Dear Sir,
we have read with great interest the paper by Deipolyi and co-workers on
the use of desmopressin during inferior petrosal sinus sampling (IPSS) in
alternative to corticotropin-releasing hormone (CRH) for the diagnostic
work-up of Cushing's disease (1). As the Authors report, evidence
collected in small series suggests that desmopressin achieves an
equivalent diagnostic accuracy to CRH, thus appears a tempting and less
expensive alternative. It is worth recalling, however, that desmopressin
is also a potent haemostatic agent and that patients with Cushing's
syndrome are at increased risk for thromboembolic events (2), some even
occuring during IPSS performed at expert centers (3). In this context, we
have recently observed that endothelial factors are released upon
administration of desmopressin to patients with Cushing's disease (4),
although the dose used for diagnostic purposes is roughly half the
haemostatic dosage. The magnitude of the increase in von Willebrand
factor, a promoter of platelet adhesion to the subendothelium in the early
phases of haemostasis, was comparable to the one observed in healthy
subjects and possibly counterbalanced by increased fibrinolytic factors
but to what extent these changes might affect general haemostatic
processes remains to be ascertained. As a consequence, as long as no
further evidence is available on the safety of this haemostatic agent
during endovascular damages, procedures which are per se at risk for
vascular events, extreme caution should be exercised when using
desmopressin instead of CRH during IPSS.
References
1. Deipolyi AR, Hirsch JA, Oklu R. Bilateral inferior petrosal sinus
sampling with desmopressin. J.Neurointervent.Surg.
2012;doi10.1136/neurointsurg-2012-010437.
2. Stuijver DJF, van Zaane B, Feelders RA, Debeij J, Cannegieter SC,
Hermus AR et al. Incidence of venous thromboembolism in patients with
Cushing's syndrome: a multicenter cohort study. J.Clin.Endocrinol.Metab.
2011;96:3525-32.
3. Doppman JL. There is no simple answer to a rare complicaton of inferior
petrosal sinus sampling. Am.J.Neuroradiology 1999;20:191-2.
4. Pecori Giraldi F, Ambrogio AG, Fatti LM, Rubini V, Cozzi G, Scacchi M
et al. Von Willebrand factor and fibrinolytic parameters during the
desmopressin test in patients with Cushing's disease. Br.J.Pharmacol.
2011;71:132-6.
Conflict of Interest:
None declared
Dear Sir, we have read with great interest the paper by Deipolyi and co-workers on the use of desmopressin during inferior petrosal sinus sampling (IPSS) in alternative to corticotropin-releasing hormone (CRH) for the diagnostic work-up of Cushing's disease (1). As the Authors report, evidence collected in small series suggests that desmopressin achieves an equivalent diagnostic accuracy to CRH, thus appears a tempting and less expensive alternative. It is worth recalling, however, that desmopressin is also a potent haemostatic agent and that patients with Cushing's syndrome are at increased risk for thromboembolic events (2), some even occuring during IPSS performed at expert centers (3). In this context, we have recently observed that endothelial factors are released upon administration of desmopressin to patients with Cushing's disease (4), although the dose used for diagnostic purposes is roughly half the haemostatic dosage. The magnitude of the increase in von Willebrand factor, a promoter of platelet adhesion to the subendothelium in the early phases of haemostasis, was comparable to the one observed in healthy subjects and possibly counterbalanced by increased fibrinolytic factors but to what extent these changes might affect general haemostatic processes remains to be ascertained. As a consequence, as long as no further evidence is available on the safety of this haemostatic agent during endovascular damages, procedures which are per se at risk for vascular events, extreme caution should be exercised when using desmopressin instead of CRH during IPSS.
References 1. Deipolyi AR, Hirsch JA, Oklu R. Bilateral inferior petrosal sinus sampling with desmopressin. J.Neurointervent.Surg. 2012;doi10.1136/neurointsurg-2012-010437. 2. Stuijver DJF, van Zaane B, Feelders RA, Debeij J, Cannegieter SC, Hermus AR et al. Incidence of venous thromboembolism in patients with Cushing's syndrome: a multicenter cohort study. J.Clin.Endocrinol.Metab. 2011;96:3525-32. 3. Doppman JL. There is no simple answer to a rare complicaton of inferior petrosal sinus sampling. Am.J.Neuroradiology 1999;20:191-2. 4. Pecori Giraldi F, Ambrogio AG, Fatti LM, Rubini V, Cozzi G, Scacchi M et al. Von Willebrand factor and fibrinolytic parameters during the desmopressin test in patients with Cushing's disease. Br.J.Pharmacol. 2011;71:132-6.
Conflict of Interest:
None declared