Pharmacologic Therapy

Pharmacotherapy is generally reserved for patients: (a) in whom the ectopic ACTH-secreting tumor cannot be localized, (b) who are not surgical candidates, (c) have failed surgery, (d) who have had a relapse after surgery, or (e) in whom adjunctive therapy is required to achieve complete remission. 3 The drugs used are classified according to their mechanism and site of action (Table 45-7).21,24-26 The most

widely used therapeutic class is the adrenal steroidogenesis inhibitors. Agents in this class include ketoconazole, etomidate, and metyrapone. Steroidogenesis inhibitors can treat hypercortisolism by inhibiting enzymes involved in the biosynthesis of cortisol. Because of their potential to cause adrenal suppression, temporary glucocorticoid re placement, and in some cases mineralocorticoid supplementation, may be needed during and after treatment. Centrally-acting neuromodulators of ACTH release such as bromocriptine, cyproheptadine, octreotide, ritanserin, and valproic acid are generally ineffective.

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Anxiety and Depression 101

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