Practice Update: DIABETES

AACE 2017 11

Dr Mehta presented three cases of Cushing’s syndrome with var- ied presentations, etiologies, and management. Case 1 A 71-year-old male with coronary artery disease presented with fatigue and weakness, Cushingoid features, insulin resistance, and hypokalemic metabolic alkalosis. Laboratory evaluation showed an elevated 24-h urinary free cortisol and ACTH level. Pituitary MRI revealed no mass. He failed 1 and 8 mg dex- amethasone suppression tests. Both whole body PET and octreotide scans, however, showed no evidence of a source of ectopic ACTH. Subsequently, the patient underwent inferior petrosal sinus sampling, results of which were consistent with a pituitary source of ACTH. Total hypophysectomy was performed for a presumed pituitary microadenoma, but pathology instead showed corticotrophic hyperplasia. At publication, the patient continued to suffer from persis- tent Cushing’s syndrome, which is managed medically with mifepristone. Recent intolerances, however, have led to con- sideration of bilateral adrenalectomy. Case 2 A 35-year-old male developed diabetes mellitus, coronary artery disease, pulmonary embolism, and osteoporosis over a 1-year period. He was noted to harbor Cushingoid features and hypokalemic metabolic alkalosis. Random cortisol and ACTH levels were very elevated. Pituitary MRI revealed a 3-mm microadenoma, yet he failed the 8 mg dexamethasone suppression test. The patient then underwent inferior petrosal sinus sampling, results of which were consistent with a pituitary etiology. Pitu- itary microadenoma was resected, and pathology confirmed ACTH-secreting adenoma. At publication, he was being mon- itored closely postoperatively and exhibited signs of adrenal insufficiency. Case 3 A 40-year-old female with history of metastatic pancreatic neuroendocrine tumor presented with altered mental status, skin hyperpigmentation, and hypokalemic metabolic alkalo- sis. Laboratory evaluation showed an elevated 24-h urinary cortisol and ACTH level. Results of high-dose dexamethasone suppression and cor- ticotropin-releasing hormone stimulation tests suggested ectopic ACTH secretion. Pituitary MRI did not reveal any sig- nificant mass. ACTH staining of previously resected ovarian metastases of pancreatic neuroendocrine tumor showed pos- itive immunoreactivity, confirming the source of ACTH. Given the lack of surgical options due to metastatic disease, she is being managed with combination octreotide, ketoconazole, and mifepristone. Dr Mehta concluded that the three cases demonstrate the diffi- culty of applying the theoretical diagnostic algorithm to determine the etiology of Cushing’s syndrome. In addition, they demonstrate that treatment for Cushing’s syndrome should be individualized.

Guidelines for treating the new cardiovascular “extreme risk” category have been validated More intense treatment and intervention for dyslipidemia has been recommended by the American Association of Clinical Endocrinologists and American College of Endocrinology, and a new “extreme risk” category has been introduced. The updated guidelines and new risk category were presented at AACE 2017. P aul Jellinger, MD, of Memorial Regional Hospital South, Hollywood, Florida, and Yehuda Handelsman, MD, of Providence Tarzana Medical Center, Tarzana, California, highlighted the patient benefits of the recently introduced clin- ical guidelines. Drs Jellinger and Handelsman underscored the application of more aggressive treatment to reduce low-density lipoprotein cholesterol (LDL-C) in: • Patients with progressive atherosclerotic cardiovascular dis- ease who have achieved an LDL under 70 mg/dL. • Those with established atherosclerotic cardiovascular disease and diabetes, stage 3 or 4 kidney chronic kidney disease, or heterozygous familial hypercholesterolemia. • Those with a history of premature cardiovascular disease Patients with the above characteristics are now categorized as being at cardiovascular “extreme risk.” Treatment goals for these patients include: • LDL cholesterol <55 mg/dL • Non-HDL cholesterol <80 mg/dL • ApoB <70 mg/dL Coronary artery calcium score and inflammatory markers are also valuable in stratifying risk. The groundbreaking guidelines also assess the following: • Adding ezetimibe and PCSK9 inhibitors in patients with car- diovascular disease who are unable to reach LDL cholesterol goals with statin therapy. • Screening for cardiovascular risk in female patients using the Reynolds Risk Score or Framingham Risk Assessment Tool. • Special guidance for the diagnosis and management of dys- lipidemia in children and adolescents as early as possible to decrease the long-term risk of adult cardiovascular events. Dr Jellinger said, “While suggestive evidence pointed in the direction of better outcomes with more aggressive LDL treat- ment, IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) was the first prospective trial to demonstrate that driving LDL down to 53 provided a clear, significant benefit in reducing cardiovascular outcomes in high- risk groups.” “By expanding the group of patients studied in IMPROVE-IT to other very high-risk situations, our knowledge base expanded con- siderably. The new information led to the creation of the new risk category, a broader range of disease stages, and accompanying groundbreaking treatment and intervention recommendations.”

PracticeUpdate Editorial Team

PracticeUpdate Editorial Team

VOL. 1 • NO. 1 • 2017