Cushing Syndrome

Cushing syndrome is a disorder with physical and mental changes that result from having too much cortisol in the blood for a long period of time. 

• Careful history and physical
• Change in weight and body habitus
• Look at old pictures
• Not all patients have all signs and symptoms, especially “early” and “episodic” patients.
• Important to diagnose early before devastating sequelae develop.
• Initial diagnosis most difficult aspect of Cushing’s syndrome.
• “Gestalt” with as much information as possible
• Episodic Cushing’s common, so one positive test may be worth more than 10 negative tests
• Best tests are 24 hour urines for urinary free cortisols (UFC) and 17-hydroxysteroids (17-OHS, only done at Labcorp and 11 PM-12 midnight salivary cortisols are the best tests and multiple tests should be done to catch “highs”
• Midnight serum cortisols are also good and can be done in hospitals or emergency rooms.
• Dr. Friedman does not recommend the dexamethasone suppression test or the DDAVP stimulation test. Too many patients who end up having Cushing’s disease suppress to dexamethasone and have a normal response to DDAVP.

Endocrinologist, Dr. Friedman, often uses medications to treat Cushing’s syndrome. Unlikely other doctors that may take a long time to diagnose a patient with Cushing’s and then send the patient directly to surgery, Dr. Friedman puts all patients that he has diagnosed with Cushing’s syndrome. on cortisol-lowering medications prior to pituitary surgery. He does that for 4 reasons:

1. Medications that lower cortisol can get the patient feeling better right away
2. The medications can determine if the patients’ symptoms are due to high cortisol. If the Cushing’s symptoms resolve with medications, they will likely resolve with pituitary surgery. If they do not resolve, the patient is unlikely to improve with surgery and the diagnosis of Cushing’s may need to be re-assessed.
3. Lowering cortisol before surgery decreases the risks of surgery, which includes blood clots and infections.
4. Lowering cortisol before surgery decreases the drop in cortisol after successful surgery, so cortisol withdrawal symptoms are less.

Dr. Friedman especially recommends ketoconazole; an in-depth article on ketoconazole can be found on goodhormonehealth.com. He also uses Isturisa (osilodrostat), often in combination with ketoconazole. Many patients feel so well on the medications, they don’t want surgery. Dr. Friedman has patients that have done well on ketoconazole for over 10 years.

Dr. Friedman has the most experience of using medications to treat Cushing’s disease of any Endocrinologist in the country. 

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Dr. Friedman’s web site does not offer medical advice. These materials are offered for information purposes only. Do not act or rely upon information from goodhormonehealth.com without seeking professional medical advice. Additionally, the transmission of information from the web site, goodhormonehealth.com to you, is not intended to create nor does create a physician-patient relationship between you and Dr. Friedman.