A prospective longitudinal study of Pasireotide in Nelson's syndrome

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 mu g 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.