Changes in plasma ACTH levels and corticotroph tumor size in patients with Cushing's disease during long-term treatment with the glucocorticoid receptor antagonist mifepristone

J Clin Endocrinol Metab. 2014 Oct;99(10):3718-27. doi: 10.1210/jc.2014-1843. Epub 2014 Jul 11.


Context: Pituitary effects of long-term therapy with mifepristone, a glucocorticoid receptor antagonist, in Cushing's disease (CD) patients are not well understood.

Objective: Our objective was to report changes in ACTH and pituitary magnetic resonance imaging (MRI) findings during long-term use of mifepristone in CD patients.

Design and setting: The Study of the Efficacy and Safety of Mifepristone in the Treatment of Endogenous Cushing's Syndrome (SEISMIC) was a 24-week, open-label study of mifepristone, and its long-term extension (LTE) is a multicenter U.S. study.

Patients: Forty-three CD patients (mean age 45.3 years) were enrolled in SEISMIC with 27 continuing into the LTE study.

Interventions: Mifepristone (300-1200 mg) was administered once daily.

Main outcome measures: ACTH and pituitary MRI were assessed at baseline and at regular intervals during treatment.

Results: A ≥2-fold increase in ACTH was observed in 72% of patients treated for a median duration of 11.3 months. The mean peak increase in ACTH was 2.76 ± 1.65-fold during SEISMIC, and mean ACTH concentrations remained stable during the LTE. ACTH was directly correlated with mifepristone dose and declined to near baseline levels after mifepristone discontinuation. Tumor regressed in 2 patients and progressed in 3 patients with macroadenomas. An additional microadenoma was identified after 25 months of treatment after a baseline tumor-negative MRI.

Conclusions: In the largest prospective study to date, long-term mifepristone treatment increased ACTH in approximately two-thirds of patients with CD. ACTH elevations were observed within the first few weeks of treatment, were dose-dependent, and generally remained stable over time. Corticotroph tumor progression and regression may occur over time, but patients may have significant increases in ACTH levels without evidence of tumor growth.

Trial registration: NCT00569582 NCT00936741.

Publication types

  • Clinical Trial
  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adenoma / drug therapy
  • Adenoma / metabolism
  • Adenoma / pathology
  • Adrenocorticotropic Hormone / blood*
  • Adult
  • Corticotrophs / metabolism
  • Corticotrophs / pathology
  • Female
  • Hormone Antagonists / administration & dosage
  • Hormone Antagonists / adverse effects
  • Humans
  • Hydrocortisone / blood
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Mifepristone / administration & dosage*
  • Mifepristone / adverse effects
  • Pituitary ACTH Hypersecretion / drug therapy*
  • Pituitary ACTH Hypersecretion / metabolism
  • Pituitary ACTH Hypersecretion / pathology
  • Pituitary Neoplasms / drug therapy
  • Pituitary Neoplasms / metabolism
  • Pituitary Neoplasms / pathology
  • Prospective Studies
  • Receptors, Glucocorticoid / antagonists & inhibitors*


  • Hormone Antagonists
  • Receptors, Glucocorticoid
  • Mifepristone
  • Adrenocorticotropic Hormone
  • Hydrocortisone

Associated data