The Diagnosis of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline

[~MaryO~]

http://jcem.endojournals.org/cgi/content/a.../jc.2008-0125v1

 

The Diagnosis of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline

Lynnette K. Nieman M.D.*, Beverly M.K. Biller M.D., James W. Findling M.D., John Newell-Price Ph.D., F.R.C.P., Martin O. Savage M.D., Paul M. Stewart M.D, F.R.C.P., F.Med.Sci., and Victor M. Montori M.D., M.Sc.

 

Program on Reproductive and Adult Endocrinology, NICHD, National Institutes of Health (L.K.N.), Bethesda, Maryland; Harvard Medical School/Massachusetts General Hospital (B.M.K.B.), Boston, Massachusetts; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin; University of Sheffield (J.N-P.), Sheffield, United Kingdom; Queen Mary University of London (M.O.S.), London, United Kingdom; University of Birmingham (P.M.S.), Birmingham, United Kingdom; and Mayo Clinic (V.M.M.), Rochester, Minnesota

 

* To whom correspondence should be addressed. E-mail: govt-prof@endo-society.org.

 

Objective: To develop clinical practice guidelines for the diagnosis of Cushing's syndrome.

 

Participants: The Task Force included a chair, selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society, five additional experts, a methodologist, and a medical writer. The Task Force received no corporate funding or remuneration.

 

Consensus Process: Consensus was guided by systematic reviews of evidence and discussions. The guidelines were reviewed and approved sequentially by The Endocrine Society's CGS and Clinical Affairs Core Committee, members responding to a Web posting, and The Endocrine Society Council. At each stage the Task Force incorporated needed changes in response to written comments.

 

Conclusions: After excluding exogenous glucocorticoid use, we recommend testing for Cushing's syndrome in (a) patients with multiple and progressive features compatible with the syndrome, particularly those with a high discriminatory value, and ( patients with adrenal incidentaloma. We recommend initial use of one test with high diagnostic accuracy (urine cortisol, late night salivary cortisol, 1-mg overnight or 2-mg 48-hour dexamethasone suppression test). We recommend that patients with an abnormal result see an endocrinologist and undergo a second test, either one of the above or, in some cases, a serum midnight cortisol or dexamethasone-CRH test. Patients with concordant abnormal results should undergo testing for the cause of Cushing's syndrome. Patients with concordant normal results should not undergo further evaluation. We recommend additional testing in patients with (a) discordant results, ( normal responses suspected of cyclic hypercortisolism, or © initially normal responses who accumulate additional features over time.

[philb]

Freaks.

[denney]

Hi Mary,

 

I appreciate your posting this. It gives patients a heads up on info that doctors are looking at and if doctors don't make it all the way through the article to the concluding comments they might determine that just a few tests will satisfy their responsibility to their patients.

 

Forewarned is forearmed more or less and I did notice that the researchers in the last sentences of their conclusions point out that while...

 

"Patients with concordant normal results should not undergo further evaluation. We recommend additional testing in patients with (a) discordant results, normal responses suspected of cyclic hypercortisolism, or © initially normal responses who accumulate additional features over time."

 

 

I would hope that their definition of discordant would at least include variations in diurnal cycles as evidenced through testing and low results in the face of multiple symptoms. I appreciated that suspicion of cyclic hypercortisolism was mentioned as a trigger for additional investigation and I have noticed that the cyclic experts will send patients home when the laboratory evidence is insufficient to move toward treatment to wait for either a progression of the disease to rear its ugly head or a sufficiently high cycle that will reveal itself on lab findings.

 

Sincerely,

 

den

[Caroline]

Thanks for posting this Mary,

 

Very interesting - particularly as one of the authors isn't too far away from me and might be worth contacting! It does worry me though that people might still be dismissed after one normal result initially....and they still seem to talk about cyclical being rare. I'm glad they have recommended against the Insulin Tolerance Test for diagnosing cushings - my endo seems to think that my 200nmol rise in cortisol definitively rules out cushings. Perhaps I should send him this article!

 

Love,

Caroline x

[twinkie]

Thanks Mary! I view this as mixed. At least they mentioned "cyclical"....that's a move in the right direction. Thank God for our fistful of doctors who help us.

love,

melly in nv