THERAPY IN ENDOCRINE DISEASE: Etomidate in the management of hypercortisolaemia in Cushing's syndrome: a review

Abstract

The authors apologise for the publication of an error in Table 2 of this article published in the European Journal of Endocrinology 167 137–143. They wish to make clear in Table 2 that they are stipulating the dose of etomidate and that the corresponding dose of hydrocortisone for complete blockade should be 0.5–1.0 mg/h. The correct table is published in full below.Table 2Treatment of hypercorticolism with etomidate: Recommendations.Infusion rate optionsBlockadeCortisol levelBiochemical monitoringOtherEtomidate (IV) 0.04–0.05 m/kg per h=2.5–3.0 mg/hPartial to complete depending on clinical circumstance of the patientTitrate to serum cortisol 500–800 nmol/l in physiologically stressed patient, 150–300 nmol/l in non-physiologically stressed patientPotassium level Cortisol levelSedation scoring initially every two hours then every 12 hours after first 24 hoursHydrocortisone IV 0.5–1.0 mg/hComplete (will need steroid replacement)<150 nmol/lPotassium level Cortisol levelThis table could now be used as a practical guide for clinicians commencing infusions on the ward of etomidate and required hydrocortisone replacement.

A critical reappraisal of bilateral adrenalectomy for ACTH-dependent Cushing's syndrome

“…I.v. low-dose etomidate infusion rates for the treatment of hypercortisolaemia are 0.04-0.05 mg/kg per h, which equates to 2.5-3 mg/h with dose titration according to serum cortisol levels (31), and a maximum dose of up to 5 mg/h in selected cases. Based on the pharmacokinetic properties of etomidate, cortisol levels fall within 12-24 h (32).…”

“…Monitoring of serum cortisol levels is necessary to achieve the desired blockade and to prevent hypoadrenalism. The aim is to titrate serum cortisol levels to 500-800 nmol/l in physiologically stressed patients and to 150-300 nmol/l in unstressed patients (31). The treatment goals depend on the patient's presentation, and they include the normalisation of hypokalaemia, the control of hypertension and myopathy, the amelioration of psychosis and immunosuppression.…”

“…The treatment goals depend on the patient's presentation, and they include the normalisation of hypokalaemia, the control of hypertension and myopathy, the amelioration of psychosis and immunosuppression. Whether ICU stay during etomidate application should be mandatory remains controversial (31,33). Our approach requires the initiation of etomidate in the ICU for 2 days and transfer to a normal ward thereafter when cortisol levels are in a safe and stable range and surgery cannot be performed immediately.…”

Treatment of Cushing's disease: a mechanistic update

“…Glucocorticoid replacement to prevent adrenal insufficiency is warranted after 24 h of etomidate infusion. Clinical use of etomidate in CS has been limited by sedative side effects, but could be safe and effective in significant biochemical disturbance, sepsis, severe psychosis, and in preoperative instability (Heyn et al 2012, Preda et al 2012). …”

Emerging drugs for Cushing’s disease

“…It may be useful in hospitalised patients, when infused intravenously at a low dose [33]. It is the only available agent for patients unable to take medication by mouth and can be a useful therapy for severe hypercortisolaemia in patients intolerant of or unable to take oral medication.…”