Recurrent Cushing’s Disease (CD):

How big is the problem and what are our options?

Beverly MK Biller, MDProfessor of Medicine

Harvard Medical School

Neuroendocrine Clinical Center

Massachusetts General Hospital

Boston, MA

PI of research grants from Cortendo & Novartis to MGH

Occasional consulting for Cortendo, Novartis

Slides will indicate investigational medications (includes those available for other indications but not approved for Cushing’s)

Disclosure of potential relevant conflicts

of interest and non-approved medications

Cushing’s disease (CD) Case 1

- 36 year old pregnant woman with

• facial rounding

• hypertension

• fungal infections

- Cushing’s syndrome later

diagnosed with high urine free

cortisols (UFCs)

- ACTH not suppressed

- Head MRI ? small right lesion

- Inferior petrosal sinus

sampling centralized

Clear clinical and biochemical features of CS; testing points to pituitary

Patient

photo

Cushing’s disease (CD) Case

Before

surgery

~8 years after

surgery;

Moved to AZ

• 36 year old with CD pituitary surgery by expert surgeon

very low cortisol levels post-op

• In remission good clinical improvement, euthyroid, eugonadal,

normal growth hormone axis

• HPA axis recovered in ~1 year off glucocorticoids

Patient

photo

Patient

photo

Case 2

- 27 yo F with CD diagnosed after pregnancy

- MRI showed 1cm macroadenoma

- Pituitary surgery 2011 levels normal (not low)

- Good clinical improvement over the next year

Patient

photos

Cushing’s disease (CD) Cases

What are their chances of recurrence?

We used to say 5-10% of CD cases recur, but

Swearingen Ann Int Med 1999

Patient

photos

0

Valassi 2010 (n=620)

Alwani 2010 (n=79)

Jagannathan 2009 (n=261)

Fomekong 2009 (n=40)

Atkinson 2008 (n=42)

Jehle 2008 (n=193)

Prevedello 2008 (n=167)

Xing 2008 (n=266)

Carrasco 2008 (n=68)

Romanholi 2008 (n=57)

Patil 2008 (n=215)

Rollin 2007 (n=108)

Pouratian 2007 (n=111)

Acebes 2007 (n=44)

Shah 2006 (n=65)

Hoffmann 2006 (n=100)

Esposito 2006 (n=40)

Atkinson 2005 (n=63)

Hammer 2004 (n=289)

Rollin 2004 (n=41)

Pereira 2003 (n=78)

Chen 2003 (n=174)

Flitsch 2003 (n=147)

Shimon 2002 (n=82)

Rees 2002 (n=54)

Barbetta 2001 (n=68)

Chee 2001 (n=61)

Imaki 2001 (n=49)

10 20 30 40 50 60 70 80 90 100

Patients (%)

Remission

Recurrence

Recurrence rates wereas high as 27%!

Studies in the last 5 years have shown even higher rates

Most are from expert centers

Recurrent Cushing’s after transsphenoidal surgery(28 studies with varied definitions of biochemical control, follow up, number of subjects)

(70-90% with expert surgeon)

• 2012 new diabetes (DM), weight

gain, ↑ blood pressure

• Told no, because - metformin controlled the DM

- she was able to lose wt

- serum cortisol was “normal”

Case 1

1990s

~2013

• Came to Boston for evaluation

• 8/8 UFCs were normal; looked well

• but 66% of late night salivary

cortisols (LNSCs) were high

Patient

photos

Case

Head MRI(first in many years)

Mass on right side of

pituitary gland

~1.5 x 1.3 x 0.7 cm

? right cavernous sinus

invasion

Normal gland pushed left

Case 2

• Fall 2013 recurrent symptoms

‒ emotional lability/moodiness

‒ weight gain

‒ but did not look Cushingoid

• Serum cortisols done locally were “normal”

• LNSCs & UFCs 1-2 fold upper limit of normal

• Head MRIs unchanged over 2 years

Patient

photo

• These patients had typical

recurrences− mild clinical features

− mild biochemical abnormalities

− one had unchanged MRI, abnormal UFCs

− one had normal UFCs, abnormal MRI

• Case 2 had a high probability of recurrence– tumor >1cm

– no adrenal insufficiency post-op but

• Patients without positive predictors may

also recur (Case 1)

(Tritos Nature Rev Endocrinol 2011)

CasesPatient

photos

• Recurrence may be many years after surgery− 31 series with N>40: relapse between 6m-12y

− Case 1 recurred at 21 years! Longest we’ve seen: 27y

• Sequence of hormone changes in recurrent CD− ↑midnight cortisol (serum or saliva) usually precedes ↑UFC

− mean time to elevation: 38 months for midnight cortisol

45 months for 1mg overnight DST

51 months for UFC

• All post-op patients must be followed– Can’t rely on UFC alone for diagnosis

– Use LNSC, ONDST

– LNSC appears to be most sensitive test

Cases

(Khalil EJE 2011, Tritos Nature Rev Endocrinol 2011, Carroll ENDO 2014 , Danet-Lamasou Clin Endo 2014)

Patient

photos

Late night salivary cortisol

• High sensitivity and specificity (93-100%)

• Especially helpful in early Cushing’s, recurrences

• Normal levels exclude dx in most cases

• Easily performed at home

• Before dental care; avoid hand creams

• Pt chews on cotton, places into tube, mails

• Several samples recommended

• Normal ranges differ widely by lab

• May be high in day/night switch, late pregnancy,

other circumstances

How many of you use this test? – please raise your hand if you do

It was an effort to make this available at our hospital

Insurance coverage is variable and different for different labs

Late‐night salivary cortisol to screen for

early‐stage recurrence of CD after pituitary surgery

Danet-Lamasou Clin Endo 2014

Remission

Sequences

30

0

15

25

20

10

5

LNSC

(n

M)

Sequences: successive measurements of

LNSC for each individual patient

normalrange

Late‐night salivary cortisol to screen for

early‐stage recurrence of CD after pituitary surgery

Danet-Lamasou Clin Endo 2014

Remission

Sequences

30

0

15

25

20

10

5

LNSC

(n

M)

Recurrence

Sequences

30

0

15

25

20

10

5

LNSC

(n

M)

Sequences: successive measurements of

LNSC for each individual patient

normalrange

Lindholm 0.31 (0.14-0.69)

•

0.126 7.931

Hammer

Dekkers

Clayton

Overall(I-squared = 82.2%; p = 0.001)

1.18 (0.56-2.48)

1.80 (0.75-4.32)

3.30 (1.37-7.93)

1.20 (0.45-3.18)

Mortality among CD patients in remission

Clayton R N et al. JCEM 2011;96:632-642.

Hammer

5.06 (2.27-11.26)•

•

•

•

0.026 38.4

Clayton R N et al. JCEM 2011;96:632-642.

1

Lindholm

Dekkers

Clayton

Overall (I-squared = 67.2%, p = 0.027)

2.80 (1.33-5.87)

4.38 (1.82-10.52)

16.0 (6.66-38.44)

5.50 (2.69-11.26)

Mortality among CD patients with recurrence

CRH

ACTH

Cortisol

Adrenal glands

Pituitary gland

Cabergoline*

Pasireotide

Ketoconazole*

Metyrapone*

Mitotane*

Etomidate*

What are the treatment options for recurrent Cushing‘s disease?

GR

Mifepristone

GRs on

target tissues

Tissues(* not FDA approved for Cushing’s)

RADIATION

ADRENALECTOMY

MEDICATIONS

PITUITARY SURGERY

Repeat transsphenoidal surgery

• Pros

− Well tolerated

− Immediate effect (if successful)

− Chance for tumor removal and remission

• Cons

− Glucocorticoids needed until axis recovers

− Higher risk of pituitary hormone deficiencies

− Risk of recurrent Cushing’s

− Lower chance of success than 1st surgery (<75%)

Remission rates after repeat transsphenoidal

surgery for persistent or recurrent CD

0 20 40 60 80 100

Nakane 1987 (N=8)

Friedman 1989 (N=31)

Ram 1994 (N=17)

Knappe 1996 (N=24)

Shimon 2002 (N=13)

Locatelli 2005 (N=12)

Benveniste 2005 (N=30)

Hofmann 2006 (N=16)

Hofmann 2008 (N=35)

Aghi 2008 (N=13)

Patil 2008 (N=36)

Wagenmakers 2009 (N=8)

Remission Rate (%)

Varied definitions of biochemical control, follow up, Ns

(McLaughlin Can J Neurol Sci 2011)

1st surgery

remission

rates 70-90%

2nd surgery

remission

rates lower,

but it works for

some patients

Bilateral Adrenalectomy

• Pros

− Immediate remission from cortisol excess

− Permanent (usually)

− Well tolerated (especially if laparoscopic)

• Cons

− Risks of abdominal surgery

− Lifelong gluco- & mineralocorticoid

replacement and risk of adrenal crisis

− Long term risks› Nelson’s syndrome ~ Corticotroph Tumor Progression

› Recurrent Cushing’s (rare)

22

Radiation

CONVENTIONAL

Six weeks of daily tx• Conventional

Fractionated

• Radiosurgery (RS)

− Single high dose to target

− Lower dose to other tissue

− 3 types

› Linear accelerator (LINAC)

› Gamma knife

› Proton beam

LINAC

gamma knifeproton beam

No direct comparisons available

• RS may be faster

• For CD, similar cortisol control

23

Radiation

0 10 20 30 40 50 60 70 80 90 100

Littley 1990

Murayama 1992

Levy 1991

Tsang 1996

Estrada 1997

Witt 1998

Laws 1999

Sheehan 2000

Kobayashi 2002

Devin 2004

Colin 2005

Jagannathan 2007

Minniti 2007

Petit 2008

Wilson 2014

Patients (%)

Tumor control

(83-100%)

Biochemical

control (28-86%)

(Starke Curr Opin Endocrinol Diab Obes 2010, Tritos Nature Rev Endocrinol 2011, Wilson J Clin Neurosci 2014)

15 studies with at least 20 pts

Varied RT methods, definitions of tumor & biochemical control, follow up, Ns

24

Radiation

CONVENTIONAL

Six weeks of daily tx

• Pros

− Well tolerated

− Single treatment (if radiosurgery)

− Provides tumor control in most patients

− Biochemical control in some patients

• Cons

− Delayed effectiveness (6 months to many years)

− Medical treatment needed in the interim

− Long term risks:› Pituitary hormone deficiencies/need for replacement

› Risk to surrounding neurovascular structures

› Risk of secondary neoplasia

› Recurrence (rare)

(Starke Curr Opin Endocrinol Diab Obes 2010, Tritos Nature Rev Endocrinol 2011, Wilson J Clin Neurosci 2014)

Case 2

• 29 yo F with history of Cushing’s surgery 2011

• Fall 2013 recurrent Cushing’s, options were discussed

Patient asked,

“Isn’t there a medication

I can take instead of

having surgery again?”

Patient

photo

CRH

ACTH

Cortisol

Adrenal glands

Pituitary gland

Cabergoline*

Pasireotide

Ketoconazole*

Metyrapone*

Mitotane*

Etomidate*

LCI699*

Potential targets for medical Tx of Cushing‘s disease

GR

Mifepristone

GRs on

target tissues

Tissues(* not FDA approved for Cushing’s)

Rationale: affinity for receptors on corticotroph adenomas

• cabergoline for dopamine (D2) receptor

• pasireotide for somatostatin (sst5) receptor

↓ ACTH secretion

Cabergoline in Cushing’s disease

• 20 Cushing’s disease pts, mean UFC > 2-fold above nl

• 2-year study: 1-7mg/wk cabergoline (median 3.5mg/wk)

• 2 dropouts for “asthenia, hypotension”; adrenal insufficiency?

• Cardiac echos: tricuspid regurg progressed in 1, no change in others

• Similar findings in two other studies; suggests this is an option for CD

Non-

responders

Early response,

Later “escape”

Long-term

responders

normal range

months

(Pivonello JCEM 2009, Godbout EJE 2010, Vilar Pituitary 2010)(not FDA approved for Cushing’s disease)

“Responder” means normal UFC

2500

Pasireotide - baseline & month 6 UFCs

Individual patients sorted by baseline UFC

Color denotes starting dose

UF

C (

μg

/24

h)

0

180

360

540

720

1400 600 µg s.c. bid

900 µg s.c. bid

normal

Baseline UFC

Month 6 UFC

Month 6 UFC ULN*

<52.5 μg/24h

Normal UFC, n (%) 12 (14.6) 21 (26.3) 33 (20.4)

Colao NEJM 2012

N=103

Colao NEJM 2012

600 µg sc bid 900 µg sc bid All patients

Clinical changes on pasireotide up to 12m

Cola

oN

EJM

2

01

2

FDA approved for CD pts not controlled with/able to have surgery

Subcutaneous pasireotide side effects

• Adrenal insufficiency symptoms in 13 (8%)

– Responded to dose reduction and/or temporary corticosteroids

• Most frequent side effects were gastrointestinal

• Similar to other SMS analogues, except for hyperglycemia

• 73% of patients had at least one hyperglycemia event

– No diabetic ketoacidosis or hyperosmolar coma

– Attainment of UFC control did not prevent hyperglycemia

Colao NEJM 2012

Mechanism based on study in healthy volunteers:

Pasireotide reduces incretin & insulin secretion,

without affecting insulin sensitivity

Changes in glycemia on pasireotide

Mean fasting

plasma glucose

(mg/dL)

600 µg bid (n=82) 900 µg bid (n=80)

Mean HbA1c

(%)

600 µg bid (n=82) 900 µg bid (n=80)

90

100

110

120

130

140

150

Baseline Day 15 Month 3 Month 6 Month 12

5

6

7

8

Baseline Month 2 Month 6 Month 12

Of the 67 patients who were normoglycemic at baseline, 14 (21%) remained normal,

29 (43%) became pre-diabetic and 23 (34%) became diabetic during treatment

Henry JCEM 2013

Colao NEJM 2012

Pasireotide LAR* (once monthly)

Lacroix ENDO 2016*(not FDA approved for Cushing’s)

0 20 40 60

≥1.5 to <2.0 x ULN

≥2.0 to ≤5.0 x ULN

Pasireotide LAR 10 mg

Pasireotide LAR 30 mg

Screening mUFC

Percentage of responders

(mUFC ≤ULN at month 7)

n=18/49

n=18/51

n=13/25

n=13/25

36.7%

35.3%

52.0%

52.0%

•150 patients randomized to 10mg/month or 30mg/month

• Proportion of “Responders” (normal UFC) at month 7 by

pasireotide LAR dose according to baseline UFC group

Side effects were

similar to bid

subcutaneous

CRH

ACTH

Cortisol

Adrenal glands

Pituitary gland

Cabergoline*

Pasireotide

Ketoconazole*

Metyrapone*

Mitotane*

Etomidate*

LCI699*

Potential targets for medical Tx of Cushing‘s disease

Tissues

GR

Mifepristone

GRs on

target tissues

(* not FDA approved for Cushing’s)

Several used for over 50 years

Reduce cortisol by inhibiting adrenal steroidogenesis

ACTH ↑ in pituitary Cushing’s

(? of escape)

Ketoconazole

• Approved for treatment of fungal infections

• Inhibits several enzyme steps in cortisol production

• 4 past studies w/ >15 CD pts: cortisol control 49-99%

What‘s new?

• Large multicenter, retrospective French study− 200 patients on monotherapy at 14 centers over 17y

− Mean final dose 780mg/d (range 200-1200mg)

− Control (2 consecutive normal UFCs) in 49%

− Clinical improvements in DM, HTN, hypokalemia

− ~20% discontinued for intolerancemost common: gastrointestinal, adrenal insuff, pruritis

− Liver enzyme elevations in 18% (>5XULN, 2.5%)

• Conclusion: effective with acceptable side effects

(Castinetti EJE 2008 & JCEM 2014, Sonino Clin Endo 1991, Valassi Clin Endo 2012, clinicaltrials.gov)(not FDA approved for Cushing’s)

Metyrapone

• Inhibits last enzyme step in cortisol synthesis

• Cortisol control reportedly ~75% − 3 studies from 1970s to early 1990s (15-53 patients)

What‘s new?

• Large multicenter, retrospective UK study (ENDO 2014 oral)

− 160 patients on metyr monotherapy at 13 centers over 16y

− Control based on cortisol day curve or UFC or am cortisol

− 74% controlled overall in Cushing‘s syndrome(about 2/3rds who took metyrapone over 5m had CD)

XCortisol

11bOHlase

11deoxycortisol

(Jeffcoate BMJ 1977, Thorén Acta Endocrinol (Copenhagen)1985,

Verhelst Clin Endo 1991, Daniel ENDO 2014) (not FDA approved for Cushing’s)

(Jeffcoate BMJ 1977, Thorén Acta Endocrinol (Copenhagen)1985,

Verhelst Clin Endo 1991, Daniel ENDO 2014)

Change in 9am cortisol during treatment for each individual patient

0

300

600

900

1200

1500

1800

151 patients

9a

m c

ort

iso

l (n

mo

l/l)

ReductionIncrease

Normal: 600nmol/L=21.7 mcg/dl

Slide kindly provided by John Newell-Price

(not FDA approved for Cushing’s)

− Dose in CD patients with eucortisolemia was ~1.4 g/d

− 25% had side effects (most common: GI, hypoadrenalism)

Conclusion: effective with satisfactory safety profile

(Daniel JCEM 2015)

37

Potent inhibitor of 11β-hydroxylase (CYP11B1) and aldosterone synthase (CYP11B2)

Blocks last steps in cortisol and aldosterone production

Hormones distal to the block fall

and proximal hormones rise

- Oral, longer half-life than metyrapone (allows twice-daily dosing)

- Higher potency (in vitro IC50 for CYP11B1 of 2.5 nM vs. 7.5 nM)

IC50, half maximal inhibitory concentration

Pregnenolone

11-deoxycortisol

Cortisol

Cholesterol

ACTH

Aldosterone

CY

P11B

2

Corticosterone

18-OH corticosterone

LCI699

CYP11B1

Abnormal

feedback loop in

Cushing’s disease

Progesterone

Dehydroepiandrosterone

Androstenedione

Testosterone

11-deoxycorticosterone

Estradiol

Estrone

X

X

11-deoxycortisol

ACTH

Testosterone

11-deoxycorticosterone

Investigational medication LCI699 (osilodrostat)*

Mechanism of action

(* not FDA approved)

38

Me

an U

FC

±S

E (

fold

ULN

)

0

1

2

3

4

5

6

7

1 14 28 42 56 70 84Day

LCI699 dose escalation Washout

Open-label, proof-of-concept study with LCI699*

was positive in 12 adults with Cushing’s disease

• Oral medication, given twice daily

• Dose escalated every 2 weeks until UFC normalized

• Maintained until day 70, followed by 2-week washout

Bertagna JCEM 2014

At day 70:

• 11/12 had normal UFC

• Most common side

effects: fatigue, nausea

(* not FDA approved)

39

Longer-term extension

Change in UFC after 22 weeks of LCI699*U

FC

(n

mo

l/2

4h

)

7000

9000

11000

2000

1800

1600

1400

1200

1000

800

600

400

200

0Patients

Baseline

Week 22

Follow-up cohort

Expansion cohort

Overall response (n=19):

• Controlled, n=15 (78.9%)

• Uncontrolled, n=2 and

discontinued, n=2 (21.1%)

normal

range11–138 nmol/24h

(* not FDA approved) (Fleseriu & Pivonello Pituitary 2016, clinicaltrials.gov)

CRH

ACTH

Cortisol

Adrenal glands

Pituitary gland

Cabergoline*

Pasireotide

Ketoconazole*

Metyrapone*

Mitotane*

Etomidate*

LCI699*

Potential targets for medical Tx of Cushing‘s disease

GR

Mifepristone

GRs on

target tissues

(* not FDA approved for Cushing’s) Tissues

Blocks action of cortisol at glucocorticoid receptor (GR)

Doesn’t lower cortisol; ACTH and cortisol ↑ in pituitary Cushing’s

Oral glucocorticoid (GR) antagonist - greater affinity than

cortisol or dexamethasone for the receptor

Also has antiprogestin activity

Phase 3 clinical trial in 50 patients reported in 2012

FDA approval for Cushing’s syndrome with hyperglycemia

Mifepristone in Cushing’s Syndrome

Blocks receptor (does not ↓cortisol) so response was assessed clinically

− Patients had diabetes/impaired glucose tolerance or HTN

− Primary endpoints related to improvements in these disorders

(25% reduction in AUCgluc on OGTT, 5mmHb reduction in DBP)

(Fleseriu JCEM 2012)

Decrease in HbA1c in diabetes cohort

4

5

6

7

8

9

10

Baseline Week 16 Week 24/ET

Hb

A1c (

%)

p<0.001

vs baseline

N=25 N=22N=20

me

an ±

SD

p<0.001

vs baseline

Glucoses on

OGTT and

insulin levels

also decreased

significantly

Diabetes drugs

were reduced in

7/15 patients

(Fleseriu JCEM 2012)

(mea

n ±

SE

)Decrease in weight

-9%

-8%

-7%

-6%

-5%

-4%

-3%

-2%

-1%

0%

1%

2%

D7 D14 D28 W6 W8 W10 W12 W16 W20 W24

% C

hange f

rom

baselin

e

Baseline 99.5 ± 4.4 kg

n=46

↓ 5.7 ± 1.5%

p<0.001

vs Baseline

/ET

(Fleseriu JCEM 2012, Katznelson Clin Endo 2013)

“Global Clinical Assessment”

of many features, including

appearance in photographs,

rated by 3 independent

reviewers improved in

88% of patients (p<0.001)

• Adrenal insufficency (AI)− Classified as AI or typical symptoms & treatment with glucocorticoid (dex) in 7

− High measured cortisols despite AI may be misleading

• Most common: nausea, fatigue, headache

• Hypokalemia− Common, associated with alkalosis, edema; treated with K & spironolactone

− Likely due to mineralocorticoid receptor activation from rising cortisol

• Endometrial Effects (progesterone receptor blockade)− Increased endometrial thickness in half of women

− 5 cases of vaginal bleeding

− 3 women had D&C for unresolved endometrial thickening after discontinuation

• Thyroid – elevated TSH

• Lipids – decreased HDL

Drug-drug interactions require careful attention

Mifepristone side effects

(Fleseriu JCEM ‘12, Endocrine Practice ’13)

Phase III

Long-acting pasireotide

Levo-ketoconazole

Osilodrostat (LCI699)

Phase II

Roscovitine

Gefitinib

CORT125134

Preclinical/other

Retinoic acid

Silibinin

ALD1613

Possible future options:

What drugs* are in development?

(* not FDA approved for Cushing’s)

* Especially with mifepristone and ketoconazole

Severity/urgency, treatment goals (cortisol/tumor)

Other medications

(beware drug–drug

interactions)*

Medical history and patient

factors

Method of delivery

(oral versus injection)

Side-effect profile

Cost and availability

How do we decide which medication to use?

Consider many factors

Tailor choice to each patient’s individual situation

Case 1 Outcome

Before second surgery

2013

After second surgery

June 2014 Dec 2015

• She decided to undergo second transsphenoidal surgery by an

expert pituitary surgeon; “I’d be happy with another 20-year

remission by spending just 1 day in the hospital” in remission

• Diabetes and hypertension resolved (medications stopped)

• Pituitary hormone replacements adjusted, feeling well

Patient

photos

• 29 yo F Cushing’s disease recurrence

• Treatments discussed; considering the options

• Phone call to fellow… patient was excited to report….

• Pregnant! What are the treatment options now?

• Choices are limited

• Metyrapone* started

(* not FDA approved for this use) (Lindsay JCEM 2005)

Case 2 Outcome

- targeted UFCs in normal pregnant range, 1.5-2 fold above ULN

- due to concern about precursors proximal to 11ßOHlase blockade,

careful monitoring of potassium & blood pressure (weekly OB visits)

She delivered a healthy boy!

Patient

photo

Conclusions

• All patients in remission from CD should

have lifelong monitoring for recurrence

• Late night salivary cortisol levels are more

sensitive than other tests

• Treatment is important to lower mortality risk

• Management should be individualized

Thank you

Questions?