Shared Decision-Making Approach for Second-Line Therapies in ACTH-Dependent Cushing's Syndrome

STEP 1 — Gather Information

Collect postoperative UFC or late-night salivary cortisol, pituitary MRI to assess residual/visible lesion, comorbidities (diabetes, hypertension, hepatic function, osteoporosis), prior treatments, patient values and preferences, and contraindications to specific therapies (e.g., liver disease for ketoconazole, pregnancy for mifepristone).
Action: Proceed to assess eligibility for each second-line option.

STEP 2 — Rule In / Rule Out

Determine if a resectable pituitary lesion is visible on postoperative MRI.

• If lesion visible → consider repeat transsphenoidal surgery (TSS).
• If no visible lesion → rule out repeat TSS and evaluate medical therapy, radiation, or bilateral adrenalectomy.
  Decision: If lesion visible, advance to repeat TSS evaluation; if not, move to medical therapy/radiation/adrenalectomy evaluation.

STEP 3 — Classify or Stratify

Stratify by clinical urgency and patient factors:

• Life-threatening hypercortisolism (e.g., severe infection, psychosis) → prioritize bilateral adrenalectomy or rapid-acting medical therapy (etomidate, mifepristone).
• Non-urgent: classify by patient preference for invasiveness vs medical therapy and comorbidities (e.g., avoid ketoconazole if hepatic impairment; consider mifepristone if diabetes/glucose intolerance).
  Action: Assign patient to a preferred modality category: surgical (repeat TSS or adrenalectomy), radiation, or medical therapy.

STEP 4 — Decide

Based on classification, discuss risks/benefits of specific options within the chosen category with the patient, then initiate shared decision-making to select therapy. Order required pretreatment evaluations (e.g., liver function tests for ketoconazole, pituitary MRI for radiation planning).
Action: Implement chosen second-line therapy and schedule follow-up cortisol assessment at 6–12 weeks.

Clinical Guardrails / Mimics / Pitfalls

Do not initiate radiation without first confirming medical control of cortisol; avoid bilateral adrenalectomy without discussing lifelong glucocorticoid dependence; do not use ketoconazole in significant hepatic impairment; avoid mifepristone in pregnancy; do not delay treatment in life-threatening hypercortisolism; monitor for Nelson syndrome after adrenalectomy; assess for hypopituitarism after radiation.

Concrete Clinical Example

A 45‑year‑old woman with persistent UFC 3× normal after TSS shows a 6 mm residual adenoma on MRI, normal liver function, and wishes to avoid lifelong steroids. After discussing options, repeat TSS is selected.

Source: Treatment of Cushing’s Syndrome: An Endocrine Society, 2015, DOI:10.1210/jc.2015-1818