Bochum, 25. April 2020:

Prof. Reincke, München schlägt vor, die Stellungnahmen der Europäischen Gesellschaft für Endokrinologie, die jetzt erscheinen werden, im DGE-Blog bekannt zu machen. Hier die erste dieser Empfehlungen zum Cushing-Syndrom.

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Cushing’s syndrome: clinical management guidance during the COVID-19 Pandemic

John Newell-Price, Martin Reincke, Antoine Tabarin
European Journal of Endocrinology, accepted for publication 20 April 2020

Abstract

Principles of care: Clinical evaluation should guide those needing immediate investigation. Strict adherence to COVID-19 protection measures is necessary. Alternative ways of consultations (telephone, video) should be used. Early discussion with regional/national experts about investigation and management of potential and existing patients is strongly encouraged. Patients with moderate or severe clinical features need urgent investigation and management. Patients with active Cushing’s syndrome, especially when severe, are immunocompromised and vigorous adherence to the principles of social isolation is recommended. In patients with mild features or in whom a diagnosis is less likely, clinical re-evaluation should be repeated at three and six months or deferred until the prevalence of SARS-CoV-2 has significantly decreased; however, those individuals should be encouraged to maintain social distancing. Diagnostic pathways may need to be very different from usual recommendations in order to reduce possible exposure to SARS-CoV-2. When extensive differential diagnostic testing and/or surgery is not feasible, it should be deferred, and medical treatment should be initiated. Transsphenoidal pituitary surgery should be delayed during high SARS-CoV-2 viral prevalence. Medical management rather than surgery will be the used for most patients since the short- to mid-term prognosis depends in most cases on hypercortisolism rather than its cause; it should be initiated promptly to minimize the risk of infection in these immunosuppressed patients. The risk/benefit ratio of these recommendations will need re-evaluation every 2-3 months from April 2020 in each country (and possibly local areas) and will depend on the local health care structure and phase of pandemic.
“Il meglio e l’inimico del bene” (or ..“perfection is the enemy of the good”) Voltaire, Dictionnaire Philosophique, 1770.

Principles of care

– Minimise outpatient attendance at time of high SARS-CoV-2 virus prevalence to reduce risks of COVID-19 illness for patients and hospital staff. Telephone/video clinics should be used as the preferred option for the vast majority of patients.

– Patients with active Cushing’s syndrome are immunosuppressed and at risk of viral and other infections and should be advised to follow their government’s guidance on social distancing and self-isolation/shielding, including taking sick leave; rapid normalization of cortisol secretion is needed to minimize the risk of infection.

– Since diabetes mellitus and hypertension appear to be significant risk factors for adverse outcomes from COVID-19, these co-morbidities should be very actively managed.

 – Minimise imaging requests at time of high COVID-19 virus prevalence to reduce risks to patients and hospital staff, and emergency pressure on the radiology service.

– Surveillance imaging and laboratory investigations in otherwise stable patients should be deferred at time of high SAR-CoV-2 virus prevalence, and greater reliance placed on clinical assessment.

– Good communication with patients is essential to explain the potential tradeoffs that will result from instituting this guidance with respect to survival, quality of life and functional outcomes, and the risk of acquiring COVID-19 and the resulting sequelae.

– Discuss suspected/known Cushing’s syndrome patients with recognised experts in Cushing’s syndrome in your country to facilitate management. This is especially true where access to diagnostic and therapeutic resources is limited.

– The risk/benefit ratio of these recommendations will need re-evaluation every 2-3 months from April 2020 in each country (and possibly local areas) and will depend on the local health care structure and phase of pandemic, and how health care providers are able to structure care for patients with and without COVID-19, with a gradual return to more standard care.

Es folgen differenzierte Empfehlungen für die (Differenzial-) Diagnose und die Therapie des Cushing-Syndroms, die im Originaldokument nachzulesen sind, da sonst der Blogbeitrag zu lang geworden wäre.

Helmut Schatz, Bochum