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Psychiatric Symptoms in Patients with Cushing’s Syndrome: Prevalence, Diagnosis and Management

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Abstract

Cushing’s syndrome (CS) results from chronic exposure to cortisol excess, produced by the adrenal cortex. Hypercortisolism predisposes to psychiatric and neurocognitive disorders, mainly to depression and anxiety disorders. Screening tools to identify psychiatric symptoms are available for clinicians in their daily practice, although a specific diagnosis should be performed by specialists. Even if psychiatric symptoms improve after remission of hypercortisolism, complete recovery may not be achieved. Given the burden of these symptoms, psychiatric or psychological monitoring and treatment should be offered through all phases of CS, with a multidisciplinary approach. The aim of this article is to review data on the prevalence, diagnosis and management of psychiatric symptoms seen in patients with CS and to propose therapeutic approaches that may be followed in clinical practice. The prevalence of different psychiatric disorders has been described in both the active phase and after CS remission. Patients may not talk spontaneously about psychiatric symptoms they present, thus clinicians should ask directly about them. We recommend the use of screening tools in clinical practice to detect and treat these symptoms promptly. Even if reference endocrinologists cannot perform a definite psychiatric diagnosis, it will be important to ask patients directly about the presence of symptoms and refer if necessary to a psychiatrist. Additionally, patient information and educational programmes could be useful to manage psychiatric symptoms and to improve quality of life in patients with CS.

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References

  1. Heim C, Nemeroff CB. The role of childhood trauma in the neurobiology of mood and anxiety disorders: preclinical and clinical studies. Biol Psychiatry. 2001;50:200–4.

    Article  Google Scholar 

  2. Carpenter L, Carvalho JP, Tyrka AR, et al. Decreased adrenocorticotropic hormone and cortisol responses to stress in healthy adults reporting significant childhood maltreatment. Biol Psychiatry. 2007;62:1080–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Joëls M, Karst H, Krugers HJ, Lucassen PJ. Chronic stress: implications for neuronal morphology, function and neurogenesis. Front Neuroendocrinol. 2007;28:72–96.

    Article  PubMed  Google Scholar 

  4. Resmini E, Santos A, Gómez-Anson B, et al. Verbal and visual memory performance and hippocampal volumes, measured by 3-Tesla magnetic resonance imaging, in patients with Cushing’s syndrome. J Clin Endocrinol Metab. 2012;97:663–71.

    Article  CAS  PubMed  Google Scholar 

  5. Wang J, Barak LS, Mook RA Jr, Chen W. Glucocorticoid hedgehog agonists in neurogenesis. Vitam Horm. 2011;87:207–15.

    Article  CAS  PubMed  Google Scholar 

  6. Tata DA, Marciano VA, Anderson BJ. Synapse loss from chronically elevated glucocorticoids: relationship to neuropil volume and cell number in hippocampal area CA3. J Comp Neurol. 2006;498:363–74.

    Article  CAS  PubMed  Google Scholar 

  7. Gold PW, Drevets WC, Charney DS. New insights into the role of cortisol and the glucocorticoid receptor in severe depression. Biol Psychiatry. 2002;52:381–5.

    Article  CAS  PubMed  Google Scholar 

  8. de Kloet ER, Joëls M, Holsboer F. Stress and the brain: from adaptation to disease. Nat Rev Neurosci. 2005;6:463–75.

    Article  PubMed  Google Scholar 

  9. Goodwin G. Neurobiological aetiology of mood disorders. In: Gelder MG, Lopez-Ibor JJ, Andreasen N, editors. New Oxford textbook of psychiatry. Oxford: Oxford University Press; 2000. p. 711–9.

    Google Scholar 

  10. Sheline YI, Sanghavi M, Mintun MA, Gado MH. Depression duration but not age predicts hippocampal volume loss in medically healthy women with recurrent major depression. J Neurosci. 1999;19:5034–43.

    CAS  PubMed  Google Scholar 

  11. Resmini E, Santos A, Aulinas A, et al. Reduced DNA methylation of FKBP5 in Cushing’s syndrome. Endocrine. 2016;54:768–77.

    Article  CAS  PubMed  Google Scholar 

  12. De Leo M, Pivonello R, Auriemma RS, et al. Cardiovascular disease in Cushing’s syndrome: heart versus vasculature. Neuroendocrinology. 2010;92:50–4.

    Article  PubMed  Google Scholar 

  13. Jacoby RC, Owings JT, Ortega T, et al. Biochemical basis for the hypercoagulable state seen in Cushing syndrome. Arch Surg. 2001;136:1003–6.

    Article  CAS  PubMed  Google Scholar 

  14. Kaltsas G, Makras P. Skeletal diseases in Cushing’s syndrome: osteoporosis versus arthropathy. Neuroendocrinology. 2010;92:60–4.

    Article  CAS  PubMed  Google Scholar 

  15. Sonino N, Fava GA. Psychosomatic aspects of Cushing’s disease. Psychother Psychosom. 1998;67:140–6.

    Article  CAS  PubMed  Google Scholar 

  16. Pereira AM, Tiemensma J, Romijn JA. Neuropsychiatric disorders in Cushing’s syndrome. Neuroendocrinology. 2010;92:65–70.

    Article  CAS  PubMed  Google Scholar 

  17. Bolland MJ, Holdaway IM, Berkeley JE, et al. Mortality and morbidity in Cushing’s syndrome in New Zealand. Clin Endocrinol (Oxf). 2011;75:436–42.

    Article  Google Scholar 

  18. Santos A, Resmini E, Gómez-Ansón B, et al. Cardiovascular risk and white matter lesions after endocrine control of Cushing’s syndrome. Eur J Endocrinol. 2015;173:765–75.

    Article  CAS  PubMed  Google Scholar 

  19. Forget H, Lacroix A, Somma M, Cohen H. Cognitive decline in patients with Cushing’s syndrome. J Int Neuropsychol Soc. 2000;6:20–9.

    CAS  PubMed  Google Scholar 

  20. Sonino N, Fava GA. Psychiatric disorders associated with Cushing’s syndrome: epidemiology, pathophysiology and treatment. CNS Drugs. 2001;15:361–73.

    Article  CAS  PubMed  Google Scholar 

  21. Starkman MN, Schteingart DE, Schork MA. Depressed mood and other psychiatric manifestations of Cushing’s syndrome: relationship to hormone levels. Psychosom Med. 1981;43:3–18.

    Article  CAS  PubMed  Google Scholar 

  22. Bourdeau I, Bard C, Forget H, et al. Cognitive function and cerebral asessment in patients who have Cushing’s syndrome. Endocrinol Metab Clin N Am. 2005;34:357–69.

    Article  CAS  Google Scholar 

  23. Sonino N, Bonnini S, Fallo F, et al. Personality characteristics and quality of life in patients treated for Cushing’s syndrome. Clin Endocrinol (Oxf). 2006;64:314–8.

    Article  Google Scholar 

  24. Tiemensma J, Biermasz NR, Middelkoop HA, et al. Increased prevalence of psychopathology and maladaptive personality traits, after long-term cure of Cushing’s disease. J Clin Endocrinol Metab. 2010;95:129–41.

    Article  Google Scholar 

  25. Dimopoulou C, Ising M, Pfister H, et al. Increased prevalence of anxiety-associated personality traits in patients with Cushing’s disease: a cross-sectional study. Neuroendocrinology. 2013;97:139–45.

    Article  CAS  PubMed  Google Scholar 

  26. Michaud K, Forget H, Cohen H. Chronic glucocorticoid hypersecretion in Cushing’s syndrome exacerbates cognitive aging. Brain Cogn. 2009;71:1–8.

    Article  PubMed  Google Scholar 

  27. Webb SM, Badia X, Barahona MJ, et al. Evaluation of health-related quality of life in patients with Cushing’s syndrome with a new questionnaire. Eur J Endocrinol. 2008;158:623–30.

    Article  CAS  PubMed  Google Scholar 

  28. Lindsay JR, Nansel T, Baid S, et al. Long-term impaired quality of life in Cushing’s syndrome despite initial improvement after surgical remission. J Clin Endocrinol Metab. 2006;91:447–53.

    Article  CAS  PubMed  Google Scholar 

  29. Hawn MT, Cook D, Deveney C, Sheppard BC. Quality of life after laparoscopic bilateral adrenalectomy for Cushing’s disease. Surger. 2002;132:1064–8.

    Article  Google Scholar 

  30. Dorn LD, Burgess ES, Dubbert B, et al. Psychopathology in patients with endogenous Cushing’s syndrome: atypical or melancholic features. Clin Endocrinol. 1995;43:433–42.

    Article  CAS  Google Scholar 

  31. Kelly WF. Psychiatric aspects of Cushing’s syndrome. Q J Med. 1996;89:543–51.

    Article  CAS  Google Scholar 

  32. Santos A, Resmini E, Crespo I, et al. Small cerebellar cortex volume in patients with active Cushing’s syndrome. Eur J Endocrinol. 2014;171:461–9.

    Article  CAS  PubMed  Google Scholar 

  33. Cosci F, Fava GA, Sonino N. Mood and anxiety disorders as early manifestations of medical illness: a systematic review. Psychother Psychosom. 2015;84:22–9.

    Article  PubMed  Google Scholar 

  34. Rasmussen SA, Rosebush PI, Smyth HS, Mazurek MF. Cushing disease presenting as primary psychiatric illness: a case report and literature review. J Psychiatr Pract. 2015;21:449–57.

    Article  PubMed  Google Scholar 

  35. Tang A, O’Sullivan AJ, Diamond T, et al. Psychiatric symptoms as a clinical presentation of Cushing’s syndrome. Ann Gen Psychiatry. 2013;12:23.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Loosen PT, Chambliss B, de Bold CR, et al. Psychiatric phenomenology in Cushing’s disease. Pharmacopsychiatry. 1992;25:192–8.

    Article  CAS  PubMed  Google Scholar 

  37. Sonino N, Fava GA, Belluardo P, et al. Course of depression in Cushing’s syndrome: response to treatment and comparison with Graves’ disease. Horm Res. 1993;39:202–6.

    Article  CAS  PubMed  Google Scholar 

  38. Sonino N, Fava GA, Raffi AR, et al. Clinical correlates of major depression in Cushing’s disease. Psychopathology. 1998;31:302–6.

    Article  CAS  PubMed  Google Scholar 

  39. Sonino N, Zielezny M, Fava GA, et al. Risk factors and long-term outcome in pituitary-dependent Cushing’s disease. J Clin Endocrinol Metab. 1996;81:2647–52.

    CAS  PubMed  Google Scholar 

  40. Haskett RF. Diagnostic categorization of psychiatric disturbance in Cushing’s syndrome. Am J Psychiatry. 1985;142:911–6.

    Article  CAS  PubMed  Google Scholar 

  41. Hudson JI, Hudson MS, Griffing GT, et al. Phenomenology and family history of affective disorder in Cushing’s disease. Am J Psychiatry. 1987;144:951–3.

    Article  CAS  PubMed  Google Scholar 

  42. Sablowski N, Pawlik K, Lüdecke DK, Herrmann HD. Aspects of personality in patients with pituitary adenomas. Acta Neurochir (Wien). 1986;83:8–11.

    Article  CAS  Google Scholar 

  43. Valassi E, Santos A, Yaneva M, ERCUSYN Study Group, et al. The European Registry on Cushing’s syndrome: 2-year experience: baseline demographic and clinical characteristics. Eur J Endocrinol. 2011;165:383–92.

    Article  CAS  PubMed  Google Scholar 

  44. Dorn LD, Burgess ES, Friedman TC, et al. The longitudinal course of psychopathology in Cushing’s syndrome after correction of hypercortisolism. J Clin Endocrinol Metab. 1997;82:912–9.

    CAS  PubMed  Google Scholar 

  45. Starkman MN, Giordani B, Gebarski SS, Schteingart DE. Improvement in mood and ideation associated with increase in right caudate volume. J Affect Disord. 2007;101:139–47.

    Article  PubMed  Google Scholar 

  46. Kelly WF, Kelly MJ, Faragher B. A prospective study of psychiatric and psychological aspects of Cushing’s syndrome. Clin Endocrinol (Oxf). 1996;45:715–20.

    Article  CAS  Google Scholar 

  47. Cohen SI. Cushing’s syndrome: a psychiatric study of 29 patients. Br J Psychiatry. 1980;136:120–4.

    Article  CAS  PubMed  Google Scholar 

  48. Jeffcoate WJ, Silverstone JT, Edwards CR, Besser GM. Psychiatric manifestations of Cushing’s syndrome: response to lowering of plasma cortisol. Q J Med. 1979;48:465–72.

    CAS  PubMed  Google Scholar 

  49. Valassi E, Crespo I, Keevil BJ, et al. Affective alterations in patients with Cushing’s syndrome in remission are associated with decreased BDNF and cortisone levels. Eur J Endocrinol. 2017;176:221–31.

    Article  CAS  PubMed  Google Scholar 

  50. Ziegelstein RC, Fauerbach JA, Stevens SS, et al. Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction. Arch Intern Med. 2000;160:1818–23.

    Article  CAS  PubMed  Google Scholar 

  51. Katon WJ. Epidemiology and treatment of depresssion in patients with chronic medical illness. Dialog Clin Neurosci. 2011;13:7–23.

    Google Scholar 

  52. Ragnarsson O, Berglund P, Eder DN, Johannsson G. Long-term cognitive impairments and attentional deficits in patients with Cushing’s disease and cortisol-producing adrenal adenoma in remission. J Clin Endocrinol Metab. 2012;97:1640–8.

    Article  Google Scholar 

  53. Andela CD, van der Werff SJ, Pannekoek JN, et al. Smaller grey matter volumes in the anterior cingulate cortex and greater cerebellar volumes in patients with long-term remission of Cushing’s disease: a case–control study. Eur J Endocrinol. 2013;169:811–9.

    Article  CAS  PubMed  Google Scholar 

  54. Martin SB, Covell DJ, Joseph JE, et al. Human experience seeking correlates with hippocampus volume: convergent evidence from manual tracing and voxel-based morphometry. Neuropsychologia. 2007;45:2874–82.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Martín-Blanco A, Ferrer M, Soler J, et al. The role of hypothalamus-pituitary-adrenal genes and childhood trauma in borderline personality disorder. Eur Arch Psychiatry Clin Neurosci. 2016;266:307–16.

    Article  PubMed  Google Scholar 

  56. Martínez-Momblán MA, Gómez C, Santos A, et al. A specific nursing educational program in patients with Cushing’s syndrome. Endocrine. 2016;53:199–209.

    Article  PubMed  Google Scholar 

  57. Gotch PM. Cushing’s syndrome from the patient perspective. Endocrinol Metab Clin N Am. 1994;23:607–17.

    CAS  Google Scholar 

  58. van Aken MO, Pereira AM, Biermasz NR, et al. Quality of life in patients after long-term biochemical cure of Cushing’s disease. J Clin Endocrinol Metab. 2005;90:3279–86.

    Article  PubMed  Google Scholar 

  59. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association; 2014.

    Google Scholar 

  60. Pivonello R, Simeoli C, De Martino MC, et al. Neuropsychiatric disorders in Cushing’s syndrome. Front Neurosci. 2015;9:129.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Ritzel K, Beuschlein F, Mickisch A, Osswald A, et al. Clinical review: outcome of bilateral adrenalectomy in Cushing’s syndrome: a systematic review. J Clin Endocrinol Metab. 2013;98:3939–48.

    Article  CAS  PubMed  Google Scholar 

  62. Sonino N, Fallo F, Fava GA. Psychosomatic aspects of Cushing’s syndrome. Rev Endocr Metab Disord. 2010;11:95–104.

    Article  PubMed  Google Scholar 

  63. Santos A, Crespo I, Aulinas A, et al. Quality of life in Cushing’s syndrome. Pituitary. 2015;18:195–200.

    Article  PubMed  Google Scholar 

  64. Starkman MN. Neuropsychiatric findings in Cushing’s syndrome and exogenous glucocorticoid administration. Endocrinol Metab Clin N Am. 2013;42:477–88.

    Article  Google Scholar 

  65. Nieman LK, Biller BM, Findling JW, et al. Treatment of Cushing’s syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100:2807–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. Lau D, Rutledge C, Aghi MK. Cushing’s disease: current medical therapies and molecular insights guiding future therapies. Neurosurg Focus. 2015;38:E11.

    Article  PubMed  Google Scholar 

  67. Bratek A, Kozmin-Burzynska A, Gorniak E, Krysta K. Psychatric disorders associated with Cushing’s syndrome. Psychiatr Danub. 2015;27:S339–43.

    PubMed  Google Scholar 

  68. Saad MF, Adams F, Mackay B, et al. Occult Cushing’s disease presenting with acute psychosis. Am J Med. 1984;76:759–66.

    Article  CAS  PubMed  Google Scholar 

  69. Zielasek J, Bender G, Schlesinger S, et al. A woman who gained weight and became schizophrenic. Lancet. 2002;360:1392.

    Article  PubMed  Google Scholar 

  70. Baba M, Ray D. Severe psychosis due to Cushing’s syndrome in a patient with a carcinoid tumour in the lung: a case report and review of the current management. World J Surg Oncol. 2015;13:165.

    Article  PubMed  PubMed Central  Google Scholar 

  71. Górniak M, Rybakowski J. Paranoid syndrome in the course of Cushing’s disease. Post Psychiatr Neurol. 2005;14:18–20.

    Google Scholar 

  72. Johanssen S, Allolio B. Mifepristone (RU 486) in Cushing’s syndrome. Eur J Endocrinol. 2007;157:561–9.

    Article  CAS  PubMed  Google Scholar 

  73. Castinetti F, Fassnacht M, Johanssen S, et al. Merits and pitfalls of mifepristone in Cushing’s syndrome. Eur J Endocrinol. 2009;160:1003–10.

    Article  CAS  PubMed  Google Scholar 

  74. van der Lely AJ, Foeken K, Van Der Mast RC, Lamberts SW. Rapid reversal of acute psychosis in the Cushing syndrome with the cortisol-receptor antagonist mifepristone (RU 486). Ann Intern Med. 1991;114:143–4.

    Article  PubMed  Google Scholar 

  75. Chu JW, Matthias DF, Belanoff J, et al. Successful long-term treatment of refractory Cushing’s disease with high-dose mifepristone (RU 486). J Clin Endocrinol Metab. 2001;86:3568–73.

    CAS  PubMed  Google Scholar 

  76. Bilgin YM, van der Wiel HE, Fischer HR, De Herder WW. Treatment of severe psychosis due to ectopic Cushing’s syndrome. J Endocrinol Investig. 2007;30:776–9.

    Article  CAS  Google Scholar 

  77. Beaufrere B, de Parscau L, Chatelain P, et al. RU 486 administration in a child with Cushing’s syndrome. Lancet. 1987;2:217.

    Article  CAS  PubMed  Google Scholar 

  78. Bertagna X, Bertagna C, Laudat MH, et al. Pituitary-adrenal response to the antiglucocorticoid action of RU 486 in Cushing’s syndrome. J Clin Endocrinol Metab. 1986;63:639–43.

    Article  CAS  PubMed  Google Scholar 

  79. Chrousos GP, Laue L, Nieman LK, et al. Clinical applications of RU 486, a prototype glucocorticoid and progestin antagonist. In: Mantero F, Takeda R, Scoggins BA, et al., editors. The adrenal and hypertension: from cloning to clinic. New York: Raven Press; 1989. p. 273–84.

    Google Scholar 

  80. Cassier PA, Abou-Amara-Olivieri S, Artru P, et al. Mifepristone for ectopic ACTH secretion in metastatic endocrine carcinomas: report of two cases. Eur J Endocrinol. 2008;158:935–8.

    Article  CAS  PubMed  Google Scholar 

  81. Mutter GL, Bergeron C, Deligdisch L, et al. The spectrum of endometrial pathology induced by progesterone receptor modulators. Mod Pathol. 2008;21:591–8.

    Article  CAS  PubMed  Google Scholar 

  82. Fleseriu M, Biller BM, Findling JW, SEISMIC Study Investigators, et al. Mifepristone, a glucocorticoid receptor antagonist, produces clinical and metabolic benefits in patients with Cushing’s syndrome. J Clin Endocrinol Metab. 2012;97:2039–49.

    Article  CAS  PubMed  Google Scholar 

  83. National Collaborating Centre for Mental Health (UK). Depression: the treatment and management of depression in adults (updated edition). National Institute for Health and Clinical Excellence: guidance. Leicester: British Psychological Society; 2010.

    Google Scholar 

  84. Gallagher P, Malik N, Newham J, et al. Antiglucocorticoid treatments for mood disorders. Cochrane Database Syst Rev. 2008;1:CD005168.

    Google Scholar 

  85. Brykalski J, Papierska L, Załuska M. Acute psychosis in the course of treatment of acute adrenal crisis with hydrocortisone in the patient with secondary adrenal insufficiency: a case study. Psychiatr Pol. 2015;49:673–81.

    Article  PubMed  Google Scholar 

  86. Løvas K, Husebye ES. High prevalence and increasing incidence of Addison’s disease in western Norway. Clin Endocrinol (Oxf). 2002;56:787–91.

    Article  Google Scholar 

  87. Erichsen MM, Løvås K, Skinningsrud B, et al. Clinical, immunological, and genetic features of autoimmune primary adrenal insufficiency: observations from a Norwegian registry. J Clin Endocrinol Metab. 2009;94:4882–90.

    Article  CAS  PubMed  Google Scholar 

  88. Anglin RE, Rosebush PI, Mazurek MF. The neuropsychiatric profile of Addison’s disease: revisiting a forgotten phenomenon. J Neuropsychiatry Clin Neurosci. 2006;18:450–9.

    Article  PubMed  Google Scholar 

  89. Schultebraucks K, Wingenfeld K, Heimes J, et al. Cognitive function in patients with primary adrenal insufficiency (Addison’s disease). Psychoneuroendocrinology. 2015;55:1–7.

    Article  PubMed  Google Scholar 

  90. Thomsen AF, Kvist TK, Andersen PK, Kessing LV. The risk of affective disorders in patients with adrenocortical insufficiency. Psychoneuroendocrinology. 2006;31:614–22.

    Article  PubMed  Google Scholar 

  91. Holtzman CW, Trotman HD, Goulding SM, et al. Stress and neurodevelopmental processes in the emergence of psychosis. Neuroscience. 2013;249:172–91.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  92. Farah Jde L, Lauand CV, Chequi L, et al. Severe psychotic disorder as the main manifestation of adrenal insufficiency. Case Rep Psychiatry. 2015;2015:512430.

    PubMed  Google Scholar 

  93. Tatsuzawa Y, Ono Y, Takahashi T, et al. Case of isolated adrenocorticotropic hormone deficiency mimicking major depressive disorder. Psychiatry Clin Neurosci. 2011;65(3):302.

    Article  PubMed  Google Scholar 

  94. Martínez MA, Gómez C, Santos A, et al. Quina informació van rebre els malalts amb síndrome de Cushing i risc cardiovascular? Ag Inf. 2012;16:17–22.

    Google Scholar 

  95. Kreitschmann-Andermahr I, Psaras T, Tsiogka M, et al. From first symptoms to final diagnosis of Cushing’s disease: experiences of 176 patients. Eur J Endocrinol. 2015;172:285–9.

    Article  CAS  PubMed  Google Scholar 

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Correspondence to Eugenia Resmini.

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Alicia Santos, Eugenia Resmini, Juan Carlos Pascual, Iris Crespo and Susan Webb have no conflicts of interest directly relevant to the content of this review.

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Santos, A., Resmini, E., Pascual, J.C. et al. Psychiatric Symptoms in Patients with Cushing’s Syndrome: Prevalence, Diagnosis and Management. Drugs 77, 829–842 (2017). https://doi.org/10.1007/s40265-017-0735-z

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