Ketoconazole in Cushing's disease: is it worth a try?
BACKGROUND
The use of ketoconazole has been recently questioned after warnings from the European Medicine Agencies and the Food and Drug Administration due to potential hepatotoxicity. However, ketoconazole is frequently used as a drug to lower circulating cortisol levels. Several pharmacological agents have recently been approved for the treatment of Cushing's disease (CD) despite limited efficacy or significant side effects. Ketoconazole has been used worldwide for more than 30 years in CD, but in the absence of a large-scale study, its efficacy and tolerance are still under debate.


METHODS
We conducted a French retrospective multicenter study reviewing data from patients treated by ketoconazole as a single agent for CD, with the aim of clarifying efficacy and tolerance to better determine the benefit/risk balance.


RESULTS
Data from 200 patients were included in this study. At the last follow-up, 49.3% of patients had normal urinary free cortisol (UFC) levels, 25.6% had at least a 50% decrease, and 25.4% had unchanged UFC levels. The median final dose of ketoconazole was 600 mg/d. Forty patients (20%) received ketoconazole as a presurgical treatment; 40% to 50% of these patients showed improvement of hypertension, hypokalemia, and diabetes, and 48.7% had normal UFC before surgery. Overall, 41 patients (20.5%) stopped the treatment due to poor tolerance. Mild (<5N, inferior to 5-fold normal values) and major (>5N, superior to 5-fold normal values) increases in liver enzymes were observed in 13.5% and 2.5% of patients, respectively. No fatal hepatitis was observed.


CONCLUSIONS
Ketoconazole is an effective drug with acceptable side effects. It should be used under close liver enzyme monitoring. Hepatotoxicity is usually mild and resolves after drug withdrawal.
Aix Marseille Université, Hopital de la Timone (F.C., M.P., I.M., B.C.-D., T.B.), Service d'Endocrinologie, 13005, Marseille, France; Hôpital Cochin Service d'Endocrinologie et Maladies Métaboliques (L.G., L.Q., C.B., J.B.), 75014, Paris, France; Centre Hospitalier Universitaire (CHU) de Bordeaux Hôpital du Haut Lévêque Service d'Endocrinologie-Diabétologie et Maladies Métaboliques (P.G., A.T.), 33600 Pessac, France; CHU de Grenoble Hôpital Albert Michallon Service d'Endocrinologie-Diabétologie-Nutrition (M.Mu., M.Ma., O.C.), 38043, Grenoble, France; Université Paris-Sud Service d'Endocrinologie et Maladies de la Reproduction (P.K., P.Ch., J.Y.), 94270, Le Kremlin Bicetre, France; CHU de Nantes Hôpital G & R Laënnec St-Herblain Endocrinologie, Maladies Métaboliques et Nutrition (D.D., M.L.B.), 44093, Nantes, France; Hôpital Larrey Service d'Endocrinologie-Maladies Métaboliques-Nutrition (P.Ca., D.V.), 31400, Toulouse, France; CHU de Strasbourg Hôpital de Hautepierre (F.L., B.G.), Service de Médecine Interne et de Nutrition, 67100 Strasbourg, France; Assistance Publique-Hôpitaux de Paris, Hôpital St-Antoine Service d'Endocrinologie-Diabétologie et Médecine de la Reproduction (B.Do., S.C.-M.), 75012, Paris, France; Centre Hospitalier Regional Universitaire de Lille Hôpital Claude Huriez, Service d'Endocrinologie Métabolisme (M.C.V.), 59000 Lille, France; Hôpital Avicenne Service d'Endocrinologie, Diabétologie, et Maladies Métaboliques (H.B.), 93000 Bobigny, France; CHU de Reims Hôpital Robert Debré (B.De.), Service d'Endocrinologie-Diabète-Nutrition, 51092, Reims, France; Hôpital Neuro-cardiologique Fédération d'Endocrinologie du Pôle Est (G.R.), 39500 Bron, France; and Hôpital de Bicêtre Endocrinologie Pédiatrique (E.M.), 94270, Le Kremlin Bicetre, France.
Frederic
F
Castinetti
Laurence
L
Guignat
Pauline
P
Giraud
Marie
M
Muller
Peter
P
Kamenicky
Delphine
D
Drui
Philippe
P
Caron
Fiorina
F
Luca
Bruno
B
Donadille
Marie Christine
MC
Vantyghem
Helene
H
Bihan
Brigitte
B
Delemer
Gerald
G
Raverot
Emmanuelle
E
Motte
Melanie
M
Philippon
Isabelle
I
Morange
Bernard
B
Conte-Devolx
Laurent
L
Quinquis
Monique
M
Martinie
Delphine
D
Vezzosi
Maelle
M
Le Bras
Camille
C
Baudry
Sophie
S
Christin-Maitre
Bernard
B
Goichot
Philippe
P
Chanson
Jacques
J
Young
Olivier
O
Chabre
Antoine
A
Tabarin
Jerome
J
Bertherat
Thierry
T
Brue
D058888:14-alpha Demethylase Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000652:urine; D007654:Ketoconazole / Q000009:adverse effects / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D047748:Pituitary ACTH Hypersecretion / Q000188:drug therapy* / Q000652:urine; D012189:Retrospective Studies; D016896:Treatment Outcome
D058888:14-alpha Demethylase Inhibitors; D007654:Ketoconazole; D006854:Hydrocortisone