Challenges in post-operative management of Cushing disease

Patients with Cushing disease (CD) undergo transsphenoidal resection of the pituitary tumor as the primary management option. Post operative period is considered as one of the most challenging aspects in the CD management due to the related high morbidity and mortality.
Assessing remission following surgery is done commonly by assessing nadir serum cortisol level, a level < 2 to 5 µ,g/ dL (55-138 nmol/L) during 24 to 7 4 hours postoperatively is accepted as remission. Values more than 5-10 µ,g/dL (138-276 nmol/L) considered as non-remission.
If remission is achieved, it is important to treat the adrenal insufficiency (AI) with steroids until the Hypothalamic-Pituitary-Adrenal axis (HPA axis) recovery happens. Other anterior pituitary hormone dysfunctions should be assessed and treated appropriately. If the remission is not achieved by the surgery, secondary management options such as repeat surgery, radiotherapy and medical therapy can be used.
Prevention and management of hypercortisolemia associated complications such as infections, thromboembolic events, cardiovascular and metabolic diseases are also important aspect in the post operative management of CD. It is also challenging to manage surgery related complications such as Syndrome of Inappropriate ADH Secretion (SIADH) and Diabetes Insipidus (DI). Prevention or successful treatment of cortisol withdrawal syndrome is another challenging aspect that a physician needs to focus on.