Long‐term effects of glucocorticoid excess on the brain

Transsphenoidal surgery is the first-line treatment for Cushing's disease to selectively remove the tumor. The rate of postoperative remission is estimated around 70%-80% in expert centers. However, the long-term remission rate is lower because of recurrence during follow-up that can be observed in 15% to 25% of the patients depending on the studies and duration of follow-up. There is no significant predictive factor of recurrence before surgery, but postoperative corticotroph insufficiency and its duration has been found to be a protective factor for recurrence in many studies.The persistence of a positive response to desmopressin after surgery is associated with a higher rate of recurrence. Long term monitoring for recurrence with annual clinical and hormonal investigations after the hypothalamic-pituitary-adrenal axis postoperative recovery is advised. The biological tests used for the diagnosis of Cushing's syndrome (24 h-urinary-free cortisol [UFC], late-night salivary or serum cortisol, 1 mg dexamethasone suppression test) can be used to screen for recurrence.Several studies report that increased late night cortisol and alterations of dynamic testing can be observed before the increased 24 h-UFC. For this reason it is suggested that late-night salivary cortisol would be a very sensitive tool to diagnose recurrence, pending the realization of several assays in case of borderline or discrepant result. This review will summarize the knowledge about recurrence of Cushing's disease after pituitary surgery and the current recommendations for its monitoring and diagnosis.

Section: Discussionmentioning

confidence: 99%

Long‐term follow‐up and predictors of recurrence of Cushing's disease

Guignat

Bertherat

2022

“…Interestingly, in these patients, growth hormone replacement was found to be associated with improved outcome, whereas This article is part of an update series on the diagnosis and treatment of Cushing's syndrome. [77][78][79][80][81][82][83][84][85][86][87][88][89][90][91][92][93][94]…”

Section: In Cre a S Ed Mortalit Y De S Pite B Iochemic Al Remiss Ionmentioning

confidence: 99%

Long‐term morbidity and mortality in patients with Cushing's syndrome

Braun

Vogel

Reincke

2022

Increased multisystem morbidity and mortality in patients with Cushing's syndrome comprise clinical problems and challenges, both at the time of diagnosis and in remission. Relevant comorbidities and clinical problems include hypertension, diabetes, overweight, myopathy and a high risk for acute complications such as infections and venous thrombembolism. Although there are therapy recommendations for most of these comorbidities, there is a lack of large, prospective studies to confirm and optimise them. Mortality is especially high during active disease and within the first year after diagnosis, as a result of cardiovascular events, infections and suicide. All in all, interdisciplinary therapy management is important for reducing morbidity and mortality over the long‐term.

“…This article is part of an update series on the diagnosis and treatment of Cushing's syndrome. [27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43]…”

Section: Discussionmentioning

confidence: 99%

Medical management of Cushing's disease: When and how?

Castinetti

2022

Transsphenoidal surgery is the first‐line treatment of Cushing's disease. However, medical treatment can be given in a high proportion of patients with this rare condition. This is especially the case in severe hypercortisolism for which medical treatment will be given for a short period of time to prepare the patient for surgery, or on a long‐term basis after failed transsphenoidal surgery, or when waiting for the maximal beneficial effect of radiation techniques. These different situations all require that hypercortisolism be perfectly controlled. Severe hypercortisolism is frequently treated by a block and replace approach during which a substitutive treatment is given after the induction of adrenal insufficiency. Mild hypercortisolism, the most frequent situation, is usually treated with a titration approach with a progressive dose increase. This approach requires certainty of eucortisolism because patients may be treated for a prolonged period. This review details the main situations during which medical treatment should be considered, as well as the way in which to monitor them to avoid the long‐term consequences of mild hypo‐ or hypercortisolism.