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Cushing's Syndrome Treatment

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Key Points Î Treatment of Cushing's syndrome (CS) is essential to reduce mortality and associated comorbidities. Î Effective treatment includes the normalization of cortisol levels or action. It also includes the normalization of comorbidities via directly treating the cause of CS and by adjunctive treatments (e.g., antihypertensives). Î Surgical resection of the causal lesion(s) is generally the first-line approach. Î The choice of second-line treatments, including medication, bilateral adrenalectomy, and RT (for corticotroph tumors), must be individualized to each patient. Treatment Treatment Goals for Cushing's Syndrome Î In patients with overt CS, the Endocrine Society (ES) recommends normalizing cortisol levels or action at its receptors to eliminate the signs and symptoms of CS and treating comorbidities associated with hypercortisolism. (1|⊕⊕⊕ ) Î ES recommends against treatment to reduce cortisol levels or action if there is not an established diagnosis of CS. (1|⊕ ) Î ES suggests against treatments designed to normalize cortisol or its action when there is only borderline biochemical abnormality of the hypothalamic- pituitary-adrenal (HPA) axis without any specific signs of CS. The benefit of treating to normalize cortisol is not established in this setting. (2|⊕ ) Optimal Adjunctive Management Î ES recommends providing education to patients and their family/ caretaker(s) about their disease, treatment options, and what to expect after remission. (US) Î ES recommends that all patients receive monitoring and adjunctive treatment for cortisol-dependent comorbidities (psychiatric disorders, diabetes, hypertension, hypokalemia, infections, dyslipidemia, osteoporosis, and poor physical fitness). (US) Î ES recommends that a multidisciplinary team, including an experienced endocrinologist, takes patient values and preferences into consideration and provides education about the treatment options to the patient. (US) Î ES suggests evaluating CS patients for risk factors for venous thrombosis. (2|⊕⊕ ) Î In patients with CS undergoing surgery, ES suggests perioperative prophylaxis for venous thromboembolism. (2|⊕⊕ )

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