D021-9?2XX85/6103-0536$02.00[0
`Journal ol‘ClinicaI Endocrinology and Metabolism
`Cepyright © 1985 by The Endocrine Society
`
`Vol. 51_ No. a
`Printed in US. A.
`
`Successful Treatment of Cushing’s Syndrome with the
`Glucocorticoid Antagonist RU 486*
`
`LYNNETTE K. NIEMAN, GEORGE P. CHROUSOS, CHARLES KELLNER,
`IRVING M. SPITZ, BRUCE C. NISULA, GORDON B. CUTLER,
`GEORGE R. MERRIAM, C. WAYNE BARDIN, AND D. LYNN LORIAUX
`
`Developmental Endocrinology Branch, National Institute of Child Health and Human Development (L.K.N.,
`G.P.C., B.C.N., G. B. C. , GR. M., D.L.L.J; the Biological Psychiatry Branch, National Institute of Mental
`Health ((1K), National Institutes of Health, Bethesda, Maryland 20205; and the Population Council (Lit/1.8.,
`C, W.B.). New York, New York 00000
`
`ABSTRACT. A patient with Cushing’s syndrome due to ec—
`topic ACTH secretion was treated successfully with the new
`glucocorticoid antagonist RU 486 lITB—hydroxy—llfi—(mdimeth‘
`ylamino phenylil7o-(1-propynyllestra-4,9-dien-3-one]. This
`compound is a 19-nor steroid with substitutions at positions Cll
`and C]? which antagonizes cortisol action competitively at the
`receptor level. Oral RU 486 was given in increasing doses of 5.
`10.15,and 20 mglkg-day for a 9-week period. Treatment eficacy
`was monitored by assessment of clinical status and by measuring
`several glucoeorticoid-sensitive variables, including fasting blood
`sugar. blood sugar 120 min after oral glucose administration,
`
`and plasma concentrations of TSH, corticosteroid-binding glob-
`ulin, LH, testosterone-estradiol—binding globulin, and total and
`free testosterone. With therapy, the somatic features of Cush-
`ing‘s syndrome [buffalo hump, central obesity, and moon facies)
`ameliorated. mean arterial blood pressure normalized, suicidal
`depression resolved, and libido returned. All biochemical gluco-
`corticoid—sensitive parameters normalized. No side—effects of
`drug toxicity were observed. We conclude that RU 486 may
`provide a safe, well tolerated, and effective medical treatment
`for hypercortisolism. (J Chin. Endocrinoi Metal: 61: 536, I985)
`
`HE CURRENTLY available treatments for Cush-
`ing‘s syndrome caused by metastatic ACTH-pro-
`ducingtumors or adrenal cancer are often unsatisfactory.
`Surgical resection of the tumor, when feasible, may be
`only partially or temporarily effective in controlling
`Cushing’s syndrome. Medical therapy with adrenolytic
`agents (o,p’—DDD) or steroidogenic enzyme inhibitors
`(aminoglutethimide or metyrapone) is frequently 3330-
`ciated with toxic side-effects {1—5}.
`A clinically applicable glucocorticoid antagonist is, in
`theory, an attractive alternative treatment for hypercor-
`tisoli5m and has been sought for many years (6). The
`recently discovered compound RU 486 [lTfi—hydroxy-
`116-(4-dimethylamino phenyl)17a- (1 -propynyl)estra-
`4,9-dien-3-one], a 19-nor steroid with a high affinity for
`the rat glucocorticoid receptor with no agenist effects in.
`vitro or in. viva,
`is a potent competitive glucocorticoid
`.
`.
`.
`antagomst 1n rodents (7) ’ nonhuman primates (8’ 9)’ and
`man (10—12}.
`
`Received March 15, 1935:
`_
`,
`_
`Hailififeg’:afigsgffiggempr;gfigtgé’néégggrfigfigfig12161235?” 0f
`- Presented in part at the Seventh International Congress of Endo-
`crinoIOgy, Quebec, Canada, July 1984.
`
`536
`
`We report here the successful treatment with RU 486
`of a 25-yr-old man with Cushing’s syndrome caused by
`the ectopic secretion of ACTH. During therapy,
`the
`somatic features 0f Cushing’s Syndrome (cervical fat pad,
`central obesity, and 1110011
`facies)
`improved, suicidal
`depression cleared, and glucocorticoid-sensitive meas-
`ares. such as elevated fasting and postabsorptive blood
`5143M: normalized. The drug was tolerated “lg“: and n0
`Side-effects were noted during therapy or after its discon-
`tinuation.
`
`Case Report
`
`The patient was in excellent health until the fall of 1981
`when he noted loss of strength, short term memory, and atten-
`tion span. In the spring of 1982. because these symptoms
`worsened, h? discontinued his weight-lifting regimen. He com-
`piamed of increasing anxiety and depressron. In September
`1982, he stopped working because of these cagnitive and pay»
`chological changes. Treatment with antidepressants was initi-
`ated. His depression deepened, however, and led to two suicide
`attempts. At that time, he had moon facies, hypertension, and
`diabetes, and was evaluated for Cushing’s syndrome. Both
`serum and urinary cortisol levels were elevated, and 17-hydrox-
`ycorticosteroid excretion increased during a standard 2— and 8—
`mg dexamethasone suppresswn test {13).
`An intrathoracic mass lesion was found and was resected in
`
`

`

`ANTIGLUCOCORTICOID THERAPY
`
`537
`
`March 1983. The lesion was not contigumis with a bronchus.
`Microscopic and immunohistochemical examination of the
`specimen showed a carcinoid tumor with granules that stained
`with anti-ACTH serum. Immediately after surgery, plasma
`cortisol levels were normal. Insulin and antihypertensive and
`antidepressant medications were discontinued, and the pa-
`tient’s symptoms improved. By May 1983, however, his symp~
`toms recurred, and his urinary cortisol excretion rate was about
`500 pgfday. He was given metyrapone, but had only transient
`clinical improvement.
`_
`In August 1983, he was admitted to the NIH. He complained
`of disorientation, diminished memory and cognitive ability,
`impotence, a 20—“) weight gain over 3 yr, and long-standing
`muscle weakness. He had a ruddy round face. His blood pres—
`sure was 180/120 mm Hg, and his pulse was 90 beats/min. He
`was anxious and depressed. He performed calculations slowly.
`The thoracotomy scar was hyperpigmented. Computerized axial
`tomograms of the chest revealed multiple lung nodules. He had
`hypokalemic alkalosis (serum potassium, 1.9 meojliter; bicar-
`bonate, 38 meqfliter; chloride, 94 meqfliter; sodium, 147 meqf
`liter}.
`His medications, including maprotiline hydrochloride (Lu-
`diomil), trifloroperazine (Stelazine), benztropin mesylate (Co-
`gentin}, and metyrapone (1 gfday} were stopped before labo~
`ratory evaluation. He became withdrawn, severely depressed,
`and complained that he felt unable to think clearly. Ludiomi]
`was reinitiated because of suicidal ideation, and his depressive
`symptoms and cognition improved. Potassium supplements
`were given {20—120 meqfday). Treatment with increasing doses
`of RU 486 for 9 weeks caused marked improvement
`in all
`biochemical and clinical parameters of hypercortisolism {see
`Results].
`
`Materials and Methods
`
`Protocol
`
`The protocol for the therapeutic use of RU 486 was approved
`under an investigational exemption for new drugs by the Na-
`tional Center for Drugs and Biologics, DHHS, and by the
`NICHHD Clinical Research Committee (83-CH-87). The pa-
`tient participated in the study after giving informed consent.
`All tests were performed at the NIH Clinical Center.
`RU 486 was formulated into 50—mg tablets by Roussel-
`UCLAF (Paris, France). A single oral dose of 6 mg/kg RU 486
`given at midnight has been found to prevent morning adrenal
`suppression caused by 1 mg dexamethasone (11). Accordingly,
`the initial oral daily dose was 5 mg}kg and increased in 5 mg;f
`kg increments every 1 or 2 weeks to a maximum of 20 mg/kg-
`day {see Fig. 1}.
`.
`A number of clinical and biochemical glucocorticoid-sensi-
`tive measures were monitored to evaluate treatment efficacy.
`Clinical measures included blood pressure and body weight.
`The patient’s mood was assessed daily by a self-report ques-
`tionnaire and three times a week by psychiatric interviews {14}.
`Metabolic and hormone measures included urinary excretion
`of nitrogen and fasting and postabsorptive blood sugar, which
`are elevated by hypercortisoiism, and plasma concentrations of
`corticosteroid-binding globulin (CBG) (15), testosterone-estra-
`
`A.
`GIucou 2 mos-111mm”
`
`B
`I." trauma
`
` “\RRVKWRRKk
`
`\V
`
`Fntlng Elmo: {mural}
`
`110
`
`140
`
`'00 WWW “\W\W
`
`1's“ WWII“!
`
`LB
`
`1.0
`
`was».
`
`\sm
`
`can iHOfdl]
`
`2" mamas
`
`
`‘0 seams
`
`Iloln BP lmmflg]
`
`ass
`
`\m
`
`
`750
`
`250
`
`'I'Iltll TII‘IIIS‘IWMI
`\\V\'\\m\
`
`
`J'dll
`\K‘k‘i
`
`
`
`
`\\\\ smmssmm
`
`
`
`
`.
`"mm“
`
`
`
`Fm Twosm Ilium)
`
`2!
`
` \wmsmsssss
`
`20 Don HUM [mga'kflfd]
`
`20 Don RU "60119kath
`
`15
`
`‘5
`
`15
`75
`DAY CF MISSION
`
`I!
`
`'35
`
`FIG. 1. The effect of RU 436 treatment on glucocorticoid—sensitive
`variables. A, Two hour post-OGTT {Oral glucose tolerance test) and
`fasting blood sugar levels were elevated before RU 486 therapy and fell
`to normal levels during treatment. The serum TSH concentration was
`initially subnormal and rose progressively. CBG concentrations also
`rose into the normal range. Mean daily blood pressure decreased during
`RU 436 therapy. B, Plasma concentrations of LH, total testosterone.
`and free testosterone were initiallyr depressed; all normalized with RU
`486 therapy. TeBG capacity showed similar increases. Shaded areas
`represent the upper (u.u.l] or lower (LI—u} normal range.
`
`diol-binding globulin (TeBGJ, testosterone {16, 17), LH {16,
`17), and TSH (18, 19), which are suppressed by hypercortisoh
`15m.
`
`Plasma ACTH and plasma and urinary cortisol levels also
`were measured frequently. Metabolic and hormonal measure-
`ments were made on one to three morning blood samples drawn
`before therapy and during the final week of each dose interval.
`Standard oral glucose tolerance tests were performed after 3
`days of ingestion of a IOU-g carbohydrate diet using a 100—3
`glucose challenge. Creatinine, blood urea nitrogen (BUN),
`serum glutamic oxaioacetic acid-transaminase (SGOT), and
`serum glutamic pyruvic acid-transaminase (SGPT) measure-
`ments were monitored throughout treatment as indioes of drug
`toxicity. Serial electrocardiograms and chest x-rays were done
`for a similar purpose.
`
`

`

`538
`
`Assays
`
`Plasma testosterone (20), LH (21}, ACTH (22], steroid bio—
`synthetic intermediates (pregnenolone, 17-hydroxypregneno—
`lone, 17-hydroxyprogesterone, and 11vdeoxycortisol} (20, 23),
`plasma and urinary cortisol (23), and serum TSH (24) were
`measured by RIA as previously described. CBC and TeBG were
`measured using a solid phase Concanavalin A—Sepharose assay
`(25). The free testosterone concentration was calculated from
`the measured levels of total hormone and binding proteins
`(albumin and TeBG) (25}. Plasma glucose concentrations were
`measured with a Cobas bioanalyzer; SGOT, SGPT, BUN, cre-
`atinine and albumin concentrations were measured with an
`Autoanalyzer (Beckman, Palo Alto, CA).
`Using a previously described method for separation of bound
`from free hormone (25}, competitive binding assays were done
`to exclude displacement by RU 486 of testosterone or cortisol
`from their plasma binding proteins, an action that might result
`in spurious changes in hormone concentrations. Increasing
`concentrations of RU 486 or unlabled hormone were added to
`
`samples with known amounts of radioactively labeled hormone
`and binding globulin. RU 486 did not displace cortisol from
`CBG or testosterone from TeBG in concentrations ranging
`from 10“°—10'5 M.
`
`Results
`
`All glucocorticoid-sensitive clinical and biochemical
`parameters were initially abnormal in this patient, and
`each became normal during treatment with RU 486
`despite continued marked hypercortisolism.
`The physical stigmata of Cushing’s syndrome, includ-
`ing supraclavicular and dorsocei-vical fat pads and central
`obesity, regressed considerably by the conclusion of ther-
`apy. This change in fat distribution was not associated,
`however, with achange in total body weight, which varied
`between 85 and 89 kg both before and during RU 486
`treatment. Maximum daily systolic and diastolic blood
`pressures decreased steadily during treatment with RU
`486, from 200/120 mm Hg before therapy, to 140/90 mm
`Hg at its conclusion (Fig. 1A). The hypokalemic alkalosis
`resolved, serum potassium ranged from 3.9-4.6 meq/liter,
`and serum bicarbonate ranged fr0m 25—29 meq/liter
`following discontinuation of potassium after the sixth
`week of RU 486 therapy.
`Both subjective and objective psychological measures
`improved during RU 486 therapy. When the daily dose
`of RU 486 was increased to 15 mg/kg, Ludiomil therapy
`was stopped (fourth week of therapy}. The patient's
`depression continued to improve, and he reported in-
`creasing attention span, libido, and sense of wellbeing.
`This subjective improvement was corroborated by self-
`rating questiOnnaires and psychiatric interviews.
`Plasma glucose levels were initially 140 mg/dl in the
`fasting state (normal, <105 mg/dl) and 268 mg/dl 2 h
`after ingestion of 100 g glucose (normal, (140 mg/dl; Fig.
`1A). The fasting blood sugar level became normal while
`
`NIEMAN ET AL.
`
`JCEK: H.193!)
`Volfil-Noa
`
`the patient was taking RU 486 in a dose of 10 mg/kg-
`day, and the 2 h postoral glucose tolerance test blood
`sugar level normalized when he was taking 20 ring/kg
`(Fig. 1A). Serum TSH concentration was initially sub-
`normal (<0.18 aU/ml) and rose progressively to 1.5 aU/
`ml during treatment (normal, 0.5—4.5 ,uU/ml; Fig. 1A).
`CBC-binding capacity increased from 7.4 ag/dl (normal,
`12.2—20 ,ug/dl) to 16.8 pg/dl (Fig. 1B).
`Plasma LH levels rose during treatment with RU 486
`from 9.4 to 23.2 mIU/ml (normal, 6—26 mIU/ml; Fig.
`1B). Similarly, plasma total and free testosterone con-
`centrations and TeBG-binding capacity increased from
`subnormal to normal levels during therapy with RU 486
`(Fig. 13}. The total testosterone concentration was ini—
`tially 73 ng/dl (normal, 2004000 nngl) and rose to 842
`ng/dl when the patient was taking 20 mg/kg-day RU
`486. TeBG capacity increased fr0m 0.063 ug/dl (normal,
`0.2—1.0 tag/d1) to 1.02 pig/d1 at the conclusion of therapy.
`Free testosterone increased from 3.5 rig/d1 (normal, 5—
`30 ngfdl) to 17.4 ngfdl.
`Twenty-four hour urinary nitrogen excretion fell from
`22 g/day (normal, 12—20 g/day) before treatment to 5 g/
`day at its conclusion. No abnormalities in serum creati-
`nine, BUN, SGOT, or SGPT, urinalysis, electrocardi-
`ogram, chest radiography, or physical examination were
`found during or after therapy. The patient experienced
`no adverse subjective effects.
`In contrast to the marked improvement in these glu-
`cocorticoid—sensitive parameters, urinary cortisol,
`plasma cortisol, and ACTH levels remained significantly
`elevated throughout the treatment with RU 486. G-50
`gel chromatography revealed that 85% of ACTH immu-
`noreactivity was in the same fractions as ACTH-(L39).
`Before initiation of RU therapy, the mean plasma ACTH
`concentration was 165 i 7.6 (:SE) pg/ml (n = 5); during
`treatment, it was 241 i 14 pg/ml (n = 14; normal, 8—15
`pg/ml). The range of plasma cortisol concentration was
`29—495 ,ug/dl (mean t SE, 43.5 i 3.3 ,ug/dl; n = 7) before
`and 13.8—56.5 ug/dl (mean 1 SE, 31.8 i 2.0 pg/dl; n =
`2’?) during RU 486 administration (normal, 8—18 pg/dl).
`Mean daily urinary cortisol excretion rates also were
`elevated, ranging between 514 and 11,592 tag/day (mean
`t SE, 4865 i 1159 pig/24 h; n = 11) before therapy.
`During therapy, urinary cortisol excretion was similar
`and ranged between 106 and 8012 pg/day (mean t SE,
`1175 i 32'? ug/24 h; n = 2?; normal, 20~95 ngf24 h).
`Plasma steroid precursor concentrations during ther-
`apy were within the normal range or mildly elevated.
`Pregnenolone was 124 ng/dl (normal, <250), 17-hydrox-
`ypregnenolone was 135 ng/dl (normal, <250), l'i-hydrox-
`yprogesterone was 706 ng/dl (normal, (200), and 11-
`deoxycortisol was 431 ng/dl (normal, <200).
`No side-effects occurred during RU 486 treatment. In
`the 10th week, because limited availability of RU 486
`
`

`

`ANTIGLUCOCOR‘TICOID THERAPY
`
`539
`
`prevented further treatment, the patient underwent a
`bilateral adrenalectomy 48 h after discontinuation of
`therapy and during supplemental glucocorticoid therapy.
`Tissue vascularity was normal at the time of surgery,
`and his postoperative course and wound healing were
`satisfactory.
`
`Discussion
`
`The glucocorticoid antagonist RU 486 ameliorated the
`clinical and biochemical features of hypercortisolism in
`this patient. Treatment with RU 486 was associated with
`redistribution of body fat and resolution of severe depres—
`sion, hyperglycemia, and hypertension, obviating the
`need for a variety of medications which he previously
`required. Several hormonal disorders typical of hyper-
`cortisolism (suppressed plasma levels of TSH, LH, tes-
`tosterone, CBC, and TeBG) also reverted to normal
`during RU 486 therapy (15, 19).
`The satisfactory response to RU 486 administration
`despite persistent marked elevation of serum and urinary
`cortisol levels is consistent with studies of its mechaniSm
`of action in. vitro and in animals. RU 486 interacts with
`
`the glucocorticoid receptor and thereby blocks the effects
`of cortisol (7). The mild decline in plasma and urinary
`cortisol during therapy might be due to an additional
`effect of RU 486 to diminish adrenal steroidogenesis
`directly via enzyme inhibition or a result of spontaneous
`fluctuation in the severity of the syndrome. No major
`block occurred, however, in the enzymes BIG-hydroxyste-
`
`roid dehydrogenace-a5,A‘-isomerase,21-hydroxylase, 1’7-
`hydroxylase, or 11-hydroxylase, as suggested from the
`levels of measured steroid precursors in the patient’s
`plasma.
`Although RU 486 was an effective therapy in our
`patient with Cushing’s syndrome due to ectopic ACTH
`secretion, control may be more difficult to achieve in
`patients with hypercortisolism of pituitary origin (Cush-
`ing’s disease). Previous studies in norihuman primates
`and normal subjects suggest that the dose of RU 486
`necessary to achieve normal glucocorticoid status in
`Cushing’s syndrome will depend on the plasma free cor-
`tisol concentration and the presence of cortisol feedback.
`In nonhuman primates and normal men and women,
`doses of RU 486 greater than 5 mg/ kg cause an increase
`in both plasma cortisol and ACTH levels, presumably by
`antagonizing cortisol feedback at the pituitary or hypo-
`thalamus (8-12). In patients with Cushing’s disease in
`whom cortisol feedback is present, ACTH levels may
`increase, perhaps in an exaggerated manner, as is often
`the case with ACTH reSponses to CRI-I (22) or metyra-
`pone (26). Nevertheless, high doses of a glucocorticoid
`antagonist may overcome the reserve of the pituitary
`adrenal axis in patients with Cushing’s disease and thus
`
`alleviate the texic effects of hypercorticolism on tissues.
`If this were true, then an antiglucocorticoid could be used
`for preparation of patients for surgery.
`The lack of side-effects or toxicity associated with RU
`486 administration in our patient contrasts markedly
`with the morbidity that characterizes the other medicai
`treatments for hypercortisolism. Although the incidence
`of side-effects cannot be established until additional
`
`patients are studied, the present experience suggests that
`RU 486 therapy may be tolerated better than other
`currently available medical treatments of hypercortisol-
`ism. Greater toierance may yield greater efficacy, since
`the avaiiable medical treatments often cannot be given
`in fully effective doses because of their side-effects.
`One potential problem with RU 486 is that overtreat-
`ment might cause glucocorticoid insufficiency. Since glu-
`cocorticoid insufficiency cannot be assessed through
`measurement of adrenal steroids during RU 486 therapy,
`we suggest that patients be given RU 486 in gradually
`increasing doses in concert with careful evaluation for
`signs and symptoms of adrenal insufficiency.
`Currently, the major drawback of RU 486 is that it is
`costly to synthesize and not available in quantities suf-
`ficient for extensive clinical study. Despite these prob-
`lems, RU 486 holds promise as a safe, well tolerated, and
`effective medical therapy for hypercortisolism that mer-
`its further clinical evaluation.
`
`Acknowledgments
`We would like to thank Ms. Penny Colbert, Mary Hall, and Mary
`Beth McCole for their assistance in typing this manuscript.
`
`References
`
`4.
`
`1. Temple TE. Liddle GW 1970 Inhibitors of adrenal steroid biosyn-
`thesis. Annu Rev Pharmacol 10:199
`2. Carey RM. Orth DN, Hartmann WH 1973 Malignant melanoma
`with ectopic production of adrenocorticotropic hormone: palliative
`treatment with inhibitors of adrenal steroid biosynthesis. J Clin
`Endocrinol Metab 36:482
`3. Gordon P, Becker CE, Levey GS, Roth J 1968 Efficacy of amino-
`glutethimide in the ectopic ACTH syndrome. J Clin Endocrinol
`Metab 28:92]
`(101% R, Horner I, Kraiem Z, Gafni J 1968 Successful metyrapone
`therapy of the ectopic ACTH syndrome. Arch Intern Med 121:549
`5. Gold EM 1979 The Cushing syndrome: changing views of diagnosis
`and treatment. Ann Intern Med 90:829
`6. Chrousos GP, Cutler Jr GB, Sauer M, Simone Jr SS, Loriaux DL
`1983 Development of glucocorticoid antagonists. Pharmacol Ther
`20:263
`7. Philibert D, Deraedt R, Teutsch G. RU 38486 a potent antigluco-
`corticoicl in viva. International Congress of Pharmacology. Tokyo,
`Japan, 1981, p 668 (Abstract)
`8. Healy DL, Chrousos GP, Schulte HM, Williams RF, Baulieu EE.
`Gold PW. Hodgen GD 1983 Pituitary and adrenal responses to the
`anti-progesterone and anti-glucocorticoid steroid RU 486 in pri-
`mates. J Clin Endocrinol Metab 57:863
`9. Healy DL, Chrousos GP, Schulte HM. Gold PW, and Hodgen GD
`1985 Increased ACTH, cortisol and arginine vasopressin {AVP)
`secretion following the antiglucocorticoid RU 486: dose-response
`relationships. J Clin Endocrinol Metah 66:1
`
`

`

`540
`
`NIEMAN ET AL.
`
`JCE&M'1935
`Vol 51 - No a
`
`10. Hen-menu W. Wyss R. Riondel A. Philibert D. Teutsch G. Sakiz
`E 1932 Effet d'un steroide anti-progesterone chez la femme: inter—
`ruption da cycle menstruel et de la grosseese au debut. C R Acad
`Sci [D] (Paris) 294:933
`11. Gaillard RC, Riondel A, Herrmann W. Muller AF, Baulieu EB.
`The antifertility steroid RU 486 is an anticorticosteroid derepresa-
`ingthe pituitary-adrenalsyatemin the human,but only atespecific
`time during the day. 65th Annual Meeting of the Endocrine Society,
`San Antonio TX. 1983.1: 219 (Abstract)
`12. Bertagna X. Bertagna C, Luton JP. Husson JM. Girard F 1984
`The new steroid analog RU 486 inhibits glucocorticoid action in
`man. J Clin Endocrinol Metab 59:25
`13. Liddle GW 1960 Tests of pituitary-adrenal suppressibilitg.r in the
`diagnosis of Cushing’s syndrome. J Clin Endocrinol Metab 20:1539
`14. Spielberger CD, Corsuch RL. Lushene RE 1970 State-Trait Anxi-
`ety Inventory (STAl) Manual. Consulting Psychologists Press,
`Palo Alto
`15. Nieman LK, Chrousos GP, Schulte HM. Lariaux DL. Nisula BC.
`Adrenal regulation of corticosteroid-binding globulin [CBC]. 7th
`International Congress of Endocrinology. Quebec. Canada. 1984
`Excerpt Med Int. Congr Ser 652:1096 [Abstract 1672]
`16. Smals AGH. Kloppenborg PWC, Benraad TJ 1977 Plasma testos-
`terone profiles in Cushing’s syndrome. J Clin Endocrinol Metab
`451240
`17. Luton J -P. Thieblot P, Valke J~C, Mahoudeau JA, Bricaire H 1977
`Reversible gonadotropin deficiency in male Cushing’s disease. J
`Clin Endocrinol Metab 45:488
`
`18. Van Canter E. Leclercq R. Vanhaelst L, Golstein J 1974 Simulta-
`neous study of cortisol and TSH dailyr variations in normal subjects
`and patients with hyperadrenalcorticism. J Clin Endocrinol Metab
`39:645
`19. Duick DS. Wahner HW 1979 Thyroid axis in patients with Cush—
`ing‘s syndrome. Arch Intern Med 139:767
`20. Abraham GE 1974 Radioimmunoassay of steroids in biological
`materials. Acta Endocrinol [Suppl 183] {Copenh} 75:?
`21. Odell WD. Ross GR. Rayford PL 1966 Radioimmunoassay of
`human luteinizing hormone. Metab Clin Exp 15:28?
`‘22. Chrousos GP. Schulte HM. Oldfield EH. Gold PW, Cutler GB,
`Loriaux DL 1984 The corticotropin—releasing factor stimulation
`test: an aid in the evaluation of patients with Cushing’s syndrome.
`N Engl J Med 310:622
`23. Kao M. Voina S, Nichols A. Horton R 1975 Parallel radioimrnu-
`noassay for plasma cortisol and ll-deoxycortisol. Clin Chem
`21:16:14
`24. Wehmann RE. Rubenstein BA, Nisula BC 1979 A sensitive con-
`venient radioimmunoassay procedure which demonstrates that
`serum hTSl-I is suppressed below the normal range in thyrotoxic
`patients. Endocr Res Cami-nun 6:249
`25. Dunn JF. Nisula BC, Rodbard D 1981 Transport of steroid hor-
`mones: binding of 21 endogenous steroids to both testosterone-
`binding globulin and corticosteroid-binding globulin in human
`plasma. J Clin Endocrinol Metab 53:53
`26. Tucci JR 1975 Metyrapone test in Cushing’s disease. J Clin En-
`dDCrinol Metab 40:520
`
`