New Clinical Practice Guidelines on the Diagnosis of Cushing's Syndrome

[~MaryO~]

http://www.newswise.com/articles/view/540136/

 

Source: Endocrine Society Released: Mon 28-Apr-2008, 08:00 ET

New Clinical Practice Guidelines on the Diagnosis of Cushing's Syndrome

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CUSHING'S SYNDROME, GUIDELINES, CORTISOL

 

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The Endocrine Society has released new clinical practice guidelines for the diagnosis of Cushing?s syndrome. The guidelines appear in the May issue of the Journal of Clinical Endocrinology & Metabolism (JCEM), a publication of The Endocrine Society.

 

Newswise ? The Endocrine Society has released new clinical practice guidelines for the diagnosis of Cushing?s syndrome. The guidelines appear in the May issue of the Journal of Clinical Endocrinology & Metabolism (JCEM), a publication of The Endocrine Society.

 

Cushing?s syndrome is an endocrine disorder caused by an abnormally high circulating level of cortisol, a corticosteroid hormone produced in the adrenal gland. The vast majority of cases of Cushing?s syndrome are caused by steroid medications, such as those used to treat asthma or rheumatoid arthritis. This type of Cushing?s, referred to as exogenous (since the causes come from outside the body), is temporary and goes away after the patient ceases taking the medication.

 

Endogenous Cushing?s syndrome is unusual. It usually comes on slowly and can be difficult to diagnose. It is caused either by a problem with the adrenal glands, the pituitary (a gland located at the base of the brain), or a tumor in another location. In the adrenal glands, the problem is caused by a tumor (usually non-cancerous) that produces too much cortisol. When the problem originates outside of the adrenal glands, it is caused by a tumor that produces too much ACTH (spell out ACTH)?the hormone that tells the adrenal glands to make cortisol.

 

Signs and symptoms of Cushing?s syndrome include weight gain, high blood sugar, high blood pressure, thin bones, easily bruised skin, depression, and reduced sex drive. Although Cushing?s syndrome is clinically unmistakable when full-blown, the spectrum of clinical presentations [can we say ?symptoms?? presentations is rather jargon] is broad, and the diagnosis can be challenging in mild cases.

 

?Patients with Cushing?s syndrome often have a number of features that are caused by cortisol excess but which are also common in the general population, such as obesity, depression, diabetes, hypertension, or menstrual irregularity,? said Lynnette Nieman, MD, of the National Institute of Child Health and Human Development and chair of the task force that developed these guidelines. ?If Cushing?s syndrome is not considered, the diagnosis is all too often delayed, and this is unfortunate as early recognition and treatment could reduce the risk of morbidity.?

 

After excluding steroid medications, the guidelines suggest testing of Cushing?s syndrome in patients with multiple and progressive features compatible with the syndrome. They also provide recommendations for which tests to use and how to proceed if the tests results are abnormal.

 

The guidelines were developed by a task force chaired by Dr. Nieman. Other members of the task force included Beverly Biller of Harvard Medical School in Boston, Massachusetts; James Findling of Medical College of Wisconsin in Milwaukee, Wisconsin; John Newell-Price of the University of Sheffield in Sheffield, United Kingdom; Martin Savage of Queen Mary University in London, United Kingdom; Paul Stewart of the University of Birmingham in Birmingham, United Kingdom; and Victor Montori of Mayo Clinic in Rochester, Minnesota.

[Sylvia3]

I'm not sure what this is saying. Maybe I missed it. I wish they would be more clear on the types of tests and that the patient needs to do most of them and more than once to rule it in or out.

 

I know, baby steps, at least someone is talking about it at all!

[cat lady]

I saw that yesterday and have been digging around ever since trying to find the actual guidelines. I think they've got them under lock and key on an endo only website. Sigh...Glad to hear they've updated the guidelines though!

[staticnrg]

I think I found the author's manuscript:

 

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

 

Is this it?

 

XOXO

Robin

[~MaryO~]

Looks like it!

[Annie]

I find it very interesting that they suggest against using the dext test in patients suspected of having Cyclic Cushings syndrome. Rather they suggest the use of UFC and midnight salivary cortisol tests!

 

And to think my so called endo ruled out Cyclic Cushings with only half of my dex test results!!

 

*sigh*

[denney]

Thank you Mary, thank you Robin. This looks like one I will keep for reference. Wonder how resistant endo's will respond to this info. It may be especially helpful to me in the next few weeks with an appointment coming up for my MIL. I noticed on page 17 of the article it mentions individuals with osteo and compression fractures as patients where Cushing's should be considered.

 

MIL has severe and progressive osteo with two compression fractures despite aggressive treatment (GH injections, Intravenous Zoledronic Acid, major Vit D replacement). I noticed on her MRI's she has a very distinctive fat pad at the base of her neck not sure yet if it might be related to steroid injections in her back for pain but she has had the "hump" for as long as I can remember. I just thought it was perhaps poor posture over the years. I have been wondering how I could address the possibility with her new osteo doctor in a couple of weeks and this article makes it a straight shot to get it on the table. This along with some info that JudyC brought to my attention about a possible connection between PTH and cortisol should at least get the docs attention.

 

Thanks again,

 

den

[sue3708]

From what I read it looks like I have been tested correctly. This is a great resource. Thank you!

 

Sue

[JenS]

I don't think I would have been diagnosed under this criteria...

[garcia9]

The end of page 12, beggining of 13 it talks about the Morbidity and mortality of Cushing?s syndrome. It says markers of cardiovascular risk remain abnormal for up to 5 years after surgery, further studies are needed to assess long-term SMR. (standard mortality ratio)

 

I didn't realize we had cardiovascular risks for that long after surgery.

[conti]

Mary,

 

Thanks for this interesting reference. I have recently started seeing one of the authors and find this very heartening. Well worth saving as Den said.

[scarlett12]

Thanks for the resource! Maybe I missed it... but I didn't see anything about midnight serum cortisols, just salivas. And it still seems as though they think cyclical Cushing's only happens in very rare circumstances. One of the doctors that helped publish this is from Mayo and the testing protocol fits what they did for me almost exactly.

 

 

Paige

[staticnrg]

Well, frankly, I agree with Jen.... If Dr. F has just used UFC's and midnight salivaries when I started testing, I would never have been diagnosed. Eventually, I did have high UFCs and salivaries, but the midnight serums were what helped me along tremendously. That and the diurnal variation that comes with CUshing's. I still believe this is too rigid for cyclical, and that very few doctors truly understand the nature of the disease. Again, I believe it's not nearly as rare as the paper leads one to believe. Nor do those who truly understand cyclical/intermittent/episodic Cushing's.

 

Hugs,

Robin