A prospective longitudinal study of Pasireotide in Nelson's syndrome

Eleni Daniel, Miguel Debono, Sharon Caunt, Constantine Girio-Fragkoulakis, Stephen J Walters, Scott A Akker, Ashley B Grossman, Peter J Trainer, John Newell-Price, Eleni Daniel, Miguel Debono, Sharon Caunt, Constantine Girio-Fragkoulakis, Stephen J Walters, Scott A Akker, Ashley B Grossman, Peter J Trainer, John Newell-Price

Abstract

Purpose: Nelson's syndrome is a challenging condition that can develop following bilateral adrenalectomy for Cushing's disease, with high circulating ACTH levels, pigmentation and an invasive pituitary tumor. There is no established medical therapy. The aim of the study was to assess the effects of pasireotide on plasma ACTH and tumor volume in Nelson's syndrome.

Methods: Open labeled multicenter longitudinal trial in three steps: (1) a placebo-controlled acute response test; (2) 1 month pasireotide 300-600 μg s.c. twice-daily; (3) 6 months pasireotide long-acting-release (LAR) 40-60 mg monthly.

Results: Seven patients had s.c. treatment and 5 proceeded to LAR treatment. There was a significant reduction in morning plasma ACTH during treatment (mean ± SD; 1823 ± 1286 ng/l vs. 888.0 ± 812.8 ng/l during the s.c. phase vs. 829.0 ± 1171 ng/l during the LAR phase, p < 0.0001). Analysis of ACTH levels using a random intercept linear mixed-random effects longitudinal model showed that ACTH (before the morning dose of glucocorticoids) declined significantly by 26.1 ng/l per week during the 28-week of treatment (95% CI - 45.2 to - 7.1, p < 0.01). An acute response to a test dose predicted outcome in 4/5 patients. Overall, there was no significant change in tumor volumes (1.4 ± 0.9 vs. 1.3 ± 1.0, p = 0.86). Four patients withdrew during the study. Hyperglycemia occurred in 6 patients.

Conclusions: Pasireotide lowers plasma ACTH levels in patients with Nelson's syndrome. A longer period of treatment may be needed to assess the effects of pasireotide on tumor volume.

Trial registration: Clinical Trials.gov ID, NCT01617733.

Keywords: Corticotroph pituitary adenoma; Medical therapy; Nelson’s; Pasireotide.

Conflict of interest statement

Conflict of interest

JNP has research awards and consultancy from Novartis. The other authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in the study involving human participants were in accordance with the ethical standards of the UK Health Research Authority (reference 10/H1005/53) and with the 1964 Helsinki declaration and its later amendments. This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Figures

Fig. 1
Fig. 1
Pasireotide treatment in Nelson’s syndrome: study design
Fig. 2
Fig. 2
Mean plasma ACTH at 0 h prior to the morning dose of glucocorticoids improved during pasireotide treatment (mean baseline 1823 ± 1286 ng/l vs. 888.0 ± 812.8 ng/l during the s.c. phase and vs. 829.0 ± 1171 ng/l during the LAR phase, p 

Fig. 3

Individual plasma ACTH changes during…

Fig. 3

Individual plasma ACTH changes during the study in eight patients (ACTH levels before…

Fig. 3
Individual plasma ACTH changes during the study in eight patients (ACTH levels before the morning dose of hydrocortisone)

Fig. 4

Acute response of plasma ACTH…

Fig. 4

Acute response of plasma ACTH levels to a single dose of pasireotide 600…

Fig. 4
Acute response of plasma ACTH levels to a single dose of pasireotide 600 μg s.c. in 7 patients [Patients a 2, b 3, c 4, d 5, e 6, f 7]

Fig. 5

a Mean fasting glucose increased…

Fig. 5

a Mean fasting glucose increased during pasireotide treatment (values from 7 patients included…
Fig. 5
a Mean fasting glucose increased during pasireotide treatment (values from 7 patients included in the baseline mean value and s.c. phase, 5 patients for the LAR phase). b Mean HbA1c levels increased during pasireotide treatment (values from 7 patients during s.c. phase and 5 patients during LAR phase)
Fig. 3
Fig. 3
Individual plasma ACTH changes during the study in eight patients (ACTH levels before the morning dose of hydrocortisone)
Fig. 4
Fig. 4
Acute response of plasma ACTH levels to a single dose of pasireotide 600 μg s.c. in 7 patients [Patients a 2, b 3, c 4, d 5, e 6, f 7]
Fig. 5
Fig. 5
a Mean fasting glucose increased during pasireotide treatment (values from 7 patients included in the baseline mean value and s.c. phase, 5 patients for the LAR phase). b Mean HbA1c levels increased during pasireotide treatment (values from 7 patients during s.c. phase and 5 patients during LAR phase)

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