Frequently Asked Questions

In the CATALYST study, patients with difficult-to-control T2D were defined as having an HbA1c of 7.5% - 11.5% and taking¹:

• ≥3 T2D medications OR

• Insulin and other T2D medication(s) OR

• ≥2 T2D medications AND

  • The presence of ≥1 microvascular or macrovascular complication AND/OR

  • ≥2 hypertension medications

Yes, select patients with hypertension have an increased risk for hypercortisolism. A meta-analysis of 6 studies including 2283 patients revealed that patients with hypertension and T2D were 2x more likely to be diagnosed with hypercortisolism (odds ratio: 2.14; 95% CI 0.81-5.64).²

In fact, in the CATALYST study, the prevalence of hypercortisolism was higher in patients with T2D who were taking ≥3 antihypertensive medications. More than 1 in 3 (37%) were identified to have endogenous hypercortisolism.³

Of the 1057 patients with difficult-to-control type 2 diabetes, 82% of patients were also taking antihypertension medications.³

The 2008 Endocrine Society Guidelines recommend screening for hypercortisolism in patients with hypertension who also have overlapping conditions, such as diabetes, depression, and obesity. Patients with hypertension onset at a younger age should be screened for hypercortisolism.⁵

Treatment that targets excess cortisol production is recommended, as patients with hypertension secondary to hypercortisolism often have difficult-to-control hypertension despite treatment with multiple standard antihypertensive medications.⁶

Both hyperaldosteronism and hypercortisolism can be caused by an adrenal abnormality, but there are different recommended approaches to testing. Hyperaldosteronism can be diagnosed with a blood test showing elevated serum aldosterone (at least 15 ng/mL), while hypercortisolism is diagnosed by a post 1-mg DST cortisol >1.8 μg/dL with AM dexamethasone ≥140 ng/dL.^1,7,8

Multiple publications support the use of DST to screen for ACS. The Endocrine Society Guidelines and the European Society of Endocrinology recommend a 1-mg DST cortisol cutoff of >1.8 µg/dL to screen patients who do not exhibit the clinical features or signs and symptoms but are suspected of having ACS. Post 1-mg DST cortisol >1.8 μg/dL achieves sensitivity rates greater than 95%.^5,9

The following are some factors that may interfere with the reliability and accuracy of the results from a 1-mg DST^1,5:

• Drugs that may alter dexamethasone metabolism (eg, anticonvulsants, or other drugs that may induce CYP450 or CYP3A4 metabolism)

• Alcoholism

• Psychiatric illness

• Women on estrogen therapy including oral contraceptives

• Non-compliance with testing instructions

To help ensure accurate test results in your patients, use this 1-mg DST Patient Tool that provides directions and guidance on what to expect with screening.

No, a patient with elevated post-DST cortisol levels and normal UFC results may still have excess cortisol secretion. In patients suspected of having an adrenal adenoma, UFC results are often normal and cannot be used to confirm a diagnosis.^5,10

The Endocrine Society Guidelines recommend the use of a 1-mg DST or late-night salivary cortisol (LNSC) over a UFC test. When at least one abnormal diagnostic test result occurs, further evaluation by an endocrinologist to confirm or exclude the diagnosis is recommended.⁵

Moon face, dorsocervical fat pad/buffalo hump, and striae are considered highly specific Cushingoid features. However, there are many patients with hypercortisolism who do not present with these phenotypic features.

These patients may have multiple progressive metabolic derangements and feature comorbidities commonly seen in the general population (eg, obesity, diabetes, hypertension, and depression). The absence of Cushingoid physical features does not exclude patients from having hypercortisolism. Patients with an adrenal source of hypercortisolism do not typically display Cushingoid phenotypic features. In a meta-analysis published in 2019, only 0.2% (n=6/2745) of patients with adrenal incidentalomas developed overt Cushingoid features.¹¹

Many patients who do not present with Cushingoid features are at risk for delayed or even missed hypercortisolism diagnosis. A retrospective study of 198 individuals with adrenal adenomas from Di Dalmazi et al revealed that patients with post-DST cortisol levels >1.8 μg/dL who did not have overt Cushingoid features had a greater risk for cardiac morbidity and mortality.¹²

At www.cortisolincontrol.com, patients can learn about cortisol and how too much cortisol can keep blood sugar high, as well as other health issues such as high blood pressure and unexplained weight gain. Patients can learn about:

• Signs and symptoms of excess cortisol

• How to test for excess cortisol

• How to find a specialist in their area who may be able to test for excess cortisol

Cortisolincontrol.com also features an excess cortisol checklist that can help start a discussion to see if a DST is appropriate for the patient.