levoketoconazole levoketoconazole levoketoconazole, sold under the brand name recorlev, is a steroidogenesis inhibitor that is used for the treatment of cushing's syndrome. levoketoconazole was approved for medical use in the united states in december 2021. levoketoconazoleclinical datatrade namesrecorlevother namescor-003; (2s,4r)-ketoconazole; normocortlicense data us dailymed: levoketoconazole routes ofadministrationby mouthatc codeh02ca04 (who) legal statuslegal status us: ℞-only identifiers iupac name 1-methoxy}phenyl)-1-piperazinyl]ethanone cas number142128-57-2pubchem cid47576drugbankdb05667chemspider43284unii2dj8r0nt7kkeggd10950chebichebi:47518chemblchembl295698pdb ligandkln (pdbe, rcsb pdb)comptox dashboard (epa)dtxsid60161949 chemical and physical dataformulac26h28cl2n4o4molar mass531.43 g·mol−13d model (jsmol)interactive image smiles cc(=o)n1ccn(cc1)c2ccc(cc2)oc3co(o3)(cn4ccnc4)c5ccc(cc5cl)cl inchi inchi=1s/c26h28cl2n4o4/c1-19(33)31-10-12-32(13-11-31)21-3-5-22(6-4-21)34-15-23-16-35-26(36-23,17-30-9-8-29-18-30)24-7-2-20(27)14-25(24)28/h2-9,14,18,23h,10-13,15-17h2,1h3/t23-,26-/m1/s1key:xmaywyjoqhxeek-zeqkjwhpsa-n levoketoconazole is the levorotatory or (2s,4r) enantiomer of ketoconazole, and it is an inhibitor of the enzymes cyp11b1 (11β-hydroxylase), cyp17a1 (17α-hydroxylase/17,20-lyase), and cyp21a2 (21-hydroxylase). it inhibits glucocorticoid biosynthesis and hence circulating levels of glucocorticoids, thereby treating cushing's syndrome. in addition to its increased potency, the drug is 12-fold less potent than racemic ketoconazole in inhibiting cyp7a1 (cholesterol 7α-hydroxylase), theoretically resulting in further reduced interference with bile acid production and metabolite elimination and therefore less risk of hepatotoxicity. levoketoconazole has also been found to inhibit cyp11a1 (cholesterol side-chain cleavage enzyme) and cyp51a1 (lanosterol-14α-demethylase), similarly but more potently relative to ketoconazole.