Overnight 1 mg dexamethasone suppression test and 24 h urine free cortisol-accuracy and pitfalls when screening for Cushing's syndrome

Who and how to screen for endogenous hypercortisolism in adrenal and pituitary incidentaloma

PURPOSE

Adrenal incidentalomas (AIs) and pituitary incidentalomas (PIs) have become frequent findings in the last two decades due to the widespread use of cross-sectional imaging in clinical practice. This review investigates the prevalence of endogenous hypercortisolism in patients with AIs and PIs. We aim to underscore the importance of early detection and management of endogenous hypercortisolism in this subset of patients to mitigate associated cardiometabolic complications and reduce mortality.

METHODS

We performed a PubMed literature search to provide updates regarding the prevalence of endogenous hypercortisolism in patients with AIs and PIs, the demographic and clinical characteristics of the studied populations, and the diagnostic test accuracy for early identification of endogenous hypercortisolism.

RESULTS

Hypercortisolism, especially mild autonomous cortisol secretion (MACS), was identified in a notable proportion of patients with AIs. MACS was associated with increased cardiometabolic risks, contributing to an elevated overall mortality rate in this cohort. Furthermore, PIs were found to be linked with Cushing's disease in a subset of patients, emphasizing the need for thorough evaluation and monitoring.

CONCLUSION

Early diagnosis and appropriate management of endogenous hypercortisolism are essential in preventing complications and improving patient outcomes. As the presence of undetected hypercortisolism is associated with clinical complications over time, the accurate identification of high-risk populations to screen remains crucial.

Who and how to screen for endogenous hypercortisolism in patients with mood disorders

A strict association exists between mood disorders and endogenous hypercortisolism, namely Cushing's syndrome (CS). Indeed, CS is characterized by a wide range of mood disorders, such as major depression, generalized anxiety, panic disorders, bipolar disorders up to psychosis, with major depression being the most frequent, with a prevalence of 50-80%, and potentially representing the clinical onset of disease. Despite this observation, the exact prevalence of hypercortisolism in patients with mood disorders is unknown and who/how to screen for endogenous hypercortisolism among patients with mood disorders is still unclear. In this context, an accurate anamnestic and clinical examination are crucial in order to identify those patients who may benefit from CS screening. In particular, the presence of specific signs and symptoms of CS, comorbidities typically associated with CS, and lack of improvement of depressive symptoms with standard treatments can further guide the decision to screen for CS. Anyhow, it is noteworthy that mood disorders represent a cause of functional activation of hypothalamic-pituitary-adrenal (HPA) axis, a condition formerly known as non-neoplastic hypercortisolism (NNH). The differential diagnosis between CS and NNH is challenging. Beyond anamnestic and clinical features, various tests, including measurement of daily urinary cortisol and late-night salivary cortisol, together with low dose-dexamethasone suppression test, are used for initial screening. However, considering their low accuracy, a definitive diagnosis may require a longitudinal follow-up along with second-line dynamic tests like combined dexamethasone-CRH test and desmopressin test. In conclusion, available data suggest the need for a comprehensive assessment and follow-up of individuals with mood disorders to detect possible underlying CS, considering the pitfalls in diagnosis and the overlap of symptoms with other conditions like NNH. Specialized centers with expertise in CS diagnosis and differential testing are recommended for accurate evaluation and management of these patients.

Screening of hypercortisolism among patients with hypertension: an Italian nationwide survey

PURPOSE

Screening of Cushing Syndrome (CS) and Mild Autonomous Cortisol Secretion (MACS) in hypertensive patients is crucial for proper treatment. The aim of the study was to investigate screening and management of hypercortisolism among patients with hypertension in Italy.

METHODS

A 10 item-questionnaire was delivered to referral centres of European and Italian Society of Hypertension (ESH and SIIA) in a nationwide survey. Data were analyzed according to type of centre (excellence vs non-excellence), geographical area, and medical specialty.

RESULTS

Within 14 Italian regions, 82 centres (30% excellence, 78.790 patients during the last year, average 600 patients/year) participated to the survey. Internal medicine (44%) and cardiology (31%) were the most prevalent medical specialty. CS and MACS were diagnosed in 313 and 490 patients during the previous 5 years. The highest number of diagnoses was reported by internal medicine and excellence centres. Screening for hypercortisolism was reported by 77% in the presence of specific features of CS, 61% in resistant hypertension, and 38% in patients with adrenal mass. Among screening tests, the 24 h urinary free cortisol was the most used (66%), followed by morning cortisol and ACTH (54%), 1 mg-dexamethasone suppression test (49%), adrenal CT or MRI scans (12%), and late night salivary cortisol (11%). Awareness of referral centres with expertise in management of CS was reported by 67% of the participants, which reduced to 44% among non-excellence centres.

CONCLUSIONS

Current screening of hypercortisolism among hypertensive patients is unsatisfactory. Strategies tailored to different medical specialties and type of centres should be conceived.