Central obesity, striae, HTN, hyperglycemia, vertebral fracture
Best screen: 24-h urine cortisol (1-mg overnight dexamethasone too nonspecific)
Then measure ACTH: HIGH → pituitary vs ectopic (high-dose dex suppresses pituitary, not ectopic); LOW → adrenal (CT)
Treat: Pituitary → transsphenoidal resection; Adrenal → adrenalectomy
Order set
- 24-h urinary cortisol / late-night salivary
- 1 mg dex suppression
- ACTH
- Then imaging by ACTH
Criteria
AdmitSevere metabolic/psychiatric complications
DischargeBiochemically localised, surgical plan
Never
- Start with a head MRI in an endocrine disorder — biochemistry first
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Severe hypokalaemia (ectopic ACTH)
- Psychosis
Differentials
- Pseudo-Cushing (alcohol/depression)
- Exogenous steroids
- PCOS
Common mistakes
- Head MRI before biochemistry
- Missing exogenous steroid use
Disposition & follow-up
Localise then surgical resection; endocrine follow-up.
Discharge package
MedicationsPeri-op steroid cover as advised
Follow-upEndocrine surgery
Warning symptomsAdrenal crisis symptoms post-op (dizziness, vomiting)
💊 Treatment detail — doses & preparation
Metyrapone/ketoconazolesteroidogenesis inhibitor
DoseMetyrapone 250–500 mg QID titrated to cortisol (bridge to definitive therapy)
PreparationCapsules with food
MonitorCortisol day-curve, BP, K⁺
Definitive surgerydefinitive
DoseTranssphenoidal (pituitary), adrenalectomy (adrenal), resection (ectopic)
PreparationPeri-operative hydrocortisone cover
MonitorCortisol day-curve post-op; diabetes insipidus watch
📖 Endocrine Society CushingReviewed July 2026