Evolving Treatment Paradigms in Hypercortisolism: Integrating Emerging Evidence into Practice - Episode 5
Approaches to Medical Management of Hypercortisolism in Type 2 Diabetes
Panelists discuss how medical management options include steroidogenesis inhibitors and glucocorticoid receptor antagonists such as mifepristone, with particular emphasis on managing the complex withdrawal symptoms and coordinating care across multiple comorbidities including diabetes, hypertension, and osteoporosis.
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When surgical intervention is not feasible, medical management becomes essential for patients with hypercortisolism. Richard Auchus, MD, PhD, outlines 3 main therapeutic approaches: steroidogenesis inhibitors that block cortisol production, glucocorticoid receptor antagonists that block cortisol action, and tumor-directed therapies for specific cases. Mifepristone stands out as the only medication approved specifically for glucose control in hypercortisolism, having gained FDA approval based on its glucose-lowering effects in the SEISMIC study. Other options include ketoconazole, metyrapone, and osilodrostat for blocking cortisol synthesis, each with different mechanisms and adverse effect profiles.
Natalie Bellini, DNP, FNP, BC-ADM, CDCES, emphasizes that medical management requires a holistic approach addressing multiple systems affected by chronic cortisol excess. Treatment goals include improving glucose control, managing hypertension, addressing osteoporosis, and helping patients understand the interconnected nature of their symptoms. Patient education becomes crucial, as individuals need to understand why they have developed multiple comorbidities and what to expect during treatment. The approach requires careful coordination of diabetes medications, particularly reducing insulin and sulfonylureas as cortisol levels decrease, while maintaining cardioprotective agents such as glucagon-like peptide-1 agonists and SGLT2 inhibitors.
Medical management of hypercortisolism requires careful attention to cortisol withdrawal symptoms, which can make patients feel worse initially before improvement occurs. The panel recommends a slow, stepwise approach with frequent monitoring and clear communication with patients about expected adverse effects. Ralph DeFronzo, MD, describes providing direct contact information to patients on insulin therapy, emphasizing the need for close glucose monitoring as cortisol levels decrease. Continuous glucose monitoring becomes valuable for patients on insulin, allowing real-time adjustment of therapy as insulin sensitivity improves with treatment.
