27th May 2025

Management

The management of Cushing’s syndrome depends on the aetiology. Management in each case is summarised below:

Aetiology	Management	Comments
Cushing’s disease (ACTH-secreting pituitary adenoma)	Transsphenoidal pituitary adenomectomy	Performed endoscopically or microscopically.
	Somatostatin analogues e.g. pasireotide, steroidogenesis inhibitors e.g. osilodrostat, glucocorticoid receptor antagonists e.g. mifepristone	These are used to address short-term severe hypercortisolism whilst awaiting definitive treatment, or if the patient is not fit for surgery.
	Hormonal replacement	Due to pituitary resection, replacement of thyroxine, gonadal hormones, somatropin and desmopressin may be needed.
	Pituitary radiotherapy	Indicated if high cortisol persists post-tumour resection.
Ectopic ACTH	Surgical resection of tumour/metastases	Resection of ectopic tumours responsible for ACTH (or CRH) production.
	Steroidogenesis inhibitors, glucocorticoid receptor antagonists	As above.
	Chemotherapy and radiotherapy	As above.
Adrenal carcinoma or adenoma	Laparoscopic adrenalectomy or tumour resection	Unilateral resection is often curative without subsequent adrenal insufficiency.
	Steroidogenesis inhibitors, glucocorticoid receptor antagonists	As above.
	Chemotherapy and radiotherapy	Adrenal carcinoma will often require this, as it often will have progressed at time of diagnosis.
Bilateral adrenal hyperplasia or adenoma	Bilateral adrenalectomy	Resection is often curative without subsequent adrenal insufficiency. In some cases mineralocorticoid and corticosteroid replacement may be indicated.
Bilateral adrenal hyperplasia or adenoma	Steroidogenesis inhibitors, glucocorticoid receptor antagonists	As above.
Exogenous glucocorticoids	Gradual withdrawal of glucocorticoids	Aiming to discontinue or reduce maintenance dose.

Table 2: Management of Cushing’s syndrome dependent on aetiology.

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