Subclinical Cushing’s syndrome: definition and management

Clinical Endocrinology

Volume 76, Issue 1, pages 12–18, January 2012

Full text: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2265.2011.04253.x/full#t1

Terzolo, M., Pia, A. and Reimondo, G. (2012), Subclinical Cushing’s syndrome: definition and management. Clinical Endocrinology, 76: 12–18. doi: 10.1111/j.1365-2265.2011.04253.x

Summary

Subclinical Cushing’s syndrome is an ill-defined endocrine disorder that may be observed in patients bearing an incidentally found adrenal adenoma. The concept of subclinical Cushing’s syndrome stands on the presence of ACTH-independent cortisol secretion by an adrenal adenoma, that is not fully restrained by pituitary feed-back. A hypercortisolemic state of usually minimal intensity may ensue and eventually cause harm to the patients in terms of metabolic and vascular diseases, and bone fractures. However, the natural history of subclinical Cushing’s syndrome remains largely unknown. The present review illustrates the currently used methods to ascertain the presence of subclinical Cushing’s syndrome and the surrounding controversy. The management of subclinical Cushing’s syndrome, that remains a highly debated issue, is also addressed and discussed. Most of the recommendations made in this chapter reflects the view and the clinical experience of the Authors and are not based on solid evidence.

Since the early nineties, the serendipitous detection of clinically inapparent adrenal adenomas has been associated with a state of subtle cortisol excess. First described in case reports, subclinical hypercortisolism was then appreciated as a frequent endocrine disorder, being detected in up to 15–20% of patients with adrenal incidentalomas.^1,2 This condition was initially defined as ‘preclinical’ Cushing’s syndrome, but afterward the term ‘subclinical’ entered in use because it does not imply any assumption on the further development of a clinically overt syndrome. The National Institute of Health, State-of-the-Science Conference concluded that a more precise definition should be ‘subclinical autonomous glucocorticoid hypersecretion’ but this never gained widespread acceptance.³ The semantic quarrel underscores the uncertainties about subclinical Cushing’s syndrome that has still been recently labelled as a poorly defined entity.⁴ In this review, subclinical hypercortisolism and subclinical Cushing’s syndrome will be used synonymously.

Jump to…Top of pageAbstractDefinition of subclinical Cushing’s syndromeManagement of subclinical Cushing’s syndromeDeclaration of interestFundingReferences

Definition of subclinical Cushing’s syndrome

The concept of subclinical hypercortisolism

Subclinical Cushing’s syndrome is a common disorder assuming a frequency of up to 20% in patients harbouring incidentally discovered adrenal adenomas, which are found in approximately 4% of middle-age persons and in more than 10% of elderly population.^3,5–7Ascertainment of subclinical Cushing’s syndrome should stand on three criteria: first, the patient bears an adrenal adenoma detected serendipitously without any previous suspect of adrenal disease; second, the patient does not present a clear Cushingoid phenotype; third, the endocrine work-up shows autonomous (ACTH-independent) cortisol secretion.⁸

As to the first point, the concept of subclinical hypercortisolism may apply also to patients bearing pituitary incidentalomas and patients who are on steroid replacement;⁸ however, discussion of these conditions is beyond the scope of this review.

The second criterion is elusive depending largely on individual clinical judgment and personal practice. The problem is that Cushing’s syndrome is actually a spectrum of clinical presentations that is hard to categorize, because of a continuous variability from the more severe phenotypes to the milder ones. The less-experienced physician may not recognize (mild) signs of hypercortisolism, such as facial fullness that can be identified only after a careful assessment of the patient’s photographic material. Thus, what is subclinical for a given physician may actually be obvious for another one. The patients with ‘true’ subclinical Cushing’s syndrome should present only clinical features that are less specific for cortisol excess and are of common observation in the context of the metabolic syndrome (i.e. central obesity, hypertension).

The third point suffers from the inadequacy of current tests to detect minimal cortisol excess. Studies may demonstrate that average results of a specific test are able to differentiate patients with adenomas secreting cortisol autonomously from patients with nonfunctioning adenomas. However, there is considerable overlap between the different categories and it is usually difficult to qualify an individual patient, unless his or her results fall in the extreme ends of distribution. In this context, cortisol secretion ranges from nonfunctioning adrenal adenomas, to adenomas producing cortisol in overt excess with a manifest clinical phenotype, with adenomas associated with minimal cortisol excess and subclinical Cushing’s lying between these extremes. Thus, there is no clear dichotomy between normal and abnormal cortisol secretion, and the process of setting thresholds associated with various outcomes is arbitrary, being related, either implicitly or explicitly, to personal preferences rather than solid evidence.^3,8–10

In Table 1, we compared subclinical and mild Cushing’s syndrome; in general, patients with subclinical Cushing are older, more frequently of male gender and bearing an adrenal instead of pituitary adenoma when compared to patients with mild Cushing’s. These differences result from comparison of average data and are of limited help when evaluating an individual patient. The clinical presentation is somewhat different, because the condition is recognized serendipitously in one case and following clinical suspicion in the other, and the specific signs of cortisol excess¹¹ should not be present in the subclinical variant. Having said this, we have to admit that it is difficult to set precise boundaries separating patients with a mild phenotype from patients with a nonspecific phenotype. Only personal experience and clinical experience may help differentiating, as an example, a slight facial fullness caused by mild cortisol excess from facial roundness associated with obesity. There is also a great overlap in the biochemical presentation, even if endocrine alterations are generally more consistent in mild Cushing’s syndrome where ACTH-independent disease is less frequent.

Table 1.   Comparison of subclinical Cushing’s syndrome and mild Cushing’s syndrome.
	Subclinical Cushing	Mild Cushing
UFC, urinary free cortisol; MSC, midnight salivary cortisol; DST, dexamethasone suppression test. *For definition of specific Cushingoid signs refers to reference.11

Investigational drugs may expand medical treatment of Cushing’s syndrome

We Cushies hope that in 2012, we will see success as more patients to try these drugs. 

As you know, my pituitary continues to produce excess ACTH, a hormone that causes my Cushing's. Even after two tumors were removed during two pituitary surgeries, abnormal cells persist. Medication may be a real possibility for Cushies like me. If medication can stop this ACTH production, there will be no need for a life-changing bilateral adrenalectomy (BLA).  Click here to see the December 2011 cover story for Endocrine Today.

Investigational drugs may expand medical treatment of Cushing’s syndrome

Endocrinologists face many challenges when treating patients with Cushing’s syndrome. Diagnosis can be difficult because many of the disease’s characteristics, such as obesity, depression and hypertension, are also common in the general population. Treating the disease presents hurdles as well. With its potential for total cure, transsphenoidal surgery remains the first-line treatment. However, the problems of achieving permanent remission in all cases demonstrate the need for medical therapies for this condition. Laurence Katznelson, MD, of Stanford University, Hospital and Clinics, said pasireotide could possibly prevent pituitary tumor growth and promote tumor shrinkage in patients with Cushing’s syndrome. Photo by: Steve Gladfelter, Visual Arts at Stanford University Currently, endocrinologists use several medical therapies to treat hypercortisolism, although none have FDA approval for that particular indication. Two new investigational drugs — mifepristone (Korlym, Corcept Therapeutics) and pasireotide (SOM230, Novartis) — have the potential to meet those unmet needs, according to experts interviewed by Endocrine Today. “Recently completed research studies, which involved innovative medical therapeutic strategies that target the corticotroph adenoma itself or block the effects of cortisol in the periphery, should bring new treatment options in the future,” Maria Fleseriu, MD, associate professor, director of the Northwest Pituitary Center at Oregon Health & Science University, said in an interview. Manufacturers of both new medications have submitted new drug applications to the FDA. Corcept expects to hear from the FDA on Feb. 17, according to a spokesperson for the company. Mifepristone has a unique mode of action in that it blocks the cortisol receptor, Robert L. Roe, MD, president of Corcept Therapeutics, said in an interview. “With that receptor blocked, many of the problems associated with Cushing’s syndrome can be greatly improved, including: obesity, diabetes, insulin resistance, high blood pressure, quality of life and depression,” Roe said. The SEISMIC trial, a 24-week, multicenter, open-label study, included 50 patients with persistent or recurring Cushing’s disease, metastatic adrenal cortical carcinoma or ectopic adrenocorticotropic hormone (ACTH) syndrome that was not amenable to surgery, according to Fleseriu, who was an investigator on the study. There were two primary endpoints: blood sugar improvement in patients with glucose intolerance and an improvement in BP in patients with a diagnosis of hypertension but without abnormal blood sugar levels. The key secondary endpoint looked for global clinical improvement as determined by a three-member independent data review board. Results from the phase 3 study showed that, overall, mifepristone yielded significant clinical and metabolic improvement in patients with refractory Cushing’s syndrome, Fleseriu said. Of the glucose-intolerant patients, 60% responded, and BP improved in 38% of patients. The global clinical endpoint was positive in 87% of patients, Roe said. Maria Fleseriu “In addition, out of 34 patients who completed the main study, 30 elected to continue in the long-term extension study,” Fleseriu said. She said mifepristone “offers a new approach for the treatment of Cushing’s syndrome that [has] failed other therapies. Keeping in mind that biochemical parameters will not be available for monitoring these patients, close clinical observation is recommended.” Yet, there are aspects of mifepristone that are still unknown. “There will be a learning curve with this drug on how to dose it and use it properly to get a good response,” said James Findling, MD, professor of medicine, Endocrinology Center and Clinics, Medical College of Wisconsin, Milwaukee, who was the principal investigator of the study. James Findling Also on the horizon is the investigational agent pasireotide, a multiligand somatostatin analogue with a high affinity for the somatostatin receptor type 5, which is often expressed by corticotroph adenomas in Cushing’s disease. Pasireotide blocks the secretions from ACTH-secreting pituitary tumors. “Pasireotide works by attacking the pituitary tumor to reduce the ACTH level,” according to Laurence Katznelson, MD, professor of medicine and neurosurgery at Stanford University and medical director of the pituitary program at Stanford Hospital and Clinics. “Possibly, this drug could prevent tumor growth or lead to tumor shrinkage, although we await data to support that.” Results of the multicenter, phase 3 PASPORT-CUSHINGS trial, presented at the Endocrine Society’s 93rd Annual Meeting & Expo in June, included 162 patients with persistent/recurrent or newly diagnosed Cushing’s disease who were ineligible for surgery. Researchers randomly assigned participants to receive twice-daily subcutaneous pasireotide injections of 600 mcg or 900 mcg. The primary endpoint was urinary-free cortisol levels at 6 months without dose up-titration. Of the patients in the 900-mcg dose group, 26.3% had normal urinary-free cortisol levels at 6 months; at 12 months, 25% maintained normal levels. The median reduction from baseline in urine-free cortisol after 6 months of treatment was 47.9% for both dose groups. The researchers noted significant clinical benefit in most patients, including lower BP and total cholesterol, as well as weight loss, Fleseriu said. “It is noteworthy that while urinary-free cortisol normalization was seen in just a subset of patients, the rate of normalization was higher in patients with lower baseline urinary-free cortisol, making it, in my opinion, an attractive treatment for patients with mild elevations in urinary-free cortisol,” Fleseriu, who was also an investigator for this trial, told Endocrine Today. Pasireotide was well tolerated in the studies, she added. “Adverse events were comparable to the other somatostatin analogues, with the exception of a much higher incidence of hyperglycemia,” Fleseriu said. “Patients treated with this drug will require strict monitoring and prompt treatment of hyperglycemia.” The reasons for hyperglycemia are related to inhibition of insulin release from the pancreas by this multiligand somatostatin analogue. The type 5 receptor is abundant on pancreatic insulin secreting cells of the pancreas. Timely diagnosis, treatment critical Cushing’s syndrome is the result of chronic exposure to high levels of cortisol. Cortisol, typically released in stressful situations, controls how the body uses carbohydrates, fats and proteins. In addition, it helps decrease the immune system’s response to inflammation. Untreated, Cushing’s syndrome can have serious consequences, including significant mortality and morbidity. Timely diagnosis and appropriate treatment are critical for this rare disorder, according to Fleseriu, who is also associate professor of medicine/endocrinology and neurological surgery at Oregon Health & Science University. The endocrinologist uses the following tests to diagnose the disorder: 24-hour urinary-free cortisol levels; late-night salivary cortisol measurements; and low-dose dexamethasone suppression test. After making the diagnosis of hypercortisolism, the next step is to determine the cause of excess cortisol secretion. There are several tests available for this purpose: corticotropin-releasing hormone (CRH) simulation test; direct radiologic visualization of the pituitary and adrenal glands; and inferior petrosal sinus sampling for ACTH. The most common cause is long-term synthetic steroid use to treat inflammatory illnesses such as asthma or rheumatoid arthritis, according to Katznelson. In these cases, gradually reduction of the glucocorticoid will reverse the disorder. Another cause is an ACTH-secreting pituitary adenoma. The excess stimulates the adrenals to produce and secrete excess cortisol release, Katznelson said. This is also known as Cushing’s disease. Pituitary adenomas are responsible for 70% of Cushing’s syndrome cases, according to information from the National Institute of Diabetes and Digestive and Kidney Diseases. Surgery is first-line treatment John Carmichael First-line therapy for Cushing’s disease is transsphenoidal adenomectomy, in which the surgeon approaches the pituitary through the nose and, using either a microscope or endoscope by trained neurosurgeons, according to John Carmichael, MD, assistant professor of medicine, The Pituitary Center, Cedars-Sinai Medical Center, Los Angeles. The procedure boasts an excellent cure rate. “In good hands, with a small tumor, you can get cure rates of about 85%,” Carmichael said. “It depends on a number of factors: the skill of the surgeon, the size of the tumor and the level of invasiveness.” If surgery is curative, the patient will require cortisol replacement. “Once you remove the tumor, the normal tissue has been suppressed by the activity of the tumor for so long that it takes a long time for patients to recover and start making cortisol on their own,” Carmichael said. “It can take as long as 6 to 12 months for patients to completely recover their normal cortisol secretion once they’ve been cured.” David M. Cook However, the surgery is associated with risks, including bleeding and infection, although they are “pretty rare,” according to Carmichael. One of the most common risks is a pituitary injury that can cause diabetes insipidus, which is almost always transient. Other postoperative problems include possible cerebrospinal fluid leaks and the possibility of recurrence, said David M. Cook, MD, an endocrinologist in the department of medicine, Oregon Health & Sciences University. Sometimes the tumor is hard to find during the first surgery, Katznelson said. “The problem is, in 40% to 50% of patients who have Cushing’s disease, the tumor is very small, if not almost invisible, on the MRI scan,” he said. As a result, the surgeon may remove normal gland or possibly the entire pituitary, resulting in hypopituitarism. The patient would require hormone replacement and would still have Cushing’s syndrome. Radiation is a possible treatment for these cases. “The role of radiation is in the patient who has already had surgery for Cushing’s syndrome. The tumor is visible but cannot be completely removed. Radiation is most useful when there is a target to irradiate,” Katznelson said, adding that even in these cases, radiation cannot promise 100% efficacy. Unfortunately, radiation takes a significant amount of time to work. “People are a little reluctant to use radiation because it takes years to help,” Cook said. “It is not curative and patients can relapse from radiation also; it is not foolproof.” Ectopic ACTH syndrome Sometimes, tumors located outside the pituitary can produce ACTH, resulting in the ectopic ACTH syndrome. The tumors are usually malignant. In more than half of the cases, the tumors are found in the lungs, according to information from the NIDDK. “You would need surgery in that location to get rid of the tumor,” Carmichael said. If an adrenal tumor is stimulating an overabundance of cortisol, the definitive cure is adrenalectomy. “If we do adrenalectomy, all of the [symptoms of] Cushing’s syndrome go away, but the primary pituitary tumor, which may have been microscopic, can start to become more aggressive and grow and become more difficult to treat in the long run,” Katznelson said. “That is Nelson’s syndrome.” The adrenal insufficiency that follows adrenalectomy is serious, Cook said. “It is dangerous to not have your adrenals; it is the most dangerous disease that endocrinologists treat,” he said. “A number of sudden deaths have been reported in patients without adrenals.” Katznelson also said that managing these patients can be challenging. “Management of primary adrenal insufficiency is sometimes difficult, because not only does the patient lack cortisol, but will also lack aldosterone, which is important for maintaining electrolytes and volume status,” he said. “Patients often find it quite challenging to manage primary adrenal insufficiency.” Medical therapies for Cushing’s syndrome Besides surgery and radiation, endocrinologists can use several medical therapies to treat Cushing’s syndrome; however, to date, none has obtained FDA approval to treat the disorder. The medical treatment used most often in the United States is ketoconazole, an antifungal agent that blocks the enzymes in the adrenal glands that produce steroids, Findling toldEndocrine Today. Ketoconazole, administered two to three times daily, is generally successful. “It is an effective therapy,” Findling said. “Probably 50% to 70% of patients will have a response.” However, this drug is not the optimal choice for long-term use. “Ketoconazole has been associated with some toxicity; liver function abnormalities can occur and, in fact, liver failure can occur,” he said. Another medical treatment option is mitotane (Lysodren, Bristol-Myers Squibb), which blocks adrenal steroid enzymes, Findling said. This toxic agent takes considerable time to work; in fact, it may require roughly 3 or 4 months for cortisol levels to normalize. It is used rarely in the United States. “Mitotane has a limited future as a therapy for Cushing’s syndrome, except for in patients who have adrenal cancer, at least in the US,” Findling said. Metyrapone (Metopirone, Novartis), another agent, effectively blocks adrenal steroid enzymes; however, it is not commercially available in the United States, Findling said. Etomidate is an anesthetic agent that also inhibits adrenal steroidogenesis and is employed successfully in patients with very severe hypercortisolism who are not ready for surgery. “If etomidate were available in a pill, it would be an excellent medical treatment for Cushing’s syndrome,” Findling said. “With subhypnotic doses, etomidate lowers the cortisol level smoothly down into the normal range. … It is well tolerated, but has to be given as a continuous IV infusion, so it is not practical.” All of these medications have severe adverse effect profiles, according to Carmichael. No replacement for surgery … yet Although mifepristone and pasireotide show some promise as treatments for Cushing’s syndrome, it is not time to put the scalpels in storage, the experts said. “Neither of these drugs, at least for the foreseeable future, will replace surgical treatment of Cushing’s syndrome,” Findling said. “Like most disorders, if you have a surgical procedure that will resolve the endocrinopathy and restore normal hormonal function, it is usually the treatment of choice.” However, these medications are a welcome addition to the armamentarium, Carmichael said. “It remains to be seen exactly what their place will be and how they will be best used. But, certainly, in cases where surgery is not an option or where you need to control the disease in someone who has very severe disease, they would have a role,” he said. Currently, Carmichael sees medical therapy as an adjuvant treatment, which would follow surgery if it was not curative. Also, endocrinologists may use them in place of surgery if surgery was not an option. “There is a lot more room for work,” Carmichael said. “The ideal paradigm of having a medication that is safe and controls the disease and in a sense would replace surgery would be an ideal goal, but we are certainly not there yet.”– by Colleen Owens For more information: Colao A. OR09-6. Presented at: The Endocrine Society 93rd Annual Meeting & Expo; June 4-7, 2011; Boston. Fleseriu M. [OR09-5] Mifepristone, a glucocorticoid receptor antagonist, produces clinical and metabolic benefits in patients with refractory Cushing syndrome: results from the Study of the Efficacy and Safety of Mifepristone in the Treatment of Endogenous Cushing Syndrome (SEISMIC). Presented at: The Endocrine Society 93rd Annual Meeting & Expo; June 4-7, 2011; Boston. Gross BA. Neurosurg Focus. 2007;23:E10. National Institute of Neurological Disorders and Stroke. NINDS Cushing’s syndrome information page. Available at:www.ninds.nih.gov/disorders/cushings/cushings.htm. National Endocrine and Metabolic Diseases Information Service. Cushing’s syndrome. Available at:www.endocrine.niddk.nih.gov/pubs/cushings/cushings.aspx#causes. Disclosures: Dr. Fleseriu is principal investigator in multiple Cushing’s trials and past consultant for Novartis; she is also the principal investigator on Corcept Cushing’s trials. Dr. Findling is a paid consultant for Corcept Therapeutics. The other doctors in this article did not report any relevant financial disclosures. Which is the most reliable screening method for Cushing’s syndrome? Tests are equally accurate, but have limitations The diagnosis of Cushing’s syndrome is problematic. It is one of the most difficult endocrine diseases to diagnose. Diagnosis includes assessing the symptoms and signs of Cushing’s syndrome because the symptoms and signs overlap with common disorders, including obesity, depression and polycystic ovary syndrome. Many patients consult websites in an attempt to find an explanation for their weight gain, fatigue, depression and other symptoms. They ask frequently after a Web search if their symptoms could be Cushing’s syndrome. Screening tests for Cushing’s syndrome include three different tests: an 11 p.m. or midnight salivary cortisol level; a 24-hour urine free cortisol level; and an 8 a.m. cortisol level after ingestion of 1 mg of dexamethasone at midnight the previous night. How reliable are these tests? They are equally accurate — approximately 90% to 92% reliable, which is actually good for screening tests. However, all three tests have limitations. Results of the nighttime salivary cortisol test are affected by laboratory accuracy (not all laboratories are equally reliable) and sleep patterns. In severe depression cases, the results may be falsely elevated. The 24-hour urine free cortisol test is an indicator of overall cortisol production. The most accurate method of measurement — tandem mass spectrometry with concomitant measurement of urine volume and urine creatinine — provides a good measure. It may take several 24-hour urine collections to confirm hypercortisolism. The 1-mg overnight dexamethasone suppression test is reliable, but with several caveats. The test is standardized according to administering dexamethasone at midnight and measurement of serum cortisol promptly at 8 a.m. the following day. However, while the patient may have gone to the lab at 8 a.m., the blood sample may have been obtained later, which invalidates the test. Additionally, if the patient is taking medications that alter dexamethasone metabolism, the results may not be valid. The endocrinologist must measure a serum dexamethasone level to confirm the validity of the test. The diagnosis of Cushing’s syndrome is dependent upon confirming consistent overproduction of cortisol. The diagnosis may require repeated testing and this should be done in any patient in which there is a suspicion of Cushing’s syndrome. Mary Lee Vance, MD, is professor of medicine and neurosurgery at University of Virginia Health System, Charlottesville, Va. Disclosure: Dr. Vance reports no relevant financial disclosures. Late-night salivary cortisol is best initial test Ty Carroll No test is perfect for all patients. In addition, it is important to remember that some patients will require multiple, different tests to confirm or exclude Cushing’s syndrome. However, that being said, late-night salivary cortisol is the best initial screening for most patients with suspected Cushing’s syndrome. Late-night salivary cortisol is the most specific test for Cushing’s syndrome. The sensitivity and specificity are very good. Multiple studies have examined late night salivary cortisol testing, and the majority of those studies show sensitivity of more than 95% and a specificity in the range of 90% to 100%. That is comparable to — or better than — other methods to diagnose Cushing’s syndrome. Also important to note: It is easy for patients to perform late-night salivary testing. Patients are able to do the collection at home and mail in the completed samples to a reference lab, whereas urinary free cortisol and dexamethasone suppression testing can be difficult for some patients to complete. In addition, for the most part, late-night salivary cortisol is not affected by other medications that patients take, unlike dexamethasone suppression testing, which can be affected by several medications that patients often take to treat other conditions. Ty Carroll, MD, is assistant professor of medicine at Endocrinology Center and Clinics, Menomonee Falls, Wisc. Disclosure: Dr. Carroll is an investigator in Corcept’s clinical trials of mifepristone.

Fatal Infections Linked to Neti Pots

CAUTION CUSHIES.

Many Cushie patients use Neti pots after pituitary surgery to clear the sinuses. They swear by them. But be careful.

http://abcnews.go.com/m/story?id=15170230

"If you are irrigating, flushing or rinsing your sinuses, for example, by using a Neti pot, use distilled, sterile or previously boiled water to make up the irrigation solution," Louisiana State epidemiologist Dr. Raoult Ratard said in a statement. "Tap water is safe for drinking but not for irrigating your nose."

My Friends with Adrenal Insufficiency

     Patients with Cushing's disease and those with Addison's disease face the same bully every day.

     Cortisol is an omnipresent force, always lurking and lingering, so ready to remind you that you do not control your body. The cortisol does.

     Cortisol runs through the bodies of healthy people and continues about its job without notice. Its predictable, daily function is required to sustain life. 

     For those enslaved by the adrenals' whims, it is a constant thorn in your side. You see, Cushie bodies make too much cortisol, while Addisonians make no or insufficient cortisol. While each disease respond differently to the cortisol malfunction, both patient sets deal with the life-threatening risks of adrenal crises.

     Cushies walk in the shoes of their Addi cousins after pituitary surgery (to stop excess cortisol production by renegade ACTH tumors) or adrenal surgery (to remove the cortisol-making once and for all by removing adrenals. Just look what happens when adrenal glands do not respond to signals from the pituitary gland properly.

     Both Cushies and Addis can suffer symptoms of low cortisol and the devastating consequences if these symptoms are not treated in time. 

     What starts as mild adrenal insufficiency can turn into acute adrenal crisis very quickly, putting the patient at risk for shock and sudden death.  Think you can go to a paramedic or hospital for help. Think again. As you may have caught on by now, there is nothing easy... or even FAIR... about Cushing's disease.

• Imagine if the medics in the ambulance didn't know what could save your life.
• Imagine if the medics knew, but the state has laws in place that prevent them from keeping a supply of it in the ambulances.
• Imagine if the medics refuse to administer the Solu-Cortef injectible medication you have with you, along with an adrenal crisis letter from your physician, but too disoriented to give yourself, because of state regulations limiting its availability
• Imagine getting to the hospital only to find emergency room staff ignore both your CRISIS letter from your physician and medical alert bracelets, necklaces, and even tattoos-- all intended to save your life and speak for you when you can not.
• Imagine waiting for hours and hours for your medical team to run enough tests to *believe* you are sick, and then to follow the still squabble over following the protocol outlined in your crisis letter.
• Imagine if the hospital, like the ambulance, does not carry the Solu-Cortef injectable at all, or, insist on giving you a lesser grade of cortisol shot that acts much more slowly and will not bring you out of the near coma you are in or about to fall into, despite clear instructions in the crisis letter
• Imagine your friend or family member getting hauled away by security and thrown out of the hospital for advocating emphatically on your behalf.

THIS JUST CAN NOT CONTINUE TO HAPPEN ** ANY MORE. ** 

     Do you think I may be overdramatizing things?!  Well, I can add a name to every *Imagine* line above, a name of a person who nearly died because solu-cortef and its life-saving formula was kept from them from ambulances and hospitals who are supposed to protect and save them. If you are the prove-it-to-me-one-more-time type, you can read plenty of personal testimonials for yourself.

     Access to Solu-cortef should be as standard in ambulances and ERs as glucagon shots for diabetics. Deaths due to adrenal insufficiency heartbreaking and so preventable. 

     I want to thank the Adrenal Insufficiency United organization for creating the wonderful video below. On behalf of Cushing's patients everywhere, we thank you for their efforts to increase access to Solu-Cortef for all patients with unpredictable or absent cortisol production.

     In addition, a shout out to the CARES Foundation which supports patients with congenital adrenal hyperplasia.  Like the Adrenal Insufficiency United organization, CARES advocates for the widespread availability of Solu Cortef in ambulances and hospitals -- without question -- for any patients who may face low cortisol levels.  

     In light of the dangers presented in this post, it is always best to administer Solu-cortef before you even go for medical help.  The patient or the caregiver must be ready to administer the injection on his/her own.  Here are some instructions to download, so you are prepared to save your life no matter what.

My Friends with Adrenal Insufficiency

     Patients with Cushing's disease and those with Addison's disease face the same bully every day.

     Cortisol is an omnipresent force, always lurking and lingering, so ready to remind you that you do not control your body. The cortisol does.

     Cortisol runs through the bodies of healthy people and continues about its job without notice. Its predictable, daily function is required to sustain life. 

     For those enslaved by the adrenals' whims, it is a constant thorn in your side. You see, Cushie bodies make too much cortisol, while Addisonians make no or insufficient cortisol. While each disease respond differently to the cortisol malfunction, both patient sets deal with the life-threatening risks of adrenal crises.

     Cushies walk in the shoes of their Addi cousins after pituitary surgery (to stop excess cortisol production by renegade ACTH tumors) or adrenal surgery (to remove the cortisol-making once and for all by removing adrenals. Just look what happens when adrenal glands do not respond to signals from the pituitary gland properly.

     Both Cushies and Addis can suffer symptoms of low cortisol and the devastating consequences if these symptoms are not treated in time. 

     What starts as mild adrenal insufficiency can turn into acute adrenal crisis very quickly, putting the patient at risk for shock and sudden death.  Think you can go to a paramedic or hospital for help. Think again. As you may have caught on by now, there is nothing easy... or even FAIR... about Cushing's disease.

• Imagine if the medics in the ambulance didn't know what could save your life.
• Imagine if the medics knew, but the state has laws in place that prevent them from keeping a supply of it in the ambulances.
• Imagine if the medics refuse to administer the Solu-Cortef injectible medication you have with you, along with an adrenal crisis letter from your physician, but too disoriented to give yourself, because of state regulations limiting its availability
• Imagine getting to the hospital only to find emergency room staff ignore both your CRISIS letter from your physician and medical alert bracelets, necklaces, and even tattoos-- all intended to save your life and speak for you when you can not.
• Imagine waiting for hours and hours for your medical team to run enough tests to *believe* you are sick, and then to follow the still squabble over following the protocol outlined in your crisis letter.
• Imagine if the hospital, like the ambulance, does not carry the Solu-Cortef injectable at all, or, insist on giving you a lesser grade of cortisol shot that acts much more slowly and will not bring you out of the near coma you are in or about to fall into, despite clear instructions in the crisis letter
• Imagine your friend or family member getting hauled away by security and thrown out of the hospital for advocating emphatically on your behalf.

THIS JUST CAN NOT CONTINUE TO HAPPEN ** ANY MORE. ** 

     Do you think I may be overdramatizing things?!  Well, I can add a name to every *Imagine* line above, a name of a person who nearly died because solu-cortef and its life-saving formula was kept from them from ambulances and hospitals who are supposed to protect and save them. If you are the prove-it-to-me-one-more-time type, you can read plenty of personal testimonials for yourself.

     Access to Solu-cortef should be as standard in ambulances and ERs as glucagon shots for diabetics. Deaths due to adrenal insufficiency heartbreaking and so preventable. 

     I want to thank the Adrenal Insufficiency United organization for creating the wonderful video below. On behalf of Cushing's patients everywhere, we thank you for their efforts to increase access to Solu-Cortef for all patients with unpredictable or absent cortisol production.

     In addition, a shout out to the CARES Foundation which supports patients with congenital adrenal hyperplasia.  Like the Adrenal Insufficiency United organization, CARES advocates for the widespread availability of Solu Cortef in ambulances and hospitals -- without question -- for any patients who may face low cortisol levels.  

     In light of the dangers presented in this post, it is always best to administer Solu-cortef before you even go for medical help.  The patient or the caregiver must be ready to administer the injection on his/her own.  Here are some instructions to download, so you are prepared to save your life no matter what.

Hope & Stem Cells

Lab-grown hormone factory put to work

http://www.newscientist.com/mobile/article/mg21228384.700-labgrown-hormone-fa...

Pituitary Glands Made from Stem Cells

This is the best news I have heard in a long time.

"Pituitary glands grown from mouse embryonic stem cells

If the same trick can be repeated for human pituitary glands it could transform the treatment of debilitating hormone disorders"

09.11.11 Updated 20.36

Mouse pituitary tissue grown from embryonic stem cells. Fully grown glands produced hormones when transplanted into mice. Photograph: Yoshiki Sasai/RIKEN

David Derbyshire

The Guardian, Wed 9 Nov 2011 18.26 GMT

Scientists have grown working pituitary glands in the lab that could potentially transform the treatment of people with a range of debilitating hormone disorders.

The team of Japanese researchers grew the tiny hormone-secreting organs using stem cells taken from a mouse embryo. When the tissue was transplanted into mice with pituitary gland defects, it raised levels of the missing hormones in their bodies.

Dr Yoshiki Sasai, who led the study at the RIKEN Centre for Developmental Biology in Kobe, Japan, said: "It is difficult to guess how long it will take, but we hope that we can produce human pituitary tissue in the next three years." It would take longer to develop techniques to transplant the cells, he added.

The creation of spare body parts for transplant is one of the goals of stem cell science. Stem cells are the body's "master cells" and can turn into a range of different types of tissue, such as brain, muscle or pancreatic cells.

Any tissue or organs grown from patients' own stem cells would not be rejected by the body, doing away with the need for immunosuppressant drugs.

Pituitary glands – the oval, pea-sized organs at the base of the brain – are a particular challenge for stem cell researchers because they are so complex. They have two distinct parts and secrete at least eight hormones regulating growth, fertility, breast milk production, blood pressure, contractions during childbirth, temperature and water balance.

Using mouse stem cells arranged in a three dimensional culture, Dr Sasai's team mimicked the way pituitary glands develop in the embryo. The resulting tissue contained all five types of cell found in a normal gland and took around three weeks to grow, the scientists report in the journal Nature.

"We have made hundreds of pituitary glands from embryonic stem cells," said Dr Sasai. When the tissue was transplanted into mice with pituitary defects, levels of missing hormones in their bodies rose to normal.

Although the researchers used embryonic stem cells in their experiment, they believe the technique could work with stem cells derived from adult tissue – so-called induced pluripotent stem cells. That would avoid the ethical concerns some people have about using human embryos in research and therapies.

Even if the scientists can grow a human pituitary, they still face major obstacles in creating a safe and efficient way to transplant it, Dr Sasai said. However, he believes lab-grown glands could lead to treatments for growth hormone deficiencies and damage to the pituitary glands caused by surgery and Sheehan's syndrome.

Women with Sheehan's syndrome, which results from blood loss during childbirth, have problems breastfeeding, suffer tiredness, weight gain, constipation, low blood pressure and slowed thinking.

Prof Robin Lovell-Badge, one of Britain's leading stem cell experts at the Medical Research Council's National Institute for Medical Research in London, said: "It is unlikely that these in vitro-derived pituitaries are fully developed and make hormones in precisely the same way as normal.

"However, the fact that they got as far as they did is impressive. It suggests that there is a fair amount of self-organisation, which means that it might be easier than we thought to build not just pituitaries, but also other organs from embryonic stem cells and induced pluripotent stem cells – as long as they are not too complex.

"It also opens up new possible ways for treating patients with defective or missing pituitary glands."

I'm Back, Giving Testing a Final Go

Hi to everyone.  I thank all of you for reading along and for all the letters.  I will write back soon. If I don't reply, please feel free to resend.

I accept friendly reminders.

I wanted to share this image. It made me laugh but then quickly made me upset.  Not even the coveted 'I told you so' is worth it.  Join me in Cushing's awareness.  Let's prove them all wrong.

Please promise me AND yourself that you will fight until you feel better. 

I'll be around more this fall. I'll be testing for high cortisol (already have several high ACTH values even after two pituitary surgeries) and sharing all my Cushie goodies I've rounded up over the summer.

~Melissa

PARTICIPATE: Quality of Life Survey

I encourage every Cushing's patient to complete this National Institutes for Health survey* regarding quality of life. We must seize these opportunities to educate the medical community. The Cushing's we experience is drastically more complicated than the Cushing's they study.  Please make your voice heard. ~m

Click here to go to NIH Cushing's survey.

Information about this survey and your consent to participate

Patients with Cushing's syndrome report decreased quality of life before and after surgical treatment. We are investigators at the U.S. National Institutes of Health who care for patients with Cushing's syndrome. We want to learn more about the patients' experience during the post-surgical recovery phase with particular reference to quality of life. We are inviting patients like you who have had surgical treatment to complete the survey. Your responses will be gathered anonymously and will be treated confidentially; we hope to use them in a publication so that other physicians can learn about these issues.

Please kindly complete the following online questionnaire which is comprised of approximately 27 questions and should take around 15 minutes.

Click here to go to NIH Cushing's survey.

** Thanks to MaryO for sharing this with us.