Cushing’s syndrome and

Cushing s syndrome and other glucocorticoid excess states... 

Recognize the clinical presentation of Cushing s syndrome and the physiologic consequences of cortisol excess. 

The diagnosis of Cushing s syndrome and its etiology often are complex and generally require the involvement of endocrinologists and specialized testing centers. 

Evaluate patients at risk for adrenal insufficiency as a result of treatment(s) of Cushing s syndrome and initiate glucocorticoid and miner-alocorticoid replacement therapy as appropriate. 

Perform initial screening tests to confirm Cushing s syndrome and rule out those with pseudo-Cushing s conditions (in other words, until it is determined that it is not a pseudo-Cushing s syndrome). 

Hopkins RL, Leinung MC. Exogenous Cushing s syndrome and glucocorticoid withdrawal. Endocrinol Metab Clin North Am 2005 34 371-384. 

Increasing the concentration increases the penetration, but not to the same degree. Solubility of the corticosteroid in the vehicle is an other determinant of absorption and efficacy. So different formulations of the same corticosteroid can end up in a different efficacy classification. Efficacy can be further augmented by using the corticosteroid under occlusion. Occlusion with plastic enhances penetration and also absorption. However, with increased absorption also the risk of systemic side-effects increases. Systemic absorption will suppress the pituitary-adrenal axis and may cause Cushing s syndrome and a plethora of other adverse events (see Chapter 24, Section Il.b). Even small amounts absorbed may already cause growth retardation in children. 

The steroid-inhibiting properties of metyrapone have also been used in the treatment of Cushing s syndrome, and it remains one of the more effective drugs used to treat this syndrome. However, the compensatory rise in corticotrophin levels in response to falling cortisol levels tends to maintain adrenal activity. This requires that glucocorticoids be administered concomitantly to suppress hypothalamic-pituitary activity. Although metyrapone interferes with lip- and 18-hydroxylation reactions and thereby inhibits aldosterone synthesis, it may not cause mineralocorticoid deficiency because of the compensatory increased production of 11-desoxycorticosterone. 

Tolerance to glucocorticoids in this, as in some other respects, varies from individual to individual some patients tolerate 30 mg of prednisone for a long time without developing Cushing s syndrome, while others develop symptoms at 7.5 mg the doses recommended today to avoid Cushing s syndrome in most patients are usually equivalent to hydrocortisone 20 mg. Cushing s syndrome and other systemic adverse effects can occur not only from oral and injected glucocorticoids, but also from topical and intranasal treatment (115) and intrapul-monary or epidural administration (SEDA-19, 376 SEDA-20, 370 116,117). 

The myopathy usually develops gradually, without pain, and symmetrically. However, a single epidural injection of a glucocorticoid for lumbar radicular pain has caused Cushing s syndrome and myopathy (SEDA-20, 370 97). 

The authors suggested that the development of Cushing s syndrome and its persistence at a low dosage of budesonide was caused by inhibition of the metabolism of budesonide by amiodarone. 

Chen F, Kearney T, Robinson S, Daley-Yates PT, Waldron S, Churchill DR. Cushing s syndrome and severe adrenal suppression in patients treated with ritonavir and inhaled nasal fluticasone. Sex Transm Infect 1999 75(4) 274. 

Q5 List the symptoms of Cushing s syndrome and Addison s disease. 

Certaiu medicatious have beeu associated with au iucrease iu osteoporosis risk, particularly steroids and anticonvulsants. Steroid-induced osteoporosis arises due to use of glucocorticoids, analogous to Cushing s syndrome, and involving mainly the axial skeleton prednisone... 

Ketoconazole is an effective antifungal agent by virtue of its capacity to block sterol/steroid s)mthesis (ergosterol in the case of fungi). In man it inhibits steroid s)mthesis in gonads and adrenal cortex and it has been used in Cushing s syndrome and prostatic cancer. 

TABLE 74—2. Various Etiologies of Cushing s Syndrome and Their Respective Differences... 

Newell-Price J, Trainer P, Besser M, Grossman A. The diagnosis and differential diagnosis of Cushing s syndrome and Pseudo-Cushing s states. Endocr Rev 1998 19 647-672. 

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