DOCSLIB.ORG

Isturisa : EPAR

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Isturisa : EPAR 14 November 2019 EMA/653461/2019 Corr.2 Committee for Medicinal Products for Human Use (CHMP) Assessment report Isturisa International non-proprietary name: osilodrostat Procedure No. EMEA/H/C/004821/0000 Note Assessment report as adopted by the CHMP with all information of a commercially confidential nature deleted. Official address Domenico Scarlattilaan 6 ● 1083 HS Amsterdam ● The Netherlands Address for visits and deliveries Refer to www.ema.europa.eu/how-to-find-us Send us a question Go to www.ema.europa.eu/contact Telephone +31 (0)88 781 6000 An agency of the European Union © European Medicines Agency, 2020. Reproduction is authorised provided the source is acknowledged. Table of contents 1. Background information on the procedure .............................................. 6 1.1. Submission of the dossier ..................................................................................... 6 1.2. Steps taken for the assessment of the product ........................................................ 7 2. Scientific discussion ................................................................................ 9 2.1. Problem statement ............................................................................................... 9 2.1.1. Disease or condition .......................................................................................... 9 2.1.2. Epidemiology .................................................................................................... 9 2.1.3. Aetiology and pathogenesis ................................................................................ 9 2.1.4. Clinical presentation .......................................................................................... 9 2.1.5. Management ................................................................................................... 10 2.1.6. About the product ........................................................................................... 12 2.2. Quality aspects .................................................................................................. 13 2.2.1. Introduction.................................................................................................... 13 2.2.2. Active Substance ............................................................................................. 13 2.2.3. Finished Medicinal Product ................................................................................ 15 2.2.4. Discussion on chemical, pharmaceutical and biological aspects.............................. 18 2.2.5. Conclusions on the chemical, pharmaceutical and biological aspects ...................... 18 2.2.6. Recommendation(s) for future quality development ............................................. 18 2.3. Non-clinical aspects ............................................................................................ 18 2.3.1. Pharmacology ................................................................................................. 18 2.3.2. Pharmacokinetics ............................................................................................ 20 2.3.3. Toxicology ...................................................................................................... 21 2.3.4. Ecotoxicity/environmental risk assessment ......................................................... 25 2.3.5. Discussion on non-clinical aspects ..................................................................... 25 2.3.6. Conclusion on non-clinical aspects ..................................................................... 27 2.4. Clinical aspects .................................................................................................. 27 2.4.1. Introduction.................................................................................................... 27 2.4.2. Pharmacokinetics ............................................................................................ 29 2.4.3. Pharmacodynamics .......................................................................................... 33 2.4.4. Discussion on clinical pharmacology ................................................................... 42 2.4.5. Conclusions on clinical pharmacology ................................................................. 45 2.5. Clinical efficacy .................................................................................................. 45 2.5.1. Dose response studies and main clinical studies .................................................. 45 2.5.2. Discussion on clinical efficacy ............................................................................ 76 2.5.3. Conclusions on clinical efficacy .......................................................................... 81 2.6. Clinical safety .................................................................................................... 81 2.6.1. Discussion on clinical safety ............................................................................ 111 2.6.2. Conclusions on clinical safety .......................................................................... 115 2.7. Risk Management Plan ...................................................................................... 116 2.8. Pharmacovigilance ........................................................................................... 119 2.9. New Active Substance ...................................................................................... 120 EMA/653461/2019 Page 2/134 2.10. Product information ........................................................................................ 120 2.10.1. User consultation ......................................................................................... 120 2.10.2. Additional monitoring ................................................................................... 120 3. Benefit-Risk Balance ........................................................................... 121 3.1. Therapeutic Context ......................................................................................... 121 3.1.1. Disease or condition ...................................................................................... 121 3.1.2. Available therapies and unmet medical need ..................................................... 121 3.1.3. Main clinical studies ....................................................................................... 123 3.2. Favourable effects ............................................................................................ 124 3.3. Uncertainties and limitations about favourable effects ........................................... 125 3.4. Unfavourable effects ......................................................................................... 125 3.5. Uncertainties and limitations about unfavourable effects ....................................... 128 3.6. Effects Table .................................................................................................... 130 3.7. Benefit-risk assessment and discussion ............................................................... 131 3.7.1. Importance of favourable and unfavourable effects ............................................ 131 3.7.2. Balance of benefits and risks .......................................................................... 132 3.7.3. Additional considerations on the benefit-risk balance ......................................... 133 3.8. Conclusions ..................................................................................................... 133 4. Recommendations ............................................................................... 133 EMA/653461/2019 Page 3/134 List of abbreviations ACTH adrenocorticotropic hormone AE adverse event AESI adverse event of special interest BDI Beck Depression Inventory bid bis in diem/twice a day BMD bone mineral density BMI body-mass index CD Cushing’s disease CI confidence interval Cmax the maximum (peak) plasma concentration after single dose administration CMH Cochran-Mantel-Haenszel CR complete responder CS Cushing’s syndrome CYP cytochrome P450 DBP diastolic blood pressure DDI drug-drug interactions DoE Design of experiments DSC Differential Scanning Calorimetry EAS ectopic adrenocorticotropic hormone syndrome ECG electrocardiogram EU European Union GC Gas Chromatography HbA1c glycosylated hemoglobin HPLC High performance liquid chromatography ICH International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use IR Infrared KF Karl Fischer titration MedDRA Medical Dictionary for Regulatory Activities MID minimal important difference MS Mass Spectrometry mUFC mean urinary free cortisol NMR Nuclear Magnetic Resonance Ph. Eur. European Pharmacopoeia EMA/653461/2019 Page 4/134 PK pharmacokinetics PR partial responder QoL quality of life QTPP Quality target product profile RW randomized withdrawal SAE serious adverse event SBP systolic blood pressure SD standard deviation TGA Thermo-Gravimetric Analysis Tmax time of maximum observed concentration UGT uridine 5'-diphospho-glucuronosyltransferase ULN upper limit of normal VAS visual analog scale XRPD X-Ray Powder Diffraction EMA/653461/2019 Page 5/134 1. Background information on the procedure 1.1. Submission of the dossier The applicant Novartis Europharm Limited submitted on 9 November 2018 an application for marketing authorisation to the European Medicines Agency (EMA) for Isturisa, through the centralised procedure falling within the Article 3(1) and point 4 of Annex of
Load more

Recommended publications
  • Prior Authorization Cushing’S – Isturisa® (Osilodrostat Tablets)
    Cigna National Formulary Coverage Policy Prior Authorization Cushing’s – Isturisa® (osilodrostat tablets) Table of Contents Product Identifier(s) National Formulary Medical Necessity ................ 1 64705 Conditions Not Covered....................................... 2 Background .......................................................... 2 References .......................................................... 3 Revision History ................................................... 3 INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation.
    [Show full text]
  • Update on Medical Treatment for Cushing's Disease
    Cuevas-Ramos et al. Clinical Diabetes and Endocrinology (2016) 2:16 DOI 10.1186/s40842-016-0033-9 REVIEWARTICLE Open Access Update on medical treatment for Cushing’s disease Daniel Cuevas-Ramos1, Dawn Shao Ting Lim2 and Maria Fleseriu2* Abstract Cushing’s disease (CD) is the most common cause of endogenous Cushing’s syndrome (CS). The goal of treatment is to rapidly control cortisol excess and achieve long-term remission, to reverse the clinical features and reduce long-term complications associated with increased mortality. While pituitary surgery remains first line therapy, pituitary radiotherapy and bilateral adrenalectomy have traditionally been seen as second-line therapies for persistent hypercortisolism. Medical therapy is now recognized to play a key role in the control of cortisol excess. In this review, all currently available medical therapies are summarized, and novel medical therapies in phase 3 clinical trials, such as osilodrostat and levoketoconazole are discussed, with an emphasis on indications, efficacy and safety. Emerging data suggests increased efficacy and better tolerability with these novel therapies and combination treatment strategies, and potentially increases the therapeutic options for treatment of CD. New insights into the pathophysiology of CD are highlighted, along with potential therapeutic applications. Future treatments on the horizon such as R-roscovitine, retinoic acid, epidermal growth factor receptor inhibitors and somatostatin-dopamine chimeric compounds are also described, with a focus on potential
    [Show full text]
  • Full Prescribing Information [FDA]
    HIGHLIGHTS OF PRESCRIBING INFORMATION -----------------------WARNINGS AND PRECAUTIONS----------------------­ These highlights do not include all the information needed to use • Hypocortisolism: Monitor patients closely for hypocortisolism and ISTURISA® safely and effectively. See full prescribing information for potentially life-threatening adrenal insufficiency. Dosage reduction or ISTURISA. interruption may be necessary (5.1) • QTc Prolongation: Perform electrocardiogram in all patients Use with ISTURISA (osilodrostat) tablets, for oral use caution in patients with risk factors for QTc prolongation (5.2) Initial U.S. Approval: 2020 • Elevations in Adrenal Hormone Precursors and Androgens: Monitor for ----------------------------INDICATIONS AND USAGE-------------------------­ hypokalemia, worsening of hypertension, edema, and hirsutism (5.3) ISTURISA is a cortisol synthesis inhibitor indicated for the treatment of adult ------------------------------ADVERSE REACTIONS-----------------------------­ patients with Cushing’s disease for whom pituitary surgery is not an option or Most common adverse reactions (incidence > 20%) are adrenal insufficiency, has not been curative (1) fatigue, nausea, headache, edema (6) ----------------------DOSAGE AND ADMINISTRATION----------------------­ To report SUSPECTED ADVERSE REACTIONS, contact Recordati • Correct hypokalemia and hypomagnesemia, and obtain baseline Rare Diseases, Inc. at 1-888-575-8344 or FDA at 1-800-FDA-1088 or electrocardiogram prior to starting ISTURISA (2.1, 5.2, 5.3) www.fda.gov/medwatch.
    [Show full text]
  • Minutes of the CHMP Meeting 9-12 November 2020
    05 January 2021 EMA/CHMP/708314/2020 Human Medicines Division Committee for medicinal products for human use (CHMP) Minutes for the meeting on 09-12 November 2020 Chair: Harald Enzmann – Vice-Chair: Bruno Sepodes Disclaimers Some of the information contained in these minutes is considered commercially confidential or sensitive and therefore not disclosed. With regard to intended therapeutic indications or procedure scopes listed against products, it must be noted that these may not reflect the full wording proposed by applicants and may also vary during the course of the review. Additional details on some of these procedures will be published in the CHMP meeting highlights once the procedures are finalised and start of referrals will also be available. Of note, these minutes are a working document primarily designed for CHMP members and the work the Committee undertakes. Note on access to documents Some documents mentioned in the minutes cannot be released at present following a request for access to documents within the framework of Regulation (EC) No 1049/2001 as they are subject to on- going procedures for which a final decision has not yet been adopted. They will become public when adopted or considered public according to the principles stated in the Agency policy on access to documents (EMA/127362/2006). Official address Domenico Scarlattilaan 6 ● 1083 HS Amsterdam ● The Netherlands Address for visits and deliveries Refer to www.ema.europa.eu/how-to-find-us Send us a question Go to www.ema.europa.eu/contact Telephone +31 (0)88 781 6000 An agency of the European Union © European Medicines Agency, 2020.
    [Show full text]
  • Osilodrostat (Isturisa®) EOCCO POLICY
    osilodrostat (Isturisa®) EOCCO POLICY Policy Type: PA/SP Pharmacy Coverage Policy: EOCCO190 Description Osilodrostat (Isturisa) is an orally administered cortisol synthesis inhibitor. It inhibits 11beta-hydroxylase (CYP11B1), the enzyme responsible for the final step of cortisol biosynthesis in the adrenal gland. Length of Authorization Initial: Six months Renewal: 12 months Quantity Limits Product Name Dosage Form Indication Quantity Limit 1 mg tablets osilodrostat 5 mg tablets Cushing’s disease 180 tablets/30 days (Isturisa) 10 mg tablets Initial Evaluation I. Osilodrostat (Isturisa) may be considered medically necessary when the following criteria are met: A. Member is 18 years of age or older; AND B. Medication is prescribed by, or in consultation with endocrinologist; AND C. Documentation of baseline Urinary Free Cortisol (UFC) level; AND D. A diagnosis of Cushing’s disease when the following are met: 1. Pituitary surgery is not an option OR cortisol levels remain abnormal following attempted resection; AND 2. Treatment with TWO of the following has been ineffective, not tolerated, or all are contraindicated: i. Ketoconazole; OR ii. Cabergoline (Dostinex); OR iii. Metyrapone (Metopirone); OR iv. Mitotane (Lysodren); AND 3. Treatment with pasireotide (Signifor) has been ineffective, contraindicated, or not tolerated. 1 osilodrostat (Isturisa®) EOCCO POLICY II. Osilodrostat (Isturisa) is considered investigational when used for all other conditions. Renewal Evaluation I. Member has received a previous prior authorization approval for this agent through this health plan; AND II. Member is not continuing therapy based off being established on therapy through samples, manufacturer coupons, or otherwise. Initial policy criteria must be met for the member to qualify for renewal evaluation through this health plan; AND III.
    [Show full text]
  • ISTURISA® (Osilodrostat)
    PHARMACY COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 5/21/2020 SECTION: DRUGS LAST REVIEW DATE: 5/20/2021 LAST CRITERIA REVISION DATE: 5/20/2021 ARCHIVE DATE: ISTURISA® (osilodrostat) Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage Guideline must be read in its entirety to determine coverage eligibility, if any. This Pharmacy Coverage Guideline provides information related to coverage determinations only and does not imply that a service or treatment is clinically appropriate or inappropriate. The provider and the member are responsible for all decisions regarding the appropriateness of care. Providers should provide BCBSAZ complete medical rationale when requesting any exceptions to these guidelines. The section identified as “Description” defines or describes a service, procedure, medical device or drug and is in no way intended as a statement of medical necessity and/or coverage. The section identified as “Criteria” defines criteria to determine whether a service, procedure, medical device or drug is considered medically necessary or experimental or investigational. State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered experimental or investigational and thus the drug, device or biological product may be assessed only on the basis of medical necessity. Pharmacy Coverage Guidelines are subject to change as new information becomes available. For purposes of this Pharmacy Coverage Guideline, the terms "experimental" and "investigational" are considered to be interchangeable. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
    [Show full text]
  • Stembook 2018.Pdf
    The use of stems in the selection of International Nonproprietary Names (INN) for pharmaceutical substances FORMER DOCUMENT NUMBER: WHO/PHARM S/NOM 15 WHO/EMP/RHT/TSN/2018.1 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. The use of stems in the selection of International Nonproprietary Names (INN) for pharmaceutical substances. Geneva: World Health Organization; 2018 (WHO/EMP/RHT/TSN/2018.1). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data.
    [Show full text]
  • Efficacy and Safety of Osilodrostat in Patients with Cushing's Disease (LINC 3) : a Multicentre Phase III Study with a Doubleblind, Randomised Withdrawal Phase
    This is a repository copy of Efficacy and safety of osilodrostat in patients with Cushing's disease (LINC 3) : a multicentre phase III study with a doubleblind, randomised withdrawal phase. White Rose Research Online URL for this paper: http://eprints.whiterose.ac.uk/163983/ Version: Accepted Version Article: Pivonello, R., Fleseriu, M., Newell-Price, J. et al. (14 more authors) (2020) Efficacy and safety of osilodrostat in patients with Cushing's disease (LINC 3) : a multicentre phase III study with a doubleblind, randomised withdrawal phase. The Lancet Diabetes & Endocrinology. ISSN 2213-8587 https://doi.org/10.1016/s2213-8587(20)30240-0 Article available under the terms of the CC-BY-NC-ND licence (https://creativecommons.org/licenses/by-nc-nd/4.0/). Reuse This article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND) licence. This licence only allows you to download this work and share it with others as long as you credit the authors, but you can’t change the article in any way or use it commercially. More information and the full terms of the licence here: https://creativecommons.org/licenses/ Takedown If you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing [email protected] including the URL of the record and the reason for the withdrawal request. [email protected] https://eprints.whiterose.ac.uk/ Pivonello R et al. Lancet Diabetes Endocrinol 2020; doi: S2213‒8587(20)30240-0 https://www.thelancet.com/journals/landia/home
    [Show full text]
  • Efficacy and Tolerance of Osilodrostat in Patients with Severe Cushing's
    4 183 M Haissaguerre and others Osilodrostat in severe Cushing 183:4 L7–L9 Letter Efficacy and tolerance of osilodrostat in patients with severe Cushing’s syndrome due to non-pituitary cancers Magalie Haissaguerre, Marie Puerto, Marie-Laure Nunes and Antoine Tabarin Department of Endocrinology, Diabetes and Nutrition, Hôpital Haut Lévêque, CHU and University of Bordeaux, Pessac, France Correspondence should be addressed to A Tabarin Email antoine.tabarin@chu- bordeaux.fr To the editor cortisol to 1200 nmol/L. Osilodrostat dose was immediately increased to 5 mg/day for 4 days, and based on repeated Severe hypercortisolism (SH) is a rare life-threatening plasma cortisol measurements, it was increased every 2–4 endocrine emergency, mainly caused by ectopic ACTH days in 5 mg/day steps. A maximal dose of 25 mg/day syndrome (EAS), which requires a rapid normalization was reached after 2 weeks which allowed the mean of cortisol concentrations (1, 2). Due to their rapidity of plasma cortisol concentrations (determined from 3-day action, steroidogenesis inhibitors, such as ketoconazole time samples) to be in the target range (200–500 nmol/L). and metyrapone, given in monotherapy or in association, Control of SH was sustained for 3 months until the death are recommended in this situation (1, 3, 4). Osilodrostat is of the patient due to tumoral burden (Fig. 1A). a recently developed inhibitor of adrenal 11B-hydroxylase (5) which has been shown to be effective, using a progressive titration of the drug dosage, in the treatment European Journal of Endocrinology of Cushing’s disease (5, 6, 7). Limited data are available on Patient 2 the use of osilodrostat in SH induced by EAS (8).
    [Show full text]
  • OCTOBER 2019 Mrx Pipeline a View Into Upcoming Specialty and Traditional Drugs TABLE of CONTENTS
    OCTOBER 2019 MRx Pipeline A view into upcoming specialty and traditional drugs TABLE OF CONTENTS EDITORIAL STAFF Introduction Maryam Tabatabai, PharmD Editor in Chief Senior Director, Drug Information Pipeline Deep Dive Carole Kerzic, RPh Executive Editor Drug Information Pharmacist Keep on Your Radar Consultant Panel Michelle Booth, PharmD Director, Medical Pharmacy Strategy Becky Borgert, PharmD, BCOP Pipeline Drug List Director, Clinical Oncology Product Development Lara Frick, PharmD, BCPS, BCPP Drug Information Pharmacist Glossary Robert Greer, RPh, BCOP Senior Director, Clinical Strategy and Programs Sam Leo, PharmD Director, Clinical Strategy and Innovation, Specialty Troy Phelps Senior Director, COAR - Analytics Nothing herein is or shall be construed as a promise or representation regarding past or future events and Magellan Rx Management expressly disclaims any and all liability relating to the use of or reliance on the information contained in this presentation. The information contained in this publication is intended for educational purposes only and should not be considered clinical, financial, or legal advice. By receipt of this publication, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, distributed to, or disclosed to others at any time without the prior written consent of Magellan Rx Management. 1 | magellanrx.com INTRODUCTION Welcome to the MRx Pipeline. In its third year of publication, this quarterly report offers clinical insights and competitive intelligence on anticipated drugs in development. Our universal forecast addresses trends applicable across market segments. Traditional and specialty drugs, agents under the pharmacy and medical benefits, new molecular entities, pertinent new and expanded indications for existing medications, and biosimilars are profiled in the report.
    [Show full text]
  • LCI699 (Osilodrostat) a Phase III, Multi-Center, Double-Blind, Randomized
    Clinical Development LCI699 (osilodrostat) Protocol CLCI699C2301 / NCT02180217 A Phase III, multi-center, double-blind, randomized withdrawal study of LCI699 following a 24 week, single- arm, open-label dose titration and treatment period to evaluate the safety and efficacy of LCI699 for the treatment of patients with Cushing’s disease Authors Document type Amended Protocol Version EUDRACT number 2013-004766-34 Version number v05 (Clean) Development phase III Document status Final Release date 29-Jun-2018 Property of Novartis Confidential May not be used, divulged, published, or otherwise disclosed without the consent of Novartis Template version 19-Nov-2015 Novartis Confidential Page 2 Amended Protocol Version 05 (Clean) Protocol No. CLCI699C2301 Table of contents Table of contents ................................................................................................................. 2 List of figures ...................................................................................................................... 6 List of tables ........................................................................................................................ 7 List of appendices ................................................................................................................ 8 List of abbreviations ............................................................................................................ 9 Glossary of terms ..............................................................................................................
    [Show full text]
  • Cushing's Disease
    Journal of Clinical Medicine Review Cushing’s Disease Hiroshi Nishioka 1,3 and Shozo Yamada 2,3,* 1 Department of Hypothalamic and Pituitary surgery, Toranomon Hospital, Tokyo 1058470, Japan; [email protected] 2 Hypothalamic and Pituitary Center, Moriyama Neurological Center Hospital, Tokyo 1340081, Japan 3 Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan * Correspondence: [email protected]; Tel.: +81-336-751-211 Received: 28 September 2019; Accepted: 6 November 2019; Published: 12 November 2019 Abstract: In patients with Cushing’s disease (CD), prompt diagnosis and treatment are essential for favorable long-term outcomes, although this remains a challenging task. The differential diagnosis of CD is still difficult in some patients, even with an organized stepwise diagnostic approach. Moreover, despite the use of high-resolution magnetic resonance imaging (MRI) combined with advanced fine sequences, some tumors remain invisible. Surgery, using various surgical approaches for safe maximum tumor removal, still remains the first-line treatment for most patients with CD. Persistent or recurrent CD after unsuccessful surgery requires further treatment, including repeat surgery, medical therapy, radiotherapy, or sometimes, bilateral adrenalectomy. These treatments have their own advantages and disadvantages. However, the most important thing is that this complex disease should be managed by a multidisciplinary team with collaborating experts. In addition, a personalized and individual-based approach is paramount to achieve high success rates while minimizing the occurrence of adverse events and improving the patients’ quality of life. Finally, the recent new insights into the pathophysiology of CD at the molecular level are highly anticipated to lead to the introduction of more accurate diagnostic tests and efficacious therapies for this devastating disease in the near future.
    [Show full text]