Ebola vaccine results 'remarkable'

Ebola vaccine is ‘potential game-changer’

By James Gallagher
Health editor, BBC News website
  • 31 July 2015
  • From the section Health
Man being vaccinated

A vaccine against the deadly Ebola virus has led to 100% protection and could transform the way Ebola is tackled, preliminary results suggest.

There were no proven drugs or vaccines against the virus at the start of the largest outbreak of Ebola in history, which began in Guinea in December 2013.

The World Health Organization (WHO) said the findings, being published in the Lancet, could be a “game-changer”.

Experts said the results were “remarkable”.

This trial centred on the VSV-EBOV vaccine, which was started by the Public Health Agency of Canada and then developed by the pharmaceutical company Merck.

It combined a fragment of the Ebola virus with another safer virus in order to train the immune system to beat Ebola.

A unique clinical trial took place in Guinea. When a patient was discovered, their friends, neighbours and family were vaccinated to create a “protective ring” of immunity.

Analysis

This could be the breakthrough the world has been waiting for.

There is caution as the results are still preliminary, with more data coming in.

But officials at the WHO believe the effectiveness of the vaccine will end up being between 75% and 100%.

If such a vaccine was available 18 months ago then thousands of lives could have been saved.

There are still other vaccines being trialled – notably from GSK and Johnson&Johnson – although as the number of cases continues to fall it is becoming increasingly difficult to prove how effective they are.

Ebola will inevitably come again.

The hope now is that the legacy of this unprecedented outbreak will be a vaccine that means a tragedy of this scale can never be repeated.

One hundred patients were identified in the trial between April and July and then close contacts were either vaccinated immediately, or three weeks later.

In the 2,014 close contacts who were vaccinated immediately there were no subsequent cases of Ebola.

In those vaccinated later there were 16 cases, according to the results published in the Lancet medical journal.

‘Promising’

The WHO says it is so far 100% effective, although that figure may change as more data is collected.

Close contacts of Ebola patients in Guinea will now be vaccinated immediately. And since the vaccine has been shown to be safe, that process will also be extended to include children.

Médecins sans Frontières (MSF) is involved with this research, and is part of a parallel trial for frontline healthcare workers.

Medical director Bertrand Draguez said the Lancet results should spur instant action.

“With such high efficacy, all affected countries should immediately start and multiply ring vaccinations to break chains of transmission and vaccinate all frontline workers to protect them.”

Marie-Paule Kieny, an assistant director general at the WHO told BBC News: “It is certainly promising. We have seen that where rings have been vaccinated, the transmission has stopped.

“Prior to vaccination there were cases, cases, cases. The vaccine arrives and 10 days later the cases are flat.

“It could be a game-changer because previously there was nothing, despite the disease being identified 40 years ago.

“When there is a new outbreak this vaccine will be put to use to stop the outbreak as soon as possible to not have the terrible disaster we have now.”

More than 11,000 people have died from Ebola and nearly 28,000 have been infected.

The sheer scale of the 2014-15 outbreak led to an unprecedented push on vaccines – and a decade’s work has been condensed into around 10 months.

The number of cases has fallen – and in the week up to July 26th 2015 there were just four cases in Guinea and three in Sierra Leone.

Prof John Edmunds, from the London School of Hygiene & Tropical Medicine, helped design the trial: “The development has been at an absolutely unprecedented speed.

“This is very good news, these are very significant results, the epidemic is not over and this shows we have another potential weapon.

“The trial is still continuing, these are interim results which need confirming, but there’s now light at the end of the tunnel.”

Dr Jeremy Farrar, the director of the Wellcome Trust medical charity, said this was a “remarkable result” and was the product of international collaboration.

He added: “Our hope is that this vaccine will now help bring this epidemic to an end and be available for the inevitable future Ebola epidemics.”

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HIV flushed out by cancer drug

HIV flushed out by cancer drug

By James Gallagher
Health and science reporter, BBC News website
  • 31 July 2015
  • From the section Health
HIV

HIV can be flushed out of its hiding places in the body using a cancer drug, researchers show.

The cornerstone of treatment, anti-retroviral therapy, kills the virus in the bloodstream but leaves “HIV reservoirs” untouched.

The study, published in PLoS Pathogens, showed the drug was “highly potent” at reactivating hidden HIV.

Experts said the findings were interesting, but it was important to know if the drug was safe in patients.

The power of the HIV reservoir was shown with the case of the Mississippi baby.

She was given antiretroviral drugs at birth. Despite appearing to be free of HIV for nearly two years after stopping treatment, she was found to be harbouring the virus.

‘Kick and kill’

A strategy known as “kick and kill” is thought to be key to curing HIV – the kick would wake up the dormant HIV allowing the drugs to kill it.

The team at the UC Davis School of Medicine investigated PEP005 – one of the ingredients in a treatment to prevent cancer in sun-damaged skin.

They tested the drug in cells grown in the laboratory and in parts of the immune system taken from 13 people with HIV.

The report said “PEP005 is highly potent in reactivating latent HIV” and that the chemical represents “a new group of lead compounds for combating HIV”.

One of the researchers, Dr Satya Dandekar, said: “We are excited to have identified an outstanding candidate for HIV reactivation and eradication that is already approved and is being used in patients.

“This molecule has great potential to advance into translational and clinical studies.”

However, the drug has still not been tested in people who are HIV-positive.

Prof Sharon Lewin, from the University of Melbourne, said the results were “interesting” and marked an “important advance in finding new compounds that can activate latent HIV”.

She told the BBC: “This study adds another family of drugs to test to potentially eliminate long-lived forms of HIV although much more work needs to be done to see if this works in patients.

“Although PEP005 is part of an FDA approved drug, it will first take some time to work out if it is safe to use in the setting of HIV.”

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For seniors, sexual activity is linked to higher quality of life


(Reuters Health) – Older adults who value sexual activity and engage in it have better social lives and psychological well-being, according to a small study in Scotland

Older adults said “they miss and want to engage in sexual behaviors, whether that be a kiss to intercourse,” said study coauthor Taylor-Jane Flynn in an email. “For many, these behaviors remained an important element in their life.”

Flynn, a psychology PhD candidate at Glasgow Caledonian University, said the study was inspired by her work as a health care assistant for elderly people.

Although quality of life is a key consideration for older adults, sexuality is rarely studied, write Flynn and Alan Gow, an associate professor of psychology at Heriot-Watt University in Edinburgh, in the journal Age and Ageing.

The researchers recruited 133 Scottish adults aged 65 and over by distributing questionnaires at local clubs, small businesses and older people’s groups.

About half the participants lived with a spouse or partner.

The questionnaire asked how often in the last six months participants had engaged in six sexual behaviors: touching/holding hands, embracing/hugging, kissing, mutual stroking, masturbation and intercourse.

Participants also rated how important those behaviors are to them, on a five-point scale ranging from “not at all important” to “very important.”

Additionally, the questionnaires assessed participants’ quality of life based on physical health, psychological health, social relationships and environment.

Between 75 and 89 percent said they’d engaged in kissing, hugging and holding hands or touching. Men and women scored about the same for frequency and importance of sexual behaviors overall, and for quality of life.

Although people with frequent sexual activity also placed higher importance on it, the analysis found the two measures were associated with different aspects of quality of life.

Participants reporting more frequent sexual behavior rated their social relationships as higher quality, while people who found sexual activity to be important had higher scores for psychological quality of life.

Overall, however, seniors’ health status had the strongest impact on all aspects of quality of life.

John DeLamater, a sociology professor at the University of Wisconsin – Madison, said the fact that participants were recruited in community settings – which may attract more healthy and active older people – might affect the results.

“If they are generally healthier (which the results show to be associated with quality of life), they are probably more sexually active,” DeLamater said in an email.

For people who have valued sexuality throughout their lives, he noted, “continuing activity provides protection against a sense of aging and loss, and of continuity if the person is in a long-term relationship.” That may explain the links between sex and well-being found in the study, he said.

While the current study only looked at associations and cannot determine whether sexuality raises quality of life, Gow noted, he hopes that future research will focus more on this subject.

“What we hope is that our current findings encourage other researchers interested in the determinants of health and well-being in older adults to also consider sexual behaviors,” Gow said in an email.

The sexuality of older people should be considered and encouraged, DeLamater said. “We should encourage couples to spend time alone, provide arrangements in care facilities that enable sexual intimacy, provide sexual health information in medical settings.”

SOURCE: bit.ly/1CXCiLh Age and Ageing, online July 14, 2015.


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Vaccine success holds hope for end to deadly scourge of Ebola

A member of the French Red Cross disinfects the area around a motionless person suspected of carrying the Ebola virus as a crowd gathers in Forecariah January 30, 2015. REUTERS/Misha Hussain
A member of the French Red Cross disinfects the area around a motionless person suspected of carrying the Ebola virus as a crowd gathers in Forecariah January 30, 2015.

Reuters/Misha Hussain


The world is on the verge of being able to protect humans against Ebola, the World Health Organization said on Friday, as a trial in Guinea found a vaccine to have been 100 percent effective.

    Initial results from the trial, which tested Merck (MRK.N) and NewLink Genetics’ (NLNK.O) VSV-ZEBOV vaccine on some 4,000 people who had been in close contact with a confirmed Ebola case, showed complete protection after 10 days.

    The results were described as “remarkable” and “game changing” by global health specialists.

    “We believe that the world is on the verge of an efficacious Ebola vaccine,” WHO vaccine expert Marie Paule Kieny told reporters in a briefing from Geneva.

    The vaccine could now be used to help end the worst recorded outbreak of Ebola, which has killed more than 11,200 people in West Africa since it began in December 2013.

    WHO Director-General Margaret Chan said the results, published online in the medical journal The Lancet, would “change the management of the current Ebola outbreak and future outbreaks”.

The Gavi Alliance, which buys vaccines in bulk for poor countries who struggle to afford them, immediately said it would back an Ebola shot once it is approved.

“These communities need an effective vaccine sooner rather than later,” Gavi’s chief executive Seth Berkley said. “We need to be ready to act wherever the virus is a threat.”

    This and other vaccine trials were fast-tracked with huge international effort as researchers raced to test potential therapies and vaccines while the virus was still circulating.

    “It was a race against time and the trial had to be implemented under the most challenging circumstances,” said John-Arne Røttingen of Norway’s Institute of Public Health, chair of the trial’s steering group.   

“RING VACCINATION”

The Guinea trial began on March 23 to evaluate the effectiveness and safety of a single dose of VSV-ZEBOV using a so-called “ring vaccination” strategy, where close contacts of a person diagnosed with Ebola are immunized – either immediately, or at a later date.

    As data began to emerge showing the very high protection rates in those vaccinated immediately, however, researchers decided on July 26 that they would no longer use the “delayed” strategy, since it was becoming clear that making people wait involved unethical and unnecessary risk.

    The trial is now being continued, with all participants receiving the vaccine immediately, and will be extended to include 13- to 17-year-olds and possibly also 6- to 12-year-old children, the WHO said.

    Jeremy Farrar, a leading infectious disease specialist and director of the Wellcome Trust, said the trial “dared to use a highly innovative and pragmatic design, which allowed the team in Guinea to assess this vaccine in the middle of an epidemic”.

“Our hope is that this vaccine will now help bring this epidemic to an end and be available for the inevitable future Ebola epidemics,” his statement said.

    The medical charity Doctors without Borders (MSF), which has led the fight against Ebola in West Africa, called for VSV-ZEBOV to be rolled out to the other centers of the outbreak, Liberia and Sierra Leone, where it says it could break chains of transmission and protect front-line health workers.

VSV-ZEBOV was originally developed by Canada’s public health agency before being licensed to NewLink Genetics, which then signed a deal handing Merck the responsibility to research, develop, manufacture and distribute it.

The success of the Guinea trial is a big relief for researchers, many of whom feared a sharp decline in cases this year would scupper their hopes of proving a vaccine could work.

    Another major trial in Liberia, which had aimed to recruit some 28,000 subjects, had to stop enrolling after only reaching its mid-stage target of 1,500 participants. Plans for testing in Sierra Leone were also scaled back. That left the study in Guinea, where Ebola is still infecting new victims, as the only real hope for demonstrating the efficacy of a vaccine.

(Additional reporting by Tom Miles in Geneva and Ben Hirschler in London; Editing by Kevin Liffey)


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New national survey finds lack of COPD knowledge among patients

In a new national survey of chronic obstructive pulmonary disease (COPD) patients, Health Union reveals a surprising lack of awareness of risk factors and knowledge of diagnosis stage among patients. Results demonstrate a severe impact on quality of life, employment, and ability to afford treatment.

COPD, the third most common cause of death in the United States, describes a group of lung conditions that severely impact the breathing of nearly 15 million people in the U.S. (or six percent of the population) and more than 65 million worldwide. Only 38% of respondents were aware of COPD or its risk factors prior to their diagnosis. Almost one-third did not know their initial or current diagnosis stage. Additionally, at diagnosis about two-thirds wished they knew more about the potential impact of COPD and how to stop or slow down its progression.

“I think if asked, most people actually realize that smoking causes disease. However, the survey reveals that important information about the variety and severity of these types of disease is not reaching those at risk for COPD,” said Leon C. Lebowitz, respiratory therapist and COPD.net moderator. “When armed with information, patients do take steps to change their lives. The survey shows that post diagnosis 68% of those that were current smokers quit and an additional 15% were trying to quit smoking. That’s huge.”

COPD clearly affects all aspects of life. Eighty-seven percent of respondents with COPD say they were unable to do as much as they could prior to acquiring the disease, with 32% needing some form of help from a caregiver. In addition, respiratory infections, high blood pressure, and depression were frequently experienced among respondents.

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Only 15 percent of survey respondents reported they are working full time. Twenty-eight percent were on disability with an additional forty percent fully retired. Symptoms experienced most frequently were:

  • shortness of breath during everyday activities (78%),
  • difficulty catching breath (74%), and

  • fatigue/lack of energy (69%).

COPD and the accompanying breathing difficulties can make everyday physical activities like walking and even talking extremely difficult. There is currently no known way to undo the damage to the lungs.

Like with many medical conditions, COPD patients report expense negatively impacting medical care. More than half of respondents spent at least $500 out-of-pocket for treatment and 42% avoided a medication due to cost. Forty-two percent also would switch to a generic drug if available.

While smoking is not the only cause of COPD (15% of people with COPD have never smoked), sixty-seven percent of respondents blame themselves for having COPD and 78% wish they had done things differently so that they would not have the disease.

“This survey illustrates the need for more COPD awareness and education amongst the general public and patients as well,” said Tim Armand, president and co-founder of Health Union. “As the incidence of COPD continues to grow, hopefully educational efforts like COPD in America and the new COPD.net website can bridge the information gap and ultimately improve care.”

Source:

Health Union

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Prostate cancer: Five types 'found'

Prostate cancer: Five types ‘found’

  • 30 July 2015
  • From the section Health
Dividing prostate cancer cells seen through scanning electron micrograph

Scientists have identified five types of prostate cancer, each with a distinct genetic signature.

And by comparing 250 samples removed in surgery with the patients’ subsequent progress, they have identified some types that are more likely to recur.

Until now, there has been no reliable way to know which patients have the more aggressive cancers requiring the most urgent and intensive therapy.

But much larger trials are still needed to be certain of these early results.

Spreading aggressively

Prostate cancer is the most common cancer in UK men, with 41,700 cases diagnosed each year.

Prof Malcolm Mason, of Cancer Research UK, which conducted the research with Addenbrooke’s Hospital, Cambridge, said some of the types were like a pussycat – growing slowly and causing few problems, while others were like a tiger – growing and spreading aggressively.

And researcher Dr Alastair Lamb said it could be possible to combine this genetic information with existing tests to identify patients most at risk.

He said: “These findings could help doctors decide on the best course of treatment for each individual patient, based on the characteristics of their tumour.

“The next step is to confirm these results in bigger studies and drill down into the molecular ‘nuts and bolts’ of each specific prostate cancer type.”

But he cautioned there were still many questions to be ironed out, including whether the technique could be used routinely in hospitals.

Dr Iain Frame, of Prostate Cancer UK, said: “For men to truly benefit from these findings it is now vital that the research community comes together to confirm the most efficient methods for testing for different types of prostate cancer that can be bought to the clinic. “

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Olympic athletes not worried about polluted waters

Men work on the construction site of the Rio 2016 Olympic Games athletes village in Rio de Janeiro, Brazil July 21, 2015. REUTERS/Ricardo Moraes
Men work on the construction site of the Rio 2016 Olympic Games athletes village in Rio de Janeiro, Brazil July 21, 2015.

Reuters/Ricardo Moraes


Olympic sailors are not worried about getting sick during the Rio Olympics next year in spite of reports that waters where the sailing events will take place have pollution levels equivalent to raw sewage, competitors told Reuters on Thursday.

Tests conducted by the Associated Press found levels of disease-causing viruses as much as 1.7 million times the level that would be considered hazardous on a Southern California beach.

The levels of raw sewage, the AP reported, contradict statements by Olympic organizers that the water-sports venues will be safe.

However, sailors and rowers who have sailed in the Olympic waters said they were not concerned.

“Brazilians haven’t caught anything,” Olympic gold medalist Marcelo Ferreira told Reuters. “I have never had any health problems sailing in the Guanabara Bay.

“The problem with the Guanabara Bay has been dragging on for 30 years, since I was a child. There’s no point in going on about the quality of the water, the Olympics are going to be in Rio no matter what and so this subject is dead for me.”

A spokesperson for British sailors currently in Rio for a test event said the UK competitors were also not too worried.

American Paige Railey, winner of a gold medal in the women’s laser radial in last week’s Pan American Games, said she had no fears about South America’s first-ever Olympic Games.

“We’ve spent a lot of time there the past few years and haven’t had any issues with the water,” said Railey. “I know U.S. Olympic Committee and U.S. Sailing have taken measures to make sure all of us will be healthy and fine.

“Honestly, Rio has been doing a great job with the water, we haven’t had any issues. I think it’s fine. I even swim in it, it doesn’t bug me at all.”

The waters of the Guabanara Bay on Rio’s Atlantic coast have been polluted for years and successive governments have spent hundreds of millions of dollars on supposed clean-ups to little effect.

Cities around the bay routinely pump untreated sewage into its waters and parts of the coastline are littered with garbage such as tires, sofas, old televisions and all kinds of plastic detritus.

After originally saying they would cut pollution by 80 percent ahead of the Olympics, organizers backed down and said they would only ensure the sailing lanes were clean.

(Reporting by Jeb Blount, Pedro Fonseca, Andrew Downie, Caio Saad, Steve Keating; Writing by Andrew Downie; Editing by Jeffrey Benkoe and Dan Grebler)


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Abbott strikes deals with heart valve replacement companies

An Abbott Laboratories sales staff checks the serial number of a powder milk tin during a production recall at a milk shop outside Hanoi August 6, 2013.  REUTERS/Kham
An Abbott Laboratories sales staff checks the serial number of a powder milk tin during a production recall at a milk shop outside Hanoi August 6, 2013.

Reuters/Kham


Abbott Laboratories (ABT.N) on Thursday said it would buy a small private company and has invested in another, with an option to buy, as it places bets on the future growth potential of minimally invasive systems to replace diseased heart valves.

Abbott said it has agreed to acquire the equity in Minnesota-based Tendyne Holdings Inc that it does not already own for $225 million plus future payments tied to regulatory milestones. Abbott already had a 10 percent stake in the company worth about $25 million.

In a separate transaction in which financial details were not disclosed, Abbott said it has provided capital to and secured an option to purchase California-based Cephea Valve Technologies.

Both private companies are developing systems to replace diseased mitral valves in the heart while sparing patients traditional chest-cracking open-heart surgery.

Neither deal is expected to alter Abbott’s 2015 earnings forecast, the company said.

Abbott currently sells MitraClip, a minimally invasive device used to repair a leaking mitral valve.

The incidence of mitral valve disease is about three times that of aortic valve disease, with multibillion-dollar sales potential, Abbott said.

“Given the market opportunity and clinical need, we see this as a significant driver for growth several years from now,” John Capek, head of Ventures for Abbott said in an interview.

Minimally invasive aortic valve replacement systems are considered among the most important growth drivers for both Edwards Lifesciences (EW.N) and Medtronic (MDT.N).

The dual flap mitral valve sits on the left side of the heart between upper and lower chambers and helps facilitate proper blood flow in the heart.

U.S. regulators have given the green light to a study to test the safety and effectiveness of Tendyne’s mitral valve system, which has begun enrolling patients, Abbott said. It plans to begin enrolling patients next year for a trial aimed at gaining European approval.

The Tendyne valve has been implanted in 10 people so far, Capek said.

“We’re very impressed with results,” he said. “Those 10 patients have done remarkably well.”

The Cephea valve system is at a much earlier stage of development, he said.

Abbott shares were down 33 cents at $50.73 on the New York Stock Exchange.

(Reporting by Bill Berkrot; Editing by James Dalgleish)


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Low blood level of 4 proteins can help diabetics protect against immune attack

Patients with type 1 diabetes have significantly lower blood levels of four proteins that help protect their tissue from attack by their immune system, scientists report.

Conversely, their first-degree relatives, who share some of the high-risk genes but do not have the disease, have high levels of these proteins circulating in their blood, said Dr. Jin-Xiong She, director of the Center for Biotechnology and Genomic Medicine at the Medical College of Georgia at Georgia Regents University.

Healthy individuals without the risky genes also have higher levels of the four proteins, IL8, IL-1Ra, MCP-1 and MIP-1β, according to the study in the Journal of Clinical Endocrinology & Metabolism.

The findings point toward a sort of protein cocktail that could help at-risk children avoid disease development as well as new biomarkers in the blood that could aid disease diagnosis, prognosis and management, said She, Georgia Research Alliance Eminent Scholar in Genomic Medicine and the study’s corresponding author.

The scientists looked at a total of 13 cytokines and chemokines, which are cell signaling molecules involved in regulating the immune response. They first looked at blood samples from 697 children with type 1 diabetes and from 681 individuals without antibodies to insulin-producing cells, a hallmark of this autoimmune disease. They then analyzed the blood of a second and larger set of individuals, which included 1,553 children with type 1 diabetes and 1,493 individuals without any sign of antibodies.

In this largest study of its kind, they consistently found a higher percentage of type 1 diabetes patients had significantly lower levels of the same four proteins.

“Their pancreatic cells are not secreting enough of these proteins,” said Dr. Sharad Purohit, MCG biochemist and the study’s first author. “Normally you are secreting enough of these cytokines so you prevent attack by the immune system.”

Individuals who have three of the known high-risk genes for type 1 diabetes but high serum levels of these four proteins are less likely to have disease, suggesting that these proteins may provide dominant levels of protection against type 1 diabetes even in a genetically high-risk group, Purohit said.

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“If the individuals with high-risk genes weren’t making more of the proteins, they likely would have diabetes, said Dr. Ashok Sharma, an MCG bioinformatics expert and study co-first author.

One of the proteins found at low levels in patients, MIP-1β, has been shown in animal models to protect against type 1 diabetes development. A recombinant version of IL-1Ra, already used to combat rheumatoid arthritis, is also under study for both type 1 and 2 diabetes. And, human studies have shown that newly diagnosed patients with type 1 diabetes who go into remission have higher levels of IL-1Ra than those who don’t.

Cytokines and chemokines can promote or inhibit inflammation – cytokines such as MIP-1β can do both – and the proper mix helps keep inflammation in check. As an example, IL-1Ra, a cytokine secreted by several cell types, including immune cells, is a natural antagonist of the inflammation promoting cytokine IL-1β.

“We are providing evidence that clinical trials with any of these four molecules may work, and if we use them in combination, they may work even better,” She said. “One of the major research foci in our group is to identify biomarkers for various diseases, diabetes, cancer and others. We also want to identify new therapeutic strategies or targets through the discovery of biomarkers.”

Type 1 diabetes is an autoimmune disease, which primarily surfaces in childhood, where the immune system attacks the insulin-producing cells of the pancreas, leaving children facing a lifetime of daily insulin therapy to try to keep blood sugar levels under control.

Some of the 13 cytokines and chemokines originally screened for the study were known factors in type 1 diabetes, and the scientists were curious about the role of others.

Source:

Medical College of Georgia at Georgia Regents University

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Endocrine Society recommends removal of tumor as first-line treatment for endogenous Cushing's syndrome

The Endocrine Society today issued a Clinical Practice Guideline (CPG) on strategies for treating Cushing’s syndrome, a condition caused by overexposure to the hormone cortisol.

The CPG, entitled “Treatment of Cushing’s Syndrome: An Endocrine Society Clinical Practice Guideline,” was published online and will appear in the August 2015 print issue of the Journal of Clinical Endocrinology and Metabolism (JCEM), a publication of the Endocrine Society.

Cushing’s syndrome occurs when a person has excess cortisol in the blood for an extended period, according to the Hormone Health Network. When it is present in normal amounts, cortisol is involved in the body’s response to stress, maintains blood pressure and cardiovascular function, keeps the immune system in check, and converts fat, carbohydrates and proteins into energy. Chronis overexposure to the hormone can contribute to the development of cardiovascular disease, infections and blood clots in veins.

People who take cortisol-like medications such as prednisone to treat inflammatory conditions, including asthma and rheumatoid arthritis, can develop Cushing’s syndrome. The high cortisol levels return to normal when they stop taking the medication. This is called exogenous Cushing’s syndrome.

In other cases, tumors found on the adrenal or pituitary glands or elsewhere in the body cause the overproduction of cortisol and lead to the development of Cushing’s syndrome. The Clinical Practice Guidelines focus on this form of the condition, known as endogenous Cushing’s syndrome.

“People who have active Cushing’s syndrome face a greater risk of death – anywhere from nearly twice as high to nearly five times higher – than the general population,” said Lynnette K. Nieman, MD, of the National Institutes of Health’s Eunice Kennedy Shriver National Institute of Child Health and Human Development in Bethesda, MD, and chair of the task force that authored the guideline. “To reduce the risk of fatal cardiovascular disease, infections or blood clots, it is critical to identify the cause of the Cushing’s syndrome and restore cortisol levels to the normal range.”

In the CPG, the Endocrine Society recommends that the first-line treatment for endogenous Cushing’s syndrome be the removal of the tumor unless surgery is not possible or unlikely to address the excess cortisol. Surgical removal of the tumor is optimal because it leaves intact the hypothalamic-pituitary-adrenal axis, which is integral to the body’s central stress response.

Other recommendations from the CPG include:

  • Tumors should be removed by experienced surgeons in the following situations:

    • oA tumor has formed on one or both of the two adrenal glands.

      oA tumor that secretes adrenocorticotropic hormone (ACTH) – the hormone that signals the adrenal glands to produce cortisol – has formed somewhere in the body other than the adrenal or pituitary gland.


      oA tumor has formed on the pituitary gland itself.

  • Patients who continue to have high levels of cortisol in the blood after surgery should undergo additional treatment.
  • People who had an ACTH-producing tumor should be screened regularly for the rest of their lives for high cortisol levels to spot recurrences.

  • If patients’ cortisol levels are too low following surgery, they should receive glucocorticoid replacement medications and be educated about adrenal insufficiency, a condition where the adrenal glands produce too little cortisol. This condition often resolves in 1-2 years.

  • Morning cortisol and/or ACTH stimulation tests, or insulin-induced hypoglycemia, can be used to test for the recovery of the hypothalamic-pituitary-adrenal axis in people who have low cortisol levels after surgery. Once the tests results return to normal, glucocorticoid replacement can be stopped.

  • People who have undergone pituitary surgery should be re-evaluated for other pituitary hormone deficiencies during the post-operative period.

  • Patients who have a pituitary tumor and have undergone surgery to remove both adrenal glands should be regularly evaluated for tumor progression using pituitary MRIs and tests for ACTH levels.

  • Radiation therapy may be used to treat a pituitary tumor, especially if it is growing. While awaiting the effect of radiation, which may take months to years, treatment with medication is advised.

  • To assess the effect of radiation therapy, the patient’s cortisol levels should be measured at 6- to 12-month intervals.

  • Medications may be used to control cortisol levels as a second-line treatment after surgery for a pituitary gland tumor, as a primary treatment for ACTH-secreting tumors that have spread to other parts of the body or suspected ACTH-secreting tumors that cannot be detected on scans. Medications also can be used as adjunctive treatment to reduce cortisol levels in people with adrenal cortical carcinoma, a rare condition where a cancerous growth develops in the adrenal gland.

  • People with Cushing’s syndrome should be treated for conditions associated with the disease, such as cardiovascular disease risk factors, osteoporosis and psychiatric symptoms.

  • Patients should be tested for recurrence throughout their lives except in cases where the person had a benign adrenal tumor removed.

  • Patients should undergo urgent treatment within 24 to 72 hours of detecting excess cortisol if life-threatening complications such as serious infection, pulmonary thromboembolism, cardiovascular complications and acute psychosis are present.

Source:

The Endocrine Society

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