What would Harvey Cushing say about Cushing’s disease today?

(BPT) - More than 80 years ago renowned neurosurgeon, Dr. Harvey Cushing, discovered a tumor on the pituitary gland as the cause of a serious, hormone disorder that leads to dramatic physical changes in the body in addition to life-threatening health concerns. The discovery was so profound it came to be known as Cushing’s disease. While much has been learned about Cushing’s disease since the 1930s, awareness of this rare pituitary condition is still low and people often struggle for years before finding the right diagnosis.

Read on to meet the man behind the discovery and get his perspective on the present state of Cushing’s disease.

* What would Harvey Cushing say about the time it takes for people with Cushing’s disease to receive an accurate diagnosis?

Cushing’s disease still takes too long to diagnose!

Despite advances in modern technology, the time to diagnosis for a person with Cushing’s disease is on average six years. This is partly due to the fact that symptoms, which may include facial rounding, thin skin and easy bruising, excess body and facial hair and central obesity, can be easily mistaken for other conditions. Further awareness of the disease is needed as early diagnosis has the potential to lead to a more favorable outcome for people with the condition.

* What would Harvey Cushing say about the advances made in how the disease is diagnosed?

Significant progress has been made as several options are now available for physicians to use in diagnosing Cushing’s disease.

In addition to routine blood work and urine testing, health care professionals are now also able to test for biochemical markers - molecules that are found in certain parts of the body including blood and urine and can help to identify the presence of a disease or condition.

* What would Harvey Cushing say about disease management for those with Cushing’s disease today?

Patients now have choices but more research is still needed.

There are a variety of disease management options for those living with Cushing’s disease today. The first line and most common management approach for Cushing’s disease is the surgical removal of the tumor. However, there are other management options, such as medication and radiation that may be considered for patients when surgery is not appropriate or effective.

* What would Harvey Cushing say about the importance of ongoing monitoring in patients with Cushing’s disease?

Routine check-ups and ongoing monitoring are key to successfully managing Cushing’s disease.

The same tests used in diagnosing Cushing’s disease, along with imaging tests and clinical suspicion, are used to assess patients’ hormone levels and monitor for signs and symptoms of a relapse. Unfortunately, more than a third of patients experience a relapse in the condition so even patients who have been surgically treated require careful long-term follow up.

* What would Harvey Cushing say about Cushing’s disease patient care?

Cushing’s disease is complex and the best approach for patients is a multidisciplinary team of health care professionals working together guiding patient care.

Whereas years ago patients may have only worked with a neurosurgeon, today patients are typically treated by a variety of health care professionals including endocrinologists, neurologists, radiologists, mental health professionals and nurses. We are much more aware of the psychosocial impact of Cushing’s disease and patients now have access to mental health professionals, literature, patient advocacy groups and support groups to help them manage the emotional aspects of the disease.

Learn More

Novartis is committed to helping transform the care of rare pituitary conditions and bringing meaningful solutions to people living with Cushing’s disease. Recognizing the need for increased awareness, Novartis developed the “What Would Harvey Cushing Say?” educational initiative that provides hypothetical responses from Dr. Cushing about various aspects of Cushing’s disease management based on the Endocrine Society’s Clinical Guidelines.

For more information about Cushing’s disease, visit www.CushingsDisease.com or watch educational Cushing’s disease videos on the Novartis YouTube channel at www.youtube.com/Novartis.

From http://www.jsonline.com/sponsoredarticles/health-wellness/what-would-harvey-cushing-say-about-cushings-disease-today8087390508-253383751.html

Dr Friedman: Meeting on Thyroid and Hormonal Problems

Dr. Theodore Friedman will host a free meeting on thyroid and hormonal problems on Sunday February 16 from 7-8 PM PST at Anshe Emes synagogue-1490 S. Robertson Blvd., Los Angeles, CA 90035.

The meeting will be videoconferenced to those who cannot make it in person.

To sign up for the videoconference, email mail@goodhormonehealth.com by February 14.

Cushing’s Patient Awareness Day Invitation

Cushing’s Awareness Patient Day

Saturday, February 1st, 2014

San Francisco, California

Hosted by Kate Tully, R.N. and Katherine Waidner, R.N.
Cushing’s Patient Advocates – Corcept Therapeutics

Agenda and details to follow

The day will focus on endogenous Cushing’s, a condition caused by high cortisol in your body.

The day will not cover exogenous Cushing’s caused by steroids taken for various health conditions including asthma, arthritis or lupus.

Cushing’s Awareness Patient Day

Saturday, February 1st, 2014

San Francisco, California

Hosted by Kate Tully, R.N. and Katherine Waidner, R.N.

Cushing’s Patient Advocates – Corcept Therapeutics

Agenda and details to follow

The day will focus on endogenous Cushing’s, a condition caused by high cortisol in your body.

The day will not cover exogenous Cushing’s caused by steroids taken for various health conditions including asthma, arthritis or lupus.

Tonight! Interview with Miriam K (Meeks089), Pituitary Success Story

Miriam writes in her bio:

"I suffered for eight long years with Cushings disease . I had surgery on August 1 , 2012 , I look like a different person , and act like a different person. I would love to share my journy . One that was an emotional roller coaster .

It was a long hellish journey .However I would not trade it for anything else in the world.

Although I suffered immensly, Cushings has made me who I am today. I have become strong from this disease. Although I suffered many symptoms, the emotional ones were by far the worst.

I would love to be interveiwed because I vowed when I was ill to help people when I got better.

I want to give people hope ."

MaryONote:  Miriam will be interviewed on BlogTalkRadio podcasts December 4, 2013 at 6:00PM Eastern.

If you want to ask Miriam a question, please use the call-in number: (646) 200-0162

Archives will be available at Cushings-Help on BlogTalkRadio a few hours after the conclusion of this interview.

Happy Thanksgiving!

Have a Happy Thanksgiving!

Are you carrying adrenal Cushing’s syndrome without knowing it?

Interview with Miriam K (Meeks089), Pituitary Success Story

Miriam writes in her bio:

"I suffered for eight long years with Cushings disease . I had surgery on August 1 , 2012 , I look like a different person , and act like a different person. I would love to share my journy . One that was an emotional roller coaster .

It was a long hellish journey .However I would not trade it for anything else in the world.

Although I suffered immensly, Cushings has made me who I am today. I have become strong from this disease. Although I suffered many symptoms, the emotional ones were by far the worst.

I would love to be interveiwed because I vowed when I was ill to help people when I got better.

I want to give people hope ."

MaryONote:  Miriam will be interviewed on BlogTalkRadio podcasts December 4, 2013.

Rare Disease Week

The House & Senate Congressional Calendars came out this week!

Congress is in session during Rare Disease Week – SaveTheDate!

Feb. 25th – Feb. 28th, 2013

4 Days of Rare Disease Events in Washington DC!

More info coming soon.

Adrenal Insufficiency Video

From Adrenal Insufficiency United

A video about Adrenal Insufficiency and the need for emergency protocols.

An injection which costs about $10 could save a life.

Please help us make sure it's available to all who need it.

http://youtu.be/yKPnNNM_dIw

Prince George’s woman works to raise awareness about rare disease

Lanham resident to speak at Patient Education Day event about Cushing’s disease

By Sophie Petit Staff Writer

Greg Dohler/The Gazette

Lanham resident Stacey L. Hardy, a survivor of Cushing’s disease, will speak about her experience with the pituitary disorder at an upcoming event at Johns Hopkins Hospital.

Stacy L. Hardy of Lanham described herself as athletic, which is why she became concerned when in 1996 she mysteriously gained 240 pounds that took five doctors 14 years to determine she had a potentially fatal disease.

Now Hardy said she wants to raise awareness among others who may unknowingly have Cushing’s disease, but are unaware of the symptoms and treatment.

It wasn’t until 2010 that Hardy, now 43, was diagnosed with the disease, a rare disorder that causes the body to release too much cortisol, the body’s stress or “fight or flight” hormone, said Gary Wand, a pituitary gland specialist at The Johns Hopkins Hospital in Baltimore.

Excess cortisol causes weight gain, especially in the stomach, extreme fatigue, muscle aches, anxiety and depression, he said.

“I didn’t even know what Cushing’s was. I was ready to just live with [the symptoms],” Hardy said, adding that by the time she was diagnosed she felt so tired she could barely move.

At 5 feet, 4 inches tall, Hardy said she reached 365 pounds during her struggle with the disease.

“We knew something for a while wasn’t right, but I never thought it would be something like that,” said Hardy’s daughter, Paij Hardy, 21, a student at Baltimore City Community College.

Just three out of every one million people are diagnosed with Cushing’s each year, said Wand, who estimates he sees 30 patients per year worldwide.

In 2011, Hardy underwent 16 hours of surgery at Sinai Hospital in Baltimore to remove four tumors from her pituitary gland, located at the base of the brain that controls the release of cortisol.

Today, she is 100 pounds lighter, with the weight still rapidly coming off, and said she is determined to serve as a lifelong support and education source for her fellow “cushies” — others with Cushing’s disease.

Hardy will speak Saturday at the Johns Hopkins Pituitary Gland Center’s fifth annual Patient Education Day, an event to raise awareness about the disease, Wand said.

Since the pituitary gland is the size of a kidney bean, Hardy underwent several brain scans before doctors, who previously suggested she might have leukemia or needed to diet and exercise more, could tell there were tumors on her gland, she said.

Hardy’s experience with delayed diagnosis and misdiagnosis is not unique, Wand said.

Cushing’s is a “subtle” disease, which is difficult to diagnose, and not everyone exhibits the same symptoms, he said.

If left untreated for more than a decade, the disease is fatal, but removing the pituitary gland tumors has proved extremely successful, Wand said.

“I’m evidence that there’s help out there,” Hardy said. “I can move. I can almost run. I can bend over and pick up a box. Oh my goodness, I can dance.”

From http://www.gazette.net/article/20130926/NEWS/130929354/1077/prince-george-x2019-s-woman-works-to-raise-awareness-about-rare&template=gazette

Enzyme linked to obesity

Researchers find that increased levels of an enzyme in fat cells lead to dangerous levels of abdominal obesity.

Previous studies have shown that the stress hormone cortisol can lead to an accumulation of fat round the abdomen. For instance, people with Cushing’s disease – where there’s excess cortisol in the blood – have too much abdominal fat. It’s bad for health to have fat in this area – it’s linked to diabetes and heart disease. That’s why it’s healthier to be a ‘pear shape’ rather than an ‘apple shape’. The distribution of fat in your body really does matter.

Researchers in Scotland and the US have now focussed upon an enzyme that produces cortisol to see what effect it has on abdominal fat. Working on mice genetically-modified to produce the enzyme – and therefore cortisol – in fat cells, they find that even a small increase in levels produces dramatic effects. The mice, compared with normal animals, gained fat in the abdominal area even on a low fat diet. They developed diabetes, high blood pressure, and also tended to eat more. It opens up the possibility of further studies on human obesity, and also perhaps could lead to therapies that block this enzyme and so reduce fat accumulation.

From http://www.tele-management.ca/2013/09/enzyme-linked-to-obesity/

Hormonal disorder may make weight loss more challenging

(HealthDay News) -- Losing weight is never a piece of cake, but there are some medical conditions that may make it even more difficult.

The American Academy of Family Physicians says these conditions may make weight loss more of a challenge:

• Hormonal disorders, such as diabetes, hypothyroidism, Cushing's disease and polycystic ovary syndrome.
• Cardiovascular problems, including heart-valve disorders and congestive heart failure.
• Disorders affecting sleep, including obstructive sleep apnea and upper airway resistance syndrome.
• Eating disorders, such as bulimia and carbohydrate craving syndrome.

The Man Unable to Feel Fear

Jordy is a British man who has been dealing with Cushing's and many surgeries.

http://www.youtube.com/watch?v=CZaGnFTjSsc

---

He finds rollercoasters boring, barely broke a sweat zip-wiring off the Tyne bridge and even a parachute jump did not raise his heart rate.

Just a few years ago even the thought of daredevil exploits would have terrified him, but now Jordy Cernik is frightened of nothing.

While that might sound an ideal scenario, the 38-year-old’s new-found bravery is actually the unexpected side-effect of surgery for a rare condition.

Cushing’s Syndrome resulted in the dad-of-two having an operation to remove the gland which produces adrenalin, the hormone which makes us feel scared.

He says: “I would never have had the guts to do any of this, but now nothing fazes me. I’m up for anything – I’m even thinking about doing a wing-walk on a plane too.

“I nearly did a bungee jump a few years ago, but I just couldn’t do it.

"Now I just take whatever is thrown at me and if a challenge helps me raise money for charity, the more daring the better.”

Over the past four months he has completed the parachute jump and zip-wired from the top of Newcastle’s Tyne Bridge and now he is getting ready to complete the last of a trio of challenges – next month’s Bupa Great North Run.

“The doctors didn’t tell me this could be one of the side-effects of the operation,” says Jordy. “But then the condition is so rare I don’t think they know everything about Cushing’s yet.

“Doing the skydive was the ultimate test. I thought that if I was ever going to get scared again then that would be the moment.

"But as we took off in the plane I felt nothing, and when I edged towards the door to jump I felt nothing, and even when I leapt out and pulled my parachute, I didn’t feel scared at all.

“It can be quite frustrating as well though.

"The first time I realised I had changed was when I went on the rides at a theme park with my kids and I just didn’t feel a thing. I just sat there, bored.”

However, the last of his hat-trick of challenges, the Run, will require him to push through the ever-present pain which he has endured for years as a result of Cushing’s.

Britain’s biggest mass participation event, for which The Daily Mirror is a media partner, takes place over a 13.1 mile course from Newcastle to South Shields.

But the syndrome has left Jordy, from Jarrow, near Newcastle, with arthritis, back problems and brittle bones. Worse still, the absence of adrenalin means he now lacks one of the body’s natural painkillers.

“I’m always in pain,” he says. “I’ve just had to learn to zone it out day-to-day and I’m going to have to do that even more when I’m on the run.”

Cushing’s affects around one in 50,000 people in Britain.

It causes a malfunction of the adrenal and pituitary glands which means increased amounts of corticosteroids are produced – often leading to massive, irregular weight gain.

In just three years 5ft 8in Jordy ballooned from 11st 5lb to almost 17st.

While his limbs remained slim, the former Territorial Army recruit saw the pounds pile around the major organs in his torso and head.

“I went through years of hell and I can only describe it as living in someone else’s body,” says the part-time radio presenter and events host.

“I developed this big round moon face and really quite large man boobs, which was so embarrassing.

“But there was absolutely nothing I could do about it. I could go to the gym six days a week and still couldn’t lose any of the weight.

"One of the worst things was that people would stare.

"Sometimes they’d take the mickey – often to try and make me feel better, by making light of things – but it would almost always hurt my feelings.

“And my career as a presenter suffered. I tried to play up to the character of being a big, jolly chap but I always felt I was too fat for TV, which is what I would have liked to do a lot more of.”

But it was the effect on his home life with wife Tracy, 43, and daughters Aimee, seven, and four-year-old Eive that for him was far worse.

“I had other really difficult symptoms which included profuse sweating which meant I couldn’t even hold my kids without wrapping them in towels first,” he says.

“Anyone who has children knows how hard that is, not to be able to do normal things. I often used to be in tears.

"Another symptom was extreme grumpiness, so I would find myself suddenly getting really angry and just exploding at them, plus I was always too exhausted to play with them. It was terrible.”

Jordy believes he can trace his symptoms back 15 years although his Cushing’s was only diagnosed in 2005.

He had visited his local surgery with a string of complaints, but by chance saw a different doctor one day and the syndrome was diagnosed.

“I don’t have any ill-feeling about that,” he says, “because the syndrome can be tricky to spot, partly because it is so rare.”

He went on to have both his pituitary and adrenal glands removed but needed a total of seven operations between 2005 and 2010 and not all went smoothly.

During one to remove his pituitary gland, which is inside the skull, the lining of his brain burst due to the stress of repeated surgery.

And while removing a rib to access the adrenal gland in his torso, his lung was punctured.

That wasn’t the end of the complications. He later developed severe meningitis and ended up on a life-support machine.

“But I still consider myself lucky,” he says. “The doctors told me, ‘You died twice really, you shouldn’t even be here’.”

Things have begun to look up in the past few years, however. The Cushing’s is in remission and Jordy has lost four stone.

His life hasn’t returned to normal entirely – he still has to take 30 pills a day, a cocktail of painkillers and hormones, plus drugs to slow the corrosion of his bones.

He has also been diagnosed with another rare condition, sarcoidosis, which creates nodules of irregular cells in the body and can cause serious complications. He’s convinced he has always had it but it has lain dormant until his body was at its most vulnerable.

At present the nodules can only be found on his skin and he’s being monitored to ensure that it doesn’t spread to his internal organs.

Thanks to the surgery, his life has improved enormously since 2010.

In July he had a breast reduction op which not only improved his appearance but also removed the dangerous accumulation of fat around his heart.

Part of this new chapter involves taking part in the Great North Run and raising money for the Cash for Kids appeal run by his local radio station Metro Radio.

The appeal aims to help children and young people in the North East who are disabled or have special needs, or those who suffer from abuse or neglect.

Jordy’s fundraising goal is a relatively modest £1,000, but for him joining the half marathon’s 56,000 participants on September 15 will be as rewarding as hitting his target.

“I really don’t know if I’ll be able to complete the course.” he says. “But I’m looking forward to it and I’m going to give it my best shot.

“Not feeling fear may feel like the power of a superhero, but what I really need for the Great North Run is superhero strength.”

The Bupa Great North Run is Britain’s biggest mass participation event and is organised by Nova International.

It will include world class athletes Mo Farah, Haile Gebrselassie and Kenenisa Bekele – plus 56,000 other runners.

The event is live on BBC One on Sunday 15th September between 9.30am to 13.30

For more information, visit www.greatrun.org

From  http://www.mirror.co.uk/news/real-life-stories/jordy-cernik-man-unable-fear-2208002#ixzz2cny6XeFr 

2nd Annual Patient Advocacy Summit

Come join us for our 2nd Annual “RARE Patient Advocacy Summit”
to be held on Friday, September 20, 2013
at The Balboa Bay Club & Resort in Newport Beach, CA.

Register today!

Seating is limited for in-person participation.

Webcast registration available for those unable to attend in person.

From Symptom to Cure:  The Journey of a Rare Disease Advocate ~ Equipping Patients to Make a Difference

Join Global Genes | RARE Project for a unique and interactive educational experience at our 2^nd Annual Patient Advocacy Summit on Friday, September 20, 2013.   There is no charge to participate in this event.

A rare diagnosis changes everything. It crashes plans and dreams, knocks you off your feet, and requires a continual investment of time and money as you try to determine what should be your next step.  The purpose of the RARE Patient Advocacy Summit is to help patient ADVOCATES become successful ACTIVISTS and to provide the discussion, insights and tools to move down this advocacy path, equipped and prepared.

The summit will offer practical advice, case studies and networking opportunities as we learn from one another.  The goal is to have patient advocates walk away with a better understanding of the challenges they will face and where they can be most effective in helping advocate for their disease/disorder.

Attendees will:

• Learn how to get started: obtain 501c3 status, write grants, leverage PR effectively and utilize social media to spread your message.
• Collaboration: Understand how to successfully work with other rare disease stakeholders, patient advocates, the FDA and other government entities.
• Learn the importance of patient registries, the different types of registries and how advocates can support them.
• Explore the role of foundations and advocates related to scientific discovery and drug development.
• Gain a broad understanding of the scientific process, including diagnostic and research methodologies and collaborations with academia and industry.

At the end of this day-long event, each participant will gain perspective on the complexities and questions that need to be considered in order to become effective advocates for the rare disease patients and help advance therapies in the rare diseases we represent.

Who Should Attend:

• Rare disease patients, caregivers, family members and friends
• Patient advocates

Whether you are new to this rare disease journey or an experienced traveler, an individual advocate or part of an existing rare disease organization, you will gain value from this event.

Register today!

Hotel and Travel Information

Sponsor Information

To become a sponsor or for more information, please contact Nicole Boice.  We look forward to seeing you at this year’s summit.

 View videos from our 2012 event.

Seminar: Putting Patients First

September 30, 2013 | 9:30 am - 2:30 pm
W Hotel, 515 15th Street, NW, Washington, DC

How do patients, providers, and payers know whether health information is credible, accurate, useful or appropriate?

Comparative effectiveness research (CER) has the potential to improve health outcomes by helping people make better-informed decisions. But how do we know that CER will generate information that is useful?

You can help us find the answers by joining us on September 30 for a conversation and symposium featuring a broad range of health care stakeholders—patients, providers, policymakers, payers, researchers, and those who fund research. 

We’ll focus on an effort led by the National Health Council to create a framework to guide the development of CER, evaluate its results, and assist in communicating the findings to the right audiences.

Be a part of the conversation—register today and add your voice to our efforts to make CER useful. Tweet about it using #useCER.

Bio Categories

• Acromegaly


• Addison’s Disease


• Adrenal


• Adrenal Insufficiency


• Adrenal Surgery


• Bipolar


• BlogTalkRadio


• Cancer


• Chronic Fatigue


• Cyclic


• Diabetes


• Ectopic


• Ehlers-Danlos syndrome


• Empty Sella


• Familial Cushing’s


• Fibromyalgia


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• GIP-Dependent Cushing’s


• Golden Oldies


• Hashimoto’s


• Hypothyroidism


• In Memory


• Insulin Resistance


• Interview


• Lung Surgery


• Male


• MaryO


• MEN1


• Menopause


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• News Items


• Other Diagnosis


• PCOS


• Pituitary


• Pituitary Surgery


• Prader Willi Syndrome


• Prolactinoma


• Pseudo-Cushing’s


• pseudotumor cerebri


• radiation


• Rathke’s Cleft Cyst


• Recurrence


• Steroid-Induced


• Sub-Clinical Cushing’s


• Thyroid


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• Undiagnosed


• Von Willebrand

ShineOut, an Information and Support Program for Cushing's Disease

ShineOut is an information and support program for people with Cushing’s disease, and their friends and family.

Sign up here: ShineOut

Cyclic Cushing’s syndrome: a clinical challenge

1. J R Meinardi1,2, 
2. B H R Wolffenbuttel2 and 
3. R P F Dullaart2

+Author Affiliations

1. 1Department of Internal Medicine, Canisius Wilhelmina Ziekenhuis, PO Box 9015, 6500 GS Nijmegen, The Netherlands and 2Department of Endocrinology, University Medical Centre Groningen, University of Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands

1. (Correspondence should be addressed to: R P F Dullaart; Email:r.p.f.dullaart@int.umcg.nl)

Next Section

Abstract

Cyclic Cushing’s syndrome (CS) is a rare disorder, characterized by repeated episodes of cortisol excess interspersed by periods of normal cortisol secretion. The so-called cycles of hypercortisolism can occur regularly or irregularly with intercyclic phases ranging from days to years.

To formally diagnose cyclic CS, three peaks and two troughs of cortisol production should be demonstrated. Our review of 65 reported cases demonstrates that cyclic CS originates in 54% of cases from a pituitary corticotroph adenoma, in 26% from an ectopic ACTH-producing tumour and in about 11% from an adrenal tumour, the remainder being unclassified. The pathophysiology of cyclic CS is largely unknown.

The majority of patients with cyclic CS have clinical signs of CS, which can be either fluctuating or permanent. In a minority of patients, clinical signs of CS are absent. The fluctuating clinical picture and discrepant biochemical findings make cyclic CS extremely hard to diagnose. Clinicians should therefore be aware of this clinical entity and actively search for it in all patients with suspected CS but normal biochemistry or vice versa.

Frequent measurements of urinary cortisol or salivary cortisol levels are a reliable and convenient screening tool for suspected cyclic CS. Cortisol stimulation or suppression tests may give spurious results owing to spontaneous falls or rises in serum cortisol at the time of testing. When cyclic CS is biochemically confirmed, further imaging and laboratory studies are guided by the presence or absence of ACTH dependency. In cases of suspected ectopic ACTH production, specific biochemical testing for carcinoids or neuroendocrine tumours is required, including measurements of serotonin in platelets and/or urine, chromogranin A and calcitonin.

Read the entire article here:  http://www.scribd.com/doc/159503297/Cyclic-Cushing%E2%80%99s-syndrome-a-clinical-challenge

FDA Puts Strict Limits on Oral Ketoconazole Use

By John Gever, Deputy Managing Editor, MedPage Today

SILVER SPRING, Md. -- Oral ketoconazole (Nizoral) should never be used as first-line therapy for any type of fungal infection because of the risk of liver toxicity and interactions with other drugs, the FDA said Friday.

The agency ordered a series of label changes and a new medication guide for patients that emphasize the risks, which also include adrenal insufficiency. It noted that the restrictions apply only to the oral formulation, not topical versions.

Late Thursday, the chief advisory body for the FDA's European counterpart went further. The EU's Committee on Medicinal Products for Human Use (CHMP) recommended that member nations pull oral ketoconazole from their markets entirely.

Both the FDA and the CHMP cited studies indicating high risks of severe, acute liver injury in patients taking the drug. Studies using the FDA's adverse event reporting system and a similar database in the U.K. indicated that liver toxicity was more common with oral ketoconazole than with other anti-fungals in the azole class.

The FDA also said that oral ketoconazole "is one of the most potent inhibitors" of the CYP3A4 enzyme. This effect can lead to sometimes life-threatening interactions with other drugs metabolized by CYP3A4, and also to adrenal insufficiency, since the enzyme also catalyzes release of adrenal steroid hormones.

"This accounts for clinically important endocrinologic abnormalities observed in some patients (particularly when the drug is administered at high dosages), including gynecomastia in men and menstrual irregularities in women," the FDA said.

The only indication for oral ketoconazole still supported by the FDA is for use in life-threatening mycoses in patients who cannot tolerate other anti-fungal medications or when such medications are unavailable.

In such instances, the FDA said, physicians should assess liver function before starting the drug. It is contraindicated in patients with pre-existing liver disease, and patients should be instructed not to drink alcohol or use other potentially hepatotoxic drugs.

Adrenal function should also be monitored in patients using the drug.

The CHMP also indicated the topical formulations of ketoconazole should stay on the market, but it found no basis for keeping the oral form available for any purpose.

"Taking into account the increased rate of liver injury and the availability of alternative anti-fungal treatments, the CHMP concluded that the benefits did not outweigh the risks," the panel indicated in a statement.

It recommended that physicians stop prescribing oral ketoconazole and that they should review alternatives in patients currently receiving the drug. The committee also said that patients now taking oral ketoconazole "make a non-urgent appointment" with their physicians to discuss their treatment.

From MedPage Today

Cushing's Disease - Rare Disease Quick Facts

Cushing's disease is a rare condition due to excess cortisol levels that result from a pituitary tumor secreting adrenocorticotropic hormone (ACTH), which stimulates cortisol secretion.  Cushing’s disease should not be confused with Cushing’s syndrome which is increased cortisol levels but that increase can be due to any number of factors. However, Cushing’s disease is the most common form of Cushing’s syndrome.

Symptoms

The symptoms related to Cushing's disease and Cushing's syndrome are the same, since both are related to an excess of cortisol. Also, symptoms vary extensively among patients and that, with the inherent fluctuation in hormone levels make it difficult to diagnosis both conditions.

Changes in physical characteristics of the body

• Fullness and rounding of the face
• Added fat on back of neck (so-called "buffalo hump")
• Easy bruising
• Purplish stretch marks on the abdomen (abdominal striae)
• Excessive weight gain, especially in abdominal region
• Red cheeks
• Excess hair growth on the face, neck, chest, abdomen and thighs

Changes in physiology/psychology

• Generalized weakness and fatigue
• Menstrual disorder
• Decreased fertility and/or sex drive
• High blood pressure that is often difficult to treat
• Diabetes mellitus
• Mood and behavior disorders

Diagnosis

The early stages of Cushing's disease may be difficult to recognize. However, if it is suspected, diagnosis is generally a 2 stage process. First to determine if cortisol levels are high, and if so, why they are high.

Tests to confirm high cortisol levels:

• 24-hour urine cortisol
• Dexamethasone suppression test (low dose)

Tests to determine cause:

• Blood ACTH level
• Brain MRI
• Corticotropin-releasing hormone test
• Dexamethasone suppression test (high dose)
• Petrosal sinus sampling

Treatment

Surgery

• Most patients with Cushing’s disease undergo surgery to remove the pituitary adenoma offers.
• If the tumor is isolated to the pituitary, cure rates of 80-85% are common.
• If the tumor has spread to nearby organs, cure rates of 50-55% are common.

Medicine (approved orphan drugs)

Signifor (pasireotide)

• Approved for patients with Cushing’s disease for whom pituitary is not an option or surgery has been ineffective.
• Signifor is a somatostatin receptor agonist that leads to inhibition of ACTY secretion (and subsequently decreased cortisol levels).

Korlym (mifepristone)

• Approved for patients with Cushing’s syndrome who have type 2 diabetes or glucose intolerance and have failed surgery (or not candidates for surgery).
• Korlym is a glucocorticoid receptor antagonist which in turn blocks the effects of the high levels of cortisol in the body. Korlym is used to treat high glucose levels due to elevated cortisol.

Medicines used but not indicated for Cushing’s disease include

Mitoden

ketoconazole

Metyrapone

Etomidate

Radiation

• Radiation therapy may be used in some patients and can be very effective in controlling the growth of these tumors.

Prognosis

In most cases, treatment can cure Cushing’s disease. If not treated properly, the chronic hypercortisolism can lead to excess morbidity and mortality due to increased cardiovascular and other risk factors.

For more information

National Library of Medicine, National Institute of Health

Cushing’s Disease Information (provided by Novartis Pharmaceuticals)

Images courtesy of the open access journal Orhanet Journal for Rare Diseases.  Castinetti et al. Orphanet J Rare Dis. 2012 7:41   doi:10.1186/1750-1172-7-41

- See more at: http://www.raredr.com/front-page-medicine/articles/cushings-disease-rare-disease-quick-facts-0