Is Hypercortisolism Treatable? Which Patients Should Be Treated and How-A Practical Guide for Clinicians
Abstract
Aim: To provide a practical guide on when to suspect endogenous hypercortisolism, how to use the overnight 1-mg dexamethasone suppression test (DST) for targeted case-finding, and which patients are most likely to benefit from treatment.
Materials and methods: This narrative review synthesizes evidence from clinical practice guidelines, prospective prevalence studies, randomized controlled trials, systematic reviews, and meta-analyses addressing the recognition, diagnosis, and management of endogenous hypercortisolism in patients with treatment-resistant type 2 diabetes (T2D), resistant hypertension, and adrenal incidentalomas.
Results: Confirmed endogenous hypercortisolism is found in 0.6%-3.4% of broader T2D cohorts after stepwise biochemical evaluation, but recent prospective studies-including CATALYST and MOMENTUM-report abnormal cortisol suppression in approximately one in four patients within selected high-risk groups. Mild autonomous cortisol secretion (MACS), defined as ACTH-independent cortisol production with post-dexamethasone serum cortisol > 50 nmol/L (> 1.8 μg/dL) in the absence of classic Cushingoid features, is associated with clinically meaningful increases in hypertension, T2D, visceral adiposity, and all-cause mortality. Routine screening of all patients with diabetes or hypertension is not recommended; testing should be reserved for those with multiple, progressive, or atypical cardiometabolic features, or with adrenal incidentalomas. Attention to test…
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