Approach to the Patient Treated with Steroidogenesis Inhibitors

Steroidogenesis inhibitors can be given to control the hypercortisolism of Cushing's syndrome in various situations: when surgery has been unsuccessful or not possible; in metastatic adrenocorticotropin hormone (ACTH) or cortisol-secreting tumors; when waiting for the maximal efficacy of radiation techniques; for rapid treatment of severe hypercortisolism in patients with occult ACTH-producing tumors; or as a presurgical treatment in patients with severe comorbidities. Whilst biochemical control can be achieved in more than 50% of cases, daily management of such drugs can be challenging. Indeed, with a dose-titration or a block and replace approach, defining eucortisolism is usually difficult, requiring the measurement of several biological markers. Moreover, each drug has its own side effects, which must be monitored closely. The aim of this approach to the patient is to shed light on the management of hypercortisolism with 4 steroidogenesis inhibitors (ketoconazole, levoketoconazole, metyrapone, osilodrostat) to help endocrinologists dealing with patients with Cushing's syndrome. Various points will be discussed, such as initial dose of treatment, dose schedule, monitoring of efficacy, and side effects of monotherapy. The combination of steroidogenesis inhibitors will also be discussed.

Automated summary

Steroidogenesis inhibitors are used to control hypercortisolism in Cushing's syndrome in various situations, but daily management can be challenging due to potential side effects and difficulties in defining eucortisolism. Monitoring of biological markers and proper combination of drugs are important aspects of treatment.