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MaryO

New guidelines for the diagnosis of Cushing?s

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http://endocrinetoday.com/comments.aspx?rid=29382

 

New guidelines for the diagnosis of Cushing?s

 

Posted by Michael Kleerekoper, MD, MACE July 7, 2008 07:37 AM

 

The Endocrine Society has just published new clinical guidelines for the diagnosis of Cushing?s syndrome.

 

The first recommendation is key: before any testing, obtain a complete drug history for any use of steroid preparations. I just spent three months on a Cushing?s workup before my patient asked whether the spinal injections he was getting every three months for control of back pain might be why the laboratory results weren?t making sense to me!

 

Consider Cushing?s in patients with unexpected osteoporosis or new onset hypertension, those with highly suggestive clinical features, and those with an adrenal incidentaloma.

 

For the initial testing the recommendations are 24 hour urine free cortisol (x2), or late night salivary cortisol (x2), or an overnight 1 mg dexamethasone suppression test. Few patients enjoy collecting urine in a bottle for 24 hours let alone twice. The overnight DST is straightforward but does require the patient to go the pharmacy for the tablet and present to the laboratory for blood work between 8 and 9 a.m. the next morning.

 

The late night salivary cortisol test is the most recently developed of the tests and seems the easiest for patients. On two separate occasions have the patient drool (yes that?s the word used in the guidelines) into a plastic tube. The sample is stable at room temperature for several weeks (I would not recommend waiting that long) and can be mailed to the testing laboratory.

 

As with all laboratory tests, be careful that specimens collected on separate days are sent to the same testing lab ? assay methods and reference intervals do vary.

 

The guidelines, which are evidence based and very easy to read and follow, provide many more important details about both the initial screening I have just summarized and subsequent follow-up for positive or equivocal results.

 

Comments so far

 

Comment by Fadi Al-khayer, MD -- July 8, 2008 12:04 AM

 

Beautiful summary! Cushing's disease, although rare, is very important to diagnose, as effective treatment will cure most of the negative consequences of excess production of cortisol. I have to say that in five years in community based practice, I have diagnosed Cushing's disease (secondary to a pituitary tumor, not iatrogenic) just twice. The outcome of surgery in both cases was terrific, however, I screened for Cushing's a thousand times! Yes, with the epidemic of obesity, pts present with all typical signs of classical Cushing's and many times it's impossible to make the dx clinically. Screening such pts came mostly negative for Cushing's.

 

Comment by T. Repas DO -- July 8, 2008 01:35 PM

 

I recently had a case very similar to this. The labs were confusing but the patient denied any form of steroid exposure, including injection. Then, about 2 months later and after extensive work up, he mentioned that he had been getting steroid injections for back pain. Would those make any difference?

 

Comment by Michael Kleerekoper -- July 19, 2008 07:25 AM

 

Firstly, I am enjoying your blogs. Regarding your patient, two cases makes a publication. More seriously spinal steroid injections have not been on my list of medications to ask about, and I suspect that many patients do not recall that their injections are steroids. When back pain is severe enough to require injections, the patient's major interest is getting relief as quickly as possible, not remembering what was in the injection.

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I don't know about you, but this guy sounds kind of arrogant and dismissive in his little "summary." Thinking that 24hr urines are too burdensome for patients, so just do a dex, get it over with, rule out Cushing's, and move on. I don't know, maybe I am just having an angry week and am projecting my own feelings into his "summary," but I found it incomplete, lacking compassion for the patient, and not up to date on current medical research!

 

 

Alicia :)

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It's the "OR" placed inbetween, like any of these tests are completely diagnostic 1st time around that's getting up my nose - he needs to keep up to date....bet he doesn't believe in Cyclic Cushings either!

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Hey---I missed the part where you were supposed to question the patient as to why they wanted a disease like Cushings...

Maybe I ought to do some more looking...

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And we all KNOW the dex test is SOOOOOO reliable... so that is a good thing that it is easy! HAH.

(note to self - avoid that doc...)

 

Thanks for posting this Mary!

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Vision issues are a classic symptom of a pit tumor... it's a start. At least someone is talking about it and even the pitiful amount of tests he is talking about is still twice as much and 3 times as many as any of my local doctors would let me test. It's a tiny step in the right direction.

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Vision issues are a classic symptom of a pit tumor... it's a start. At least someone is talking about it and even the pitiful amount of tests he is talking about is still twice as much and 3 times as many as any of my local doctors would let me test. It's a tiny step in the right direction.

 

 

The very first Endo I went to back in the early 90's sent me right to a Neuro Ophthalmologist, and sure enough my Pit was putting pressure my optic nerves..just wondering why this report I have of my MRI doesn't even mention my Optic Nerves.

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Well, this makes me mad. I posted the link to this full-length article on here a while back, so I've read it. Here's the link to the free PDF file. http://jcem.endojournals.org/cgi/rapidpdf/jc.2008-0125v1

Why am I mad?

  • This guy misrepresented what is in the article. He says "two times" when the article says "at least two times"
  • He doesn't say to do more testing if the physical characteristics of Cushing's are there (the article does)
  • The article says cyclical Cushing's is very rare. I totally disagree, and I think Dr. F and Dr. L would, too.
  • He does not mention: "3.8.1 We suggest the additional use of the dexamethasone-CRH test or the midnight serum cortisol test in specific situations"

The article says,

 

3.6 In individuals with normal test results in whom the pre-test probability is high (patients with clinical features suggestive of Cushing?s syndrome and adrenal incidentaloma or suspected cyclic hypercortisolism), we recommend further evaluation by an endocrinologist to confirm or exclude the diagnosis

The article starts out with a disclaimer which includes this: "These technical comments reflect the best available evidence applied to a typical patient. Often, this evidence comes from the unsystematic observations of the panelists and should, therefore, be considered suggestions."

I am not happy with the article or with this guy's synopsis. He misrepresents what is in the article, and I'm afraid that those using these as guidelines will not see the sentence I underlined above.

Not, not, not, not good!

 

Sigh....

 

Hugs.

Robin

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Robin, you should send you comments with citations the way you did here, to the publication it appeared in. My friend was published in the journal Science when he did just that, analytically and systematically refuting the reputed Lyme disease god about overdiagnosis of Lyme disease.

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Since the original link was a blog article you (Robin) and everyone can post their comments there, too. Maybe someone will actually pay attention!

 

http://endocrinetoday.com/comments.aspx?rid=29382

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You know what! I will! I just won't be able to, probably, until this weekend sometime. Think that will be timely enough?

 

(I have lots of other things I can cite, too!)

 

Hugs!

Robin

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