Editing Cushing's syndrome (section)

==Treatment==
[[File:Management algorithm of Cushing's disease.png|thumb|Management algorithm of Cushing's disease:<ref name=Fleseriu2021/><br>DST=dexamethasone suppression test.<br>IPSS=inferior petrosal sinus sampling.<br>ACTH=adrenocorticotropic hormone.<br>*Pituitary surgery should be performed by an experienced surgeon.<br>†Absence of ACTH-staining adenoma.<br>‡See table 2 and panel 3 for considerations regarding selection of medical therapy.<br>§Lifelong monitoring for hypopituitarism and secondary neoplasia in the radiation field required.<br>¶On maximum tolerated dose of the drug.]]

Most cases of Cushingoid symptoms are caused by corticosteroid medications, such as those used for asthma, arthritis, eczema and other inflammatory conditions.  Consequently, most patients are effectively treated by carefully tapering off (and eventually stopping) the medication that causes the symptoms.{{citation needed|date=August 2020}}

If an adrenal adenoma is identified, it may be removed by surgery. An ACTH-secreting corticotrophic [[pituitary adenoma]] should be removed after diagnosis. Regardless of the adenoma's location, most patients require steroid replacement postoperatively at least in the interim, as long-term suppression of pituitary ACTH and normal adrenal tissue does not recover immediately. Clearly, if both adrenals are removed, replacement with [[hydrocortisone]] or [[prednisolone]] is imperative.{{citation needed|date=August 2020}}

In those patients not suited for or unwilling to undergo surgery, several drugs have been found to inhibit cortisol synthesis (e.g. [[ketoconazole]], [[metyrapone]]) but they are of limited efficacy.{{Citation needed|date=July 2013}} [[Mifepristone]] is a powerful glucocorticoid type II receptor antagonist and, since it does not interfere with normal cortisol homeostasis type I receptor transmission, may be especially useful for treating the cognitive effects of Cushing's syndrome.<ref>{{cite journal | vauthors = Belanoff JK, Flores BH, Kalezhan M, Sund B, Schatzberg AF | title = Rapid reversal of psychotic depression using mifepristone | journal = Journal of Clinical Psychopharmacology | volume = 21 | issue = 5 | pages = 516–521 | date = October 2001 | pmid = 11593077 | doi = 10.1097/00004714-200110000-00009 | s2cid = 3067889 }}</ref> However, the medication faces considerable controversy due to its use as an [[abortifacient]]. In February 2012, the FDA approved mifepristone to control high blood sugar levels ([[hyperglycemia]]) in adult patients who are not candidates for surgery, or who did not respond to prior surgery, with the warning that mifepristone should never be used by pregnant women—although pregnancy is extremely rare during the course of Cushing's Syndrome.<ref>{{cite journal | vauthors = Parksook WW, Porntharukchareon T, Sunthornyothin S | title = Desmopressin Stimulation Test in a Pregnant Patient with Cushing's Disease | journal = AACE Clinical Case Reports | volume = 8 | issue = 3 | pages = 105–108 | date = 2022-05-30 | pmid = 35602876 | pmc = 9123553 | doi = 10.1016/j.aace.2021.11.005 }}</ref><ref>{{cite journal | vauthors = Caimari F, Valassi E, Garbayo P, Steffensen C, Santos A, Corcoy R, Webb SM | title = Cushing's syndrome and pregnancy outcomes: a systematic review of published cases | journal = Endocrine | volume = 55 | issue = 2 | pages = 555–563 | date = February 2017 | pmid = 27704478 | doi = 10.1007/s12020-016-1117-0 | s2cid = 19349163 }}</ref><ref>{{cite journal | vauthors = Lindsay JR, Jonklaas J, Oldfield EH, Nieman LK | title = Cushing's syndrome during pregnancy: personal experience and review of the literature | journal = The Journal of Clinical Endocrinology and Metabolism | volume = 90 | issue = 5 | pages = 3077–3083 | date = May 2005 | pmid = 15705919 | doi = 10.1210/jc.2004-2361 | s2cid = 37344210 | doi-access = free }}</ref><ref>{{cite web |url=http://www.salutedomani.com/il_weblog_di_antonio/2012/02/fda-approves-mifepristone-korlym-for-patients-with-endogenous-cushing-s-syndrome.html |title=FDA approves mifepristone (Korlym*) for patients with endogenous Cushing' s syndrome |date=February 18, 2012 |url-status=dead |archive-url=https://archive.today/20120909132942/http://www.salutedomani.com/il_weblog_di_antonio/2012/02/fda-approves-mifepristone-korlym-for-patients-with-endogenous-cushing-s-syndrome.html |archive-date=September 9, 2012 }}</ref> In March 2020, Isturisa ([[osilodrostat]]) oral tablets a 11-beta-hydroxylase enzyme inhibitor was approved by FDA for treating those patients who cannot undergo pituitary surgery or for patients who underwent surgery but continue to have the disease.<ref>{{Cite web | author = Office of the Commissioner|date=2020-03-24|title=FDA Approves New Treatment for Adults with Cushing's Disease|url=https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-adults-cushings-disease|access-date=2020-06-21|website=FDA|language=en}}</ref>

Removal of the adrenals in the absence of a known tumor is occasionally performed to eliminate the production of excess cortisol.<ref>{{cite journal | vauthors = Aggarwal S, Yadav K, Sharma AP, Sethi V | title = Laparoscopic bilateral transperitoneal adrenalectomy for Cushing syndrome: surgical challenges and lessons learnt | journal = Surgical Laparoscopy, Endoscopy & Percutaneous Techniques | volume = 23 | issue = 3 | pages = 324–328 | date = June 2013 | pmid = 23752002 | doi = 10.1097/SLE.0b013e318290126d | s2cid = 34513590 }}</ref> In some occasions, this removes negative feedback from a previously occult pituitary adenoma, which starts growing rapidly and produces extreme levels of ACTH, leading to hyperpigmentation. This clinical situation is known as [[Nelson's syndrome]].<ref name="pmid14426442">{{cite journal | vauthors = Nelson DH, Meakin JW, Thorn GW | title = ACTH-producing pituitary tumors following adrenalectomy for Cushing's syndrome | journal = Annals of Internal Medicine | volume = 52 | issue = 3 | pages = 560–569 | date = March 1960 | pmid = 14426442 | doi = 10.7326/0003-4819-52-3-560 }}</ref>