Tratamiento del síndrome de cushing iatrogénico: cuestiones de abstinencia de glucocorticoides

Abstract

El síndrome de Cushing iatrogénico es la forma más común de hipercortisolismo. Los glucocorticoides se usan ampliamente para el tratamiento de diversas enfermedades, a menudo en dosis altas que pueden conducir al desarrollo de hipercortisolismo severo. El hipercortisolismo iatrogénico es único, ya que la aplicación de glucocorticoides exógenos conduce a la presencia simultánea de síntomas específicos del hipercortisolismo y la supresión del eje endógeno hipotalámico-pituitario-adrenal. La función principal de su terapia está relacionada con el problema de la abstinencia de glucocorticoides. Existe una considerable variabilidad interindividual en la supresión y recuperación del eje hipotalámico-pituitario-adrenal, por lo tanto, La retirada y sustitución de glucocorticoides solo se puede realizar de manera escalonada con un seguimiento clínico cuidadoso y exámenes de laboratorio regulares con respecto a la actividad endógena del eje hipotalámico-pituitario-adrenal. Tres complicaciones principales que pueden asociarse con la abstinencia de glucocorticoides son: reactivación de la enfermedad subyacente, insuficiencia suprarrenal secundaria y síndrome de abstinencia de esteroides.

Drug induced iatrogenic Cushing’s syndrome

“…The longer the steroid treatment and the higher the dose applied; the more time is needed for withdrawal. 1 Recovery of the normal functioning of the HPA axis takes over a year. However, maintaining the HPA axis responsiveness is possible by administering a reduced amount of steroids in the morning, as morning ACTH secretion suppression occurs less frequently with this protocol.…”

“…However, maintaining the HPA axis responsiveness is possible by administering a reduced amount of steroids in the morning, as morning ACTH secretion suppression occurs less frequently with this protocol. 1 The discontinuation of glucocorticoids is only appropriate when the underlying disease is in a long-term inactive phase with a steroid dose corresponding to the daily replacement dose or only slightly exceeding it. In the case of an active disease, alternative effective treatment approaches to control the underlying pathology should be considered instead of glucocorticoids, such as other forms of immunosuppression.…”

“…In the case of an active disease, alternative effective treatment approaches to control the underlying pathology should be considered instead of glucocorticoids, such as other forms of immunosuppression. 1 Regarding the type of glucocorticoid used, two main approaches are proposed in this research. One suggests changing the steroid administration to alternate days without modifying the previously prescribed glucocorticoid.…”

“…These drugs are available in a wide variety of forms, ranging from tablets to intravenous (IV) administration, joint injections, enemas, skin creams, inhalers, and eye drops. 1 These drugs are glucocorticoid receptor agonists that activate glucocorticoid receptors in lymphocytes, achieving an anti-inflammatory effect. However, since glucocorticoid receptors are not exclusive to lymphocytes, glucocorticoid treatment will inevitably stimulate receptors present in various cell types in the body, including the skin, muscles, bones, blood vessels, pituitary gland, and brain cells.…”

“…However, withdrawing long-term treatment, persisting for several months or even years, presents a challenge for both the patient and the treating physician. 1…”