), and glucose levels should be checked due to risks like hypokalemia and hypertension.
Mifepristone requires monitoring clinical symptoms and metabolic parameters (blood glucose, weight, blood pressure) to assess treatment response. Vigilance for adrenal insufficiency symptoms, such as weakness and fatigue, is crucial. Periodic imaging may be needed to monitor for potential tumor growth, particularly in the pituitary.
Cabergoline and pasireotide require regular monitoring of cortisol and ACTH levels. Cabergoline needs blood pressure and heart function checks due to risks of hypotension and cardiac issues. Pasireotide monitoring includes blood glucose, liver function, and thyroid function due to risks of hyperglycemia, liver enzyme elevation, and hypothyroidism.
Regular imaging may be necessary to track tumor size with long-term use of these medications.
Impact on Quality of Life
Medications for Cushing's Disease can greatly enhance quality of life by helping to alleviate symptoms like fatigue, weight gain, high blood pressure, and mood disturbances. Drugs such as ketoconazole, metyrapone, mitotane, mifepristone, cabergoline, and pasireotide may help manage cortisol production or its effects, leading to symptom relief.
This can result in increased energy levels, improved weight management, better blood pressure control, and enhanced mood and cognitive function. Effective management can improve both physical and mental health, significantly boosting overall well-being.
Regular monitoring and individualized therapy adjustments are crucial to maintaining these benefits and minimizing side effects.
When to Consult Your Doctor
Individuals in recovery from Cushing’s disease may have questions regarding the efficacy of their treatments. It is important to feel comfortable reaching out to a healthcare provider with questions.
Signs That Medications Are Working
Effective management for Cushing's disease can be indicated by a noticeable reduction in symptoms such as fatigue, weight gain, high blood pressure, and mood disturbances. Additionally, laboratory tests showing normalized cortisol levels are a key marker of management success.
When to Report Side Effects
Some side effects may require immediate medical attention including severe headaches, significant changes in blood pressure, muscle weakness, unusual fatigue, hypokalemia (low potassium levels), jaundice (which may be due to liver damage from ketoconazole), or signs of adrenal insufficiency like dizziness and fainting.
It's important to promptly report these symptoms to a healthcare provider.
Adjusting Treatment Plans
Regular consultations with healthcare providers are crucial to monitor the effectiveness of the management plan and make necessary adjustments. This may involve altering dosages or switching medications to better manage symptoms, minimize side effects, and ensure optimal control of cortisol levels.
Alternative and Complementary Treatments
Management plans for Cushing’s disease may include the following:
Surgical Options
Surgery is often the first-line approach for Cushing's disease, aiming to remove the pituitary tumor responsible for excess cortisol production. Transsphenoidal resection of the ACTH-secreting tumor can effectively help normalize cortisol levels and alleviate symptoms.
Successful surgery, especially when performed by experienced surgeons, offers the best chance for long-term remission.
It is typically recommended after confirming the diagnosis and tumor localization via imaging, like MRI. The primary goals are to help restore normal cortisol levels, improve symptoms, and reduce the risk of severe complications such as cardiovascular disease and diabetes.
Radiation Therapy
Radiation therapy (RT), including external-beam radiation and stereotactic radiosurgery (SRS), is used when surgery is insufficient or tumors are aggressive.
RT can help achieve biochemical remission and control tumor growth but often leads to hypopituitarism, requiring lifelong monitoring for tumor recurrence and hormone deficiencies.
Lifestyle Modifications
Diet and lifestyle are foundational for recovery, with a focus on a healthy diet, regular exercise, good sleep, and stress management to support overall well-being and HPA axis function.
A balanced diet plays a crucial role in managing weight, blood sugar, and bone health, while regular exercise improves cardiovascular health, muscle strength, and mood.
Stress management is essential, as reducing stress helps prevent cortisol fluctuations and aids in recovery.
Ongoing medical monitoring is important for the early detection and management of complications such as hypertension, diabetes, osteoporosis, and psychological issues. Regular follow-ups are vital to ensure prompt management of emerging problems, supporting long-term health and quality of life.
[signup]
Conclusion
- Recap of Medication Options
- Adrenal Steroidogenesis Inhibitors: medications like ketoconazole, metyrapone, and osilodrostat are used to help manage cortisol production by blocking adrenal enzymes. They offer rapid cortisol management but require monitoring for side effects like liver toxicity and hypokalemia.
- Pituitary-Directed Treatments: cabergoline and pasireotide target the pituitary gland to help manage ACTH production, thus potentially lowering cortisol levels. They can be effective but may cause side effects such as hyperglycemia and potential cardiac issues.
- Glucocorticoid Receptor Antagonist: mifepristone blocks the effects of cortisol on tissues, helping to manage hyperglycemia and weight gain. It requires careful monitoring for symptoms of adrenal insufficiency and other metabolic disturbances.
- Regularly communicate with healthcare providers to monitor cortisol levels, manage side effects, report symptom changes, and adjust management plans for optimal health outcomes.
- A comprehensive management plan, including medication, lifestyle changes, and monitoring, helps manage symptoms effectively. Appropriate management improves energy, mood, and physical health, enhancing quality of life.
Achuff, J. (2024, February 12). The Surprising Health Benefits of an Extra Hour of Sleep for College Students. Rupa Health. https://www.rupahealth.com/post/the-surprising-health-benefits-of-an-extra-hour-of-sleep-for-college-students
Anderson S. 5 conditions that make it harder to lose weight. Rupa Health. Published July 22, 2022. https://www.rupahealth.com/post/cant-lose-weight-these-5-medical-problems-may-be-why
Buliman, A., Tataranu, L. G., Paun, D. L., Mirica, A., & Dumitrache, C. (2016). Cushing's disease: a multidisciplinary overview of the clinical features, diagnosis, and treatment. Journal of medicine and life, 9(1), 12–18.
Castle-Kirszbaum, M., Goldschlager, T., Shi, M. D. Y., & Fuller, P. J. (2023). Glucocorticoids and Water Balance: Implications for Hyponatremia Management and Pituitary Surgery. Neuroendocrinology, 113(8), 785–794. https://doi.org/10.1159/000530701
Chaudhry HS, Singh G. Cushing Syndrome. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470218/
Chen, Y., Li, Y., Chen, X., & Sun, Q. (2013). Neuropsychiatric disorders and cognitive dysfunction in patients with Cushing’s disease. Chinese Medical Journal, 126(16), 3156–3160. https://doi.org/10.3760/cma.j.issn.0366-6999.20130944
Chiodini, I., & Scillitani, A. (2008). Attuali conoscenze sulla patogenesi dell'osteoporosi: il ruolo dell'increzione di cortisolo [Role of cortisol hypersecretion in the pathogenesis of osteoporosis]. Recenti progressi in medicina, 99(6), 309–313.
Chourpiliadis C, Aeddula NR. Physiology, Glucocorticoids. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560897/
Cloyd J. Complementary and Integrative Medicine Approaches to Managing High Blood Pressure: Specialty Testing, Lifestyle Modifications, and Natural Remedies. Rupa Health. Published May 18, 2023. https://www.rupahealth.com/post/complementary-and-integrative-medicine-approaches-to-managing-high-blood-pressure-testing-lifestyle-modifications-and-natural-remedies
Cloyd, J. Cortisol and Anxiety: Understanding the Connection. (2024, June 7). Rupa Health. https://www.rupahealth.com/post/cortisol-and-anxiety
Cloyd, J. Cortisol and Weight Gain: Understanding the Connection. (2024, April 15). Rupa Health. https://www.rupahealth.com/post/cortisol-and-weight-gain-understanding-the-connection
Cloyd, J. A Root Cause Medicine Protocol For Patients With Osteoporosis: Testing, Therapeutic Diet, and Supportive Supplements. (2023, September 6). Rupa Health. https://www.rupahealth.com/post/a-root-cause-medicine-protocol-for-patients-with-osteoporosis-testing-therapeutic-diet-and-supportive-supplements
Cloyd, J. (2023, May 17). The Role Of Nutrition And Dietary Supplements In Preventing And Managing Cardiovascular Disease. Rupa Health. https://www.rupahealth.com/post/the-role-of-nutrition-and-dietary-supplements-in-preventing-and-managing-cardiovascular-disease
Cortisol. Rupa Health. https://www.rupahealth.com/biomarkers/cortisol
Diorio B. Functional medicine labs that are important for longevity and cognition. Rupa Health. Published January 27, 2023. https://www.rupahealth.com/post/functional-medicine-labs-that-are-important-to-longevity-and-cognition
Diorio, B. (2023, March 17). How to test for hypothalamic-pituitary-adrenal (HPA) axis dysfunction. Rupa Health. https://www.rupahealth.com/post/what-is-the-hypothalamic-pituitary-adrenal-hpa-axis
Drake, W. M., Stiles, C. E., Bevan, J. S., Karavitaki, N., Trainer, P. J., Rees, D. A., Richardson, T. I., Baldeweg, S. E., Stojanovic, N., Murray, R. D., Toogood, A. A., Martin, N. M., Vaidya, B., Han, T. S., Steeds, R. P., UK Cabergoline valvulopathy study group, Baldeweg, F. C., Sheikh, U. E., Kyriakakis, N., Parasuraman, S. K., … Anyiam, S. (2016). A Follow-Up Study of the Prevalence of Valvular Heart Abnormalities in Hyperprolactinemic Patients Treated With Cabergoline. The Journal of clinical endocrinology and metabolism, 101(11), 4189–4194. https://doi.org/10.1210/jc.2016-2224
Dziurkowska, E., & Wesolowski, M. (2021). Cortisol as a Biomarker of Mental Disorder Severity. Journal of clinical medicine, 10(21), 5204. https://doi.org/10.3390/jcm10215204
Ferraù, F., & Korbonits, M. (2015). Metabolic comorbidities in Cushing’s syndrome. European Journal of Endocrinology, 173(4), M133–M157. https://doi.org/10.1530/eje-15-0354
Fleseriu, M., Auchus, R., Bancos, I., Ben-Shlomo, A., Bertherat, J., Biermasz, N. R., Boguszewski, C. L., Bronstein, M. D., Buchfelder, M., Carmichael, J. D., Casanueva, F. F., Castinetti, F., Chanson, P., Findling, J., Gadelha, M., Geer, E. B., Giustina, A., Grossman, A., Gurnell, M., Ho, K., … Biller, B. M. K. (2021). Consensus on diagnosis and management of Cushing's disease: a guideline update. The lancet. Diabetes & endocrinology, 9(12), 847–875. https://doi.org/10.1016/S2213-8587(21)00235-7
Greenan, S. (2021, October 11). 7 Early Signs Of Insulin Resistance. Rupa Health. https://www.rupahealth.com/post/what-is-insulin-resistance
Halimova, Z., & Irgasheva, O. B. (2021). Turakulov Republican Specialized Scientific and Practical Medical Center of Endocrinology of the Ministry of Health of the Republic of Uzbekistan, Tashkent, Republic of Uzbekistan. INTERNATIONAL JOURNAL of ENDOCRINOLOGY (Ukraine), 16(4), 310–315. https://doi.org/10.22141/2224-0721.16.4.2020.208483
Kadmiel, M., & Cidlowski, J. A. (2013). Glucocorticoid receptor signaling in health and disease. Trends in pharmacological sciences, 34(9), 518–530. https://doi.org/10.1016/j.tips.2013.07.003
Kairys N, Anastasopoulou C, Schwell A. Cushing Disease. [Updated 2023 Feb 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448184/
Kalaichandran, A. (2024, April 2). The Clockwork Mood: Understanding Our Internal Rhythms. Rupa Health. https://www.rupahealth.com/post/the-clockwork-mood-understanding-our-internal-rhythms
Khakham, C. Top Labs To Run Bi-Annually On Your Depression Patients. (2023, July 28). Rupa Health. https://www.rupahealth.com/post/top-labs-to-run-bi-annually-on-your-depression-patients
Khakham, C. Top Labs To Run Bi-Annually On Your High Cholesterol Patients. Rupa Health. Published August 3, 2023. https://www.rupahealth.com/post/top-labs-to-run-bi-annually-on-your-high-cholesterol-patients
Khakham, C. (2023, August 25). Top Labs To Run Bi-Annually On Your High Blood Pressure Patients. Rupa Health. https://www.rupahealth.com/post/top-labs-to-run-bi-annually-on-your-high-blood-pressure-patients
Khakham, C. Top Labs To Run Bi-Annually On Your Male Low Libido Patients. Rupa Health. Published August 4, 2023. https://www.rupahealth.com/post/top-labs-to-run-bi-annually-on-your-male-low-libido-patients
Maholy, N. (2023, April 14). How to reduce stress through mind-body therapies. Rupa Health. https://www.rupahealth.com/post/how-to-reduce-stress-through-mind-body-therapies
Menconi, M., Fareed, M., O'Neal, P., Poylin, V., Wei, W., & Hasselgren, P. O. (2007). Role of glucocorticoids in the molecular regulation of muscle wasting. Critical care medicine, 35(9 Suppl), S602–S608. https://doi.org/10.1097/01.CCM.0000279194.11328.77
Mohd Azmi, N. A. S., Juliana, N., Azmani, S., Mohd Effendy, N., Abu, I. F., Mohd Fahmi Teng, N. I., & Das, S. (2021). Cortisol on Circadian Rhythm and Its Effect on Cardiovascular System. International journal of environmental research and public health, 18(2), 676. https://doi.org/10.3390/ijerph18020676
Nath, A., Murthy, G.V.S., Babu, G.R. et al. Effect of prenatal exposure to maternal cortisol and psychological distress on infant development in Bengaluru, southern India: a prospective cohort study. BMC Psychiatry 17, 255 (2017). https://doi.org/10.1186/s12888-017-1424-x
Nieman L. K. (2018). Recent Updates on the Diagnosis and Management of Cushing's Syndrome. Endocrinology and metabolism (Seoul, Korea), 33(2), 139–146. https://doi.org/10.3803/EnM.2018.33.2.139
Nieman, L. K., Biller, B. M., Findling, J. W., Newell-Price, J., Savage, M. O., Stewart, P. M., & Montori, V. M. (2008). The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline. The Journal of clinical endocrinology and metabolism, 93(5), 1526–1540. https://doi.org/10.1210/jc.2008-0125
Nieman, L. K., Biller, B. M., Findling, J. W., Murad, M. H., Newell-Price, J., Savage, M. O., Tabarin, A., & Endocrine Society (2015). Treatment of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline. The Journal of clinical endocrinology and metabolism, 100(8), 2807–2831. https://doi.org/10.1210/jc.2015-1818
Orbeta R. 10 Type 2 Diabetes Risk Factors You May Not Know About. Rupa Health. Published June 6, 2022. https://www.rupahealth.com/post/what-causes-type-2-diabetes
Pappachan, J. M., Hariman, C., Edavalath, M., Waldron, J., & Hanna, F. W. (2017). Cushing’s syndrome: a practical approach to diagnosis and differential diagnoses. Journal of Clinical Pathology, 70(4), 350–359. https://doi.org/10.1136/jclinpath-2016-203933
Pivonello, R., De Leo, M., Cozzolino, A., & Colao, A. (2015). The Treatment of Cushing's Disease. Endocrine reviews, 36(4), 385–486. https://doi.org/10.1210/er.2013-1048
Ramírez-Villaescusa, J., Ruiz-Picazo, D., Oliveira, C. L., & Morillas-Ariño, C. (2020). Secondary thoracolumbar deformity and sagittal imbalance due to osteoporosis in a young man with Cushing's disease: A case report. International journal of surgery case reports, 76, 134–138. https://doi.org/10.1016/j.ijscr.2020.09.182
Salvio, G., Martino, M., Giancola, G., Arnaldi, G., & Balercia, G. (2021). Hypothalamic–Pituitary Diseases and Erectile Dysfunction. Journal of Clinical Medicine, 10(12), 2551. https://doi.org/10.3390/jcm10122551
Steffensen, C., Bak, A. M., Rubeck, K. Z., & Jørgensen, J. O. (2010). Epidemiology of Cushing's syndrome. Neuroendocrinology, 92 Suppl 1, 1–5. https://doi.org/10.1159/000314297
Stratakis C. A. (2016). Skin manifestations of Cushing's syndrome. Reviews in endocrine & metabolic disorders, 17(3), 283–286. https://doi.org/10.1007/s11154-016-9399-3
Sweetnich J. Integrative Treatment Options for Adrenal Disorders: Specialty Testing, Nutrition, Supplements. Rupa Health. Published June 12, 2023. https://www.rupahealth.com/post/integrative-treatment-options-for-adrenal-disorders-specialty-testing-nutrition-supplements
Thau L, Gandhi J, Sharma S. Physiology, Cortisol. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538239/
Tomita A. (1998). Nihon rinsho. Japanese journal of clinical medicine, 56(6), 1574–1578.
Varlamov, E. V., Han, A. J., & Fleseriu, M. (2021). Updates in adrenal steroidogenesis inhibitors for Cushing's syndrome - A practical guide. Best practice & research. Clinical endocrinology & metabolism, 35(1), 101490. https://doi.org/10.1016/j.beem.2021.101490
Weinberg, J. 34 Million Americans Have This Symptomless Bone Condition - Here’s How You Can Prevent It. Rupa Health. Published August 16, 2022. https://www.rupahealth.com/post/osteopenia-prevention
Weinberg, J. ACTH Hormone: Roles, Regulation, and Health Implications. (2024, April 5). Rupa Health. https://www.rupahealth.com/post/acth-hormone-roles-regulation-and-health-implications
Whitworth, J. A., Williamson, P. M., Mangos, G., & Kelly, J. J. (2005). Cardiovascular consequences of cortisol excess. Vascular health and risk management, 1(4), 291–299. https://doi.org/10.2147/vhrm.2005.1.4.291
Yoshimura, H. (2023, November 7). The remarkable power of exercise on our health: A comprehensive overview. Rupa Health. https://www.rupahealth.com/post/the-remarkable-power-of-exercise-on-our-health-a-comprehensive-overview
%201.svg){kind=logo}
