heart attack | CushieBlog

A More Accurate Diagnosis of Cushing’s Syndrome

Posted on May 29, 2024 by MaryO

Cushing’s syndrome is associated with excessive cortisol production and, if left untreated, can result in severe complications, such as heart attacks, strokes, and type 2 diabetes. To diagnose this condition, a dexamethasone suppression test is commonly performed.

Various factors, such as metabolic rate and interactions with other medications, can affect test efficacy. Therefore, it is crucial to measure the concentration of dexamethasone concurrently with cortisol to avoid false-positive results.

To address this issue, a team of researchers at the University of Turin, led by Professor Giulio Mengozzi in the Department of Medical Sciences, has developed a liquid chromatography-tandem mass spectrometry method.

This new method enables the simultaneous quantification of cortisol, cortisone, dexamethasone, and six additional exogenous corticosteroids, leading to a more accurate diagnosis of Cushing’s syndrome.

The symptoms of Cushing’s syndrome

Cushing’s syndrome is a medical condition characterized by an abnormal and prolonged increase in cortisol production, typically affecting females between the ages of 30 and 50.¹

While the issue may originate from within the body (endogenous), it is more commonly caused by external factors, such as the use of glucocorticoid medications.

Visible symptoms of Cushing’s syndrome include weight gain, an accumulation of fat around the base of the neck, a fatty hump between the shoulders, the appearance of a “moon face”, and easy bruising. However, not all individuals with the syndrome exhibit these symptoms, rendering diagnosis challenging. Without timely treatment, Cushing’s syndrome can lead to severe complications, including heart attack, stroke, blood clots in the legs and lungs, increased susceptibility to infections, memory loss, and type 2 diabetes.

Dexamethasone testing

A commonly used method for diagnosing Cushing’s syndrome is the dexamethasone suppression test (DST), which measures the adrenal gland’s response to adrenocorticotropic hormone (ACTH).

ACTH regulates cortisol levels in the blood plasma and stimulates the adrenal cortex to produce cortisol. When cortisol levels increase, ACTH secretion is suppressed. Dexamethasone, a synthetic steroid similar to cortisol, is administered during the DST to lower ACTH levels.

DSTs are available in low-dose (LDDST) and high-dose (HDDST). They can be performed overnight or over two days.

LDDSTs are used initially to diagnose Cushing’s syndrome. If the result is positive, HDDSTs help classify the disease as ACTH-dependent or independent. These tests are typically conducted in the following manner.²

A more accurate diagnosis of Cushing’s syndrome

Cortisol is a steroid hormone of the glucocorticoid class made by the adrenal glands.

Image Credit: Shutterstock/Kateryna Kon

LDDST

Overnight protocol: 1 mg of dexamethasone is administered at 11:00 pm, and the serum cortisol levels are measured at 8:00 am the following morning.
Two-day protocol: serum cortisol levels are measured at 8:00 am and 0.5 mg of dexamethasone is administered every six hours (9:00 am, 3:00 pm, 9:00 pm, 3:00 am) for two days, totalling 4 mg. Serum cortisol levels are then measured at 9:00 am, six hours after the last dose has been delivered.

HDDST

Overnight protocol: baseline serum cortisol or 24-hour urinary free cortisol (UFC) is measured in the morning, and 8 mg of dexamethasone is given at 11.00 pm. Cortisol level in blood is then measured at 8.00 am the following morning.
Two-day protocol: Baseline serum cortisol or 24-hour UFC is measured at 8:00 am; 2 mg of dexamethasone is administered every six hours (9:00 am, 3:00 pm, 9:00 pm, 3:00 am) for two days, totaling 16 mg, in tandem with the collection of urine for UFC measurements. Serum cortisol levels are measured at 9:00 am, six hours after the last dose.

Patients whose pituitary glands produce excessive amounts of ACTH will exhibit an abnormal response to the low-dose test but a normal reaction to the high-dose test.

During the LDDST, cortisol levels should decrease following the administration of dexamethasone, and a cut-off value of below 18 ng/mL is recommended to distinguish a healthy response from an unhealthy one.

For the HDDST, a decrease in urine-free cortisol (UFC) or serum cortisol greater than 50% indicates the presence of ACTH-dependent Cushing’s syndrome. This rule applies to both the overnight LDDST and the two-day HDDST methods.

Measuring cortisol levels

Chemiluminescence immunoassay (CLIA) is a widely used method for measuring cortisol and other steroids due to its simplicity, automation, and good sensitivity.

However, it has some drawbacks, including cross-reactivity leading to overestimation of target analyte levels, non-standardization of kits, and the inability to measure more than one analyte per analysis. This is particularly problematic since studies indicate that measuring dexamethasone in combination with cortisol can reduce the number of false-positive DST results and improve interpretability. ^3,4,5

Liquid chromatography-tandem mass spectrometry (LC-MS/MS) has emerged as a popular alternative to CLIA for DSTs due to its ability to measure multiple analytes simultaneously and its superior specificity.

Analytes are separated via LC, and their concentrations are measured by MS, with triple quadrupole MS configurations commonly used for this purpose. This technique provides the ability to measure multiple analytes simultaneously, along with higher accuracy and sensitivity than CLIA.

Increased ease of use and accuracy

In the Division of Endocrinology, Diabetes, and Metabolism at the University of Turin, a team has developed an LC-MS/MS technique for simultaneous quantifying cortisol, cortisone, dexamethasone, and six other exogenous corticosteroids in serum/plasma samples.⁶

This method can be readily applied in any clinical laboratory equipped with a mass spectrometer and is effective in DSTs, enabling precise measurements of the target analytes in a single chromatographic run (Figure 1).

Sample preparation (1 Hour)

Dilute 200 μL of the serum/plasma sample with 200 μL of water.
Perform supported liquid extraction, manually transferring 400 μL of sample to a microplate.
Apply positive pressure using Tecan Resolvex^® A200 automated positive pressure processor.
Elute with 700 μL of methyl tert-butyl ether.
Evaporate and reconstitute in H2 O/MeOH (1:1, v/v).
Agitate.

LC-MS/MS analysis (10 Minutes)

LC column: C18 (100 × 2.1 mm, 1.7 μm)
Flow rate: 400 μL/min
Temperature: 30 °C
Injection volume: 20 μL
Mobile phase A: H₂O + 0.2 mM ammonium fluoride
Mobile phase B: acetonitrile
Elution programme: Table 1.

The study demonstrated a strong correlation between the results obtained from the newly developed LC-MS/MS method and those obtained using a commercially available CE IVD-marked Steroid Panel LC-MS* kit (Tecan).

The Tecan kit enables simultaneous dexamethasone, cortisol, and cortisone measurement and includes all the necessary components for easy implementation, such as calibrators and controls. The samples are prepared using solid-phase extraction (SPE), which can be semi-automatically performed on a Resolvex® A200 positive pressure processor (Tecan). The kit can measure 15 other steroids in the core steroid metabolism pathway due to the effectiveness of the SPE process.

Table 1. LC gradient elution programme. Source: Tecan

Time (min)	Mobile phase A (%)	Mobile phase B (%)
0	90	10
0.5	65	35
4.5	65	35
4.51	35	65
6.0	2	98
8.0	2	98
8.01	90	10
10.0	90	10

* In USA: for research use only. Not for use in diagnostic procedures. Product availability and regulatory status may vary from country to country. Consult with your Tecan associate for further information.

A more accurate diagnosis of Cushing’s syndrome

Figure 1. Example chromatogram of the Steroid Panel LC-MS internal standard – run 1. ESI, electrospray ionization; 1, aldosterone; 2, cortisone; 3, dehydro-epiandrosterone sulfate; 4, cortisol; 5, 21-deoxycortisol; 6, corticosterone; 7, dexamethasone; 8, 11-deoxycortisol; 9, androstenedione; 10, 11-deoxycorticosterone; 11, testosterone; 12, dehydroepiandrosterone; 13, 17-hydroxyprogesterone; 14, dihydrotestosterone; 15, progesterone.

Image Credit: Tecan

Summary

Early diagnosis of Cushing’s syndrome is critical to prevent potentially fatal complications. A reliable method for reducing the number of false positives in DSTs involves the simultaneous measurement of cortisol and dexamethasone levels, which can be accurately achieved using LC-MS/MS.

The LC-MS/MS method described in this article enables the simultaneous measurement of multiple analytes, such as cortisol, cortisone, and dexamethasone, in serum or plasma.

This analytical approach can provide clinical laboratories with a straightforward method for performing DSTs, and the commercially available kit can ensure consistent and dependable results.

References and further reading

Cushing’s syndrome [website]. National Institute of Diabetes and Digestive and Kidney Diseases 2018 (https://www.niddk.nih.gov/health-information/endocrine-diseases/cushings-syndrome).
Dogra P, Vijayashankar NP. Dexamethasone suppression test. StatPearls 2022, 8 August (https://www.ncbi.nlm.nih.gov/books/NBK542317 ).
Ceccato F, Artusi C, Barbot M, et al. Dexamethasone measurement during low-dose suppression test for suspected hypercortisolism: threshold development with and validation. J Endocrinol Invest 2020;43(8):1105–1113. doi: 10.1007/s40618-020-01197-6.
Roper SM. Yield of serum dexamethasone measurement for reducing false-positive results of low-dose dexamethasone suppression testing. J Appl Lab Med 2021;6(2):480–485. doi: 10.1093/jalm/jfaa193.
Fleseriu M, Auchus R, Bancos I, et al. Consensus on diagnosis and management of Cushing’s disease: a guideline update. Lancet Diabetes Endocrinol 2021;9(12):847–875. doi: 10.1016/S2213- 8587(21)00235-7.
Ponzetto F, Parasiliti-Caprino M, Settanni F, et al. Simultaneous measurement of cortisol, cortisone, dexamethasone and additional exogenous corticosteroids by rapid and sensitive LC-MS/MS analysis. Molecules 2022;28(1):248. doi: 10.3390/molecules28010248.

From https://www.news-medical.net/whitepaper/20240524/A-more-accurate-diagnosis-of-Cushinge28099s-syndrome.aspx

Filed under: Cushing's, Diagnostic Testing, symptoms | Tagged: cortisol, dexamethasone suppression test, diabetes, heart attack, stroke | Leave a comment »

Day 13, Cushing’s Awareness Challenge

Posted on April 13, 2024 by MaryO

Cushing’s Conventions have always been special times for me – we learn a lot, get to meet other Cushies, even get referrals to endos!

As early as 2001 (or before) my pituitary function was dropping. My former endo tested annually but did nothing to help me with the symptoms.

In the fall of 2002 my endo refused to discuss my fatigue or anything at all with me until I lost 10 pounds. He said I wasn’t worth treating in my overweight condition and that I was setting myself up for a heart attack. He gave me 3 months to lose this weight. Those 3 months included Thanksgiving, Christmas and New Years. Needless to say, I left his office in tears, again.

Fast forward 2 years to 2004. I had tried for a while to get my records from this endo. He wouldn’t send them, even at doctors’ or my requests.

I wanted to go see Dr. Vance at UVa but I had no records so she wouldn’t see me until I could get them.

Finally, my husband went to the former endo’s office and threatened him with a court order. The office manager managed to come up with about 13 pages of records. For going to him from 1986 to 2001 including weeks and weeks at NIH and pituitary surgery, that didn’t seem like enough records to me.

In April of 2004, many of us from the message boards went to the UVa Pituitary Days Convention. That’s where the picture above comes in. Other pictures from that convention are here.

By chance, we met a wonderful woman named Barbara Craven. She sat at our table for lunch on the last day and, after we learned that she was a dietitian who had had Cushing’s, one of us jokingly asked her if she’d do a guest chat for us. I didn’t follow through on this until she emailed me later. In the email, she asked how I was doing. Usually I say “fine” or “ok” but for some reason, I told her exactly how awful I was feeling.

Barbara emailed me back and said I should see a doctor at Johns Hopkins. I said I didn’t think I could get a recommendation to there, so SHE referred me. The doctor got right back to me, set up an appointment. Between his vacation and mine, that first appointment turned out to be Tuesday, Sept 14, 2004.

Just getting through the maze at Johns Hopkins was amazing. They have the whole system down to a science, moving from one place to another to sign in, then go here, then window 6, then… But it was very efficient.

My new doctor was wonderful. Understanding, knowledgeable. He never once said that I was “too fat” or “depressed” or that all this was my own fault. I feel so validated, finally.

He looked through my records, especially at my 2 previous Insulin Tolerance Tests (ITT). From those, he determined that my growth hormone has been low since at least August 2001 and I’ve been adrenal insufficient since at least Fall, 1999 – possibly as much as 17 years! I was amazed to hear all this, and astounded that my former endo not only didn’t tell me any of this, he did nothing. He had known both of these things – they were in the past records that I took with me. Perhaps that was why he had been so reluctant to share copies of those records. He had given me Cortef in the fall of 1999 to take just in case I had “stress” and that was it.

The new endo took a lot of blood (no urine!) for cortisol and thyroid stuff. I went back on Sept. 28, 2004 for arginine, cortrosyn and IGF testing.

He said that I would end up on daily cortisone – a “sprinkling” – and some form of GH, based on the testing the 28th.

For those who are interested, my new endo is Roberto Salvatori, M.D.
Assistant Professor of Medicine at Johns Hopkins

Medical School: Catholic University School of Medicine, Rome, Italy
Residency: Montefiore Medical Center
Fellowship: Cornell University, Johns Hopkins University
Board Certification: Endocrinology and Metabolism, Internal Medicine

Clinical Interests: Neuroendocrinology, pituitary disorders, adrenal disorders

Research Interests: Control of growth hormone secretion, genetic causes of growth hormone deficiency, consequences of growth hormone deficiency.

Although I have this wonderful doctor, a specialist in growth hormone deficiency at Johns Hopkins, in November, 2004, my insurance company saw fit to over-ride his opinions and his test results based on my past pharmaceutical history! Hello??? How could I have a history of taking GH when I’ve never taken it before?

Of course, I found out late on a Friday afternoon. By then it was too late to call my case worker at the drug company, so we had to appeal on Monday. My local insurance person also worked on an appeal, but the whole thing was just another long ordeal of finding paperwork, calling people, FedExing stuff, too much work when I just wanted to start feeling better by Thanksgiving.

As it turned out the insurance company rejected the brand of hGH that was prescribed for me. They gave me the ok for a growth hormone was just FDA-approved for adults on 11/4/04. The day this medication was approved for adults was the day after my insurance said that’s what is preferred for me. In the past, this form of hGH was only approved for children with height issues. Was I going to be a ginuea pig again?

The new GH company assigned a rep for me, submitted info to pharmacy, and waited for insurance approval, again.

I finally started the Growth Hormone December 7, 2004.

Was the hassle and 3 year wait worth it?

Stay tuned for April 15, 2016 when all will be revealed.

Read

Read Dr. Barbara Craven’s Guest Chat, October 27, 2004

Thanks for reading 🙂

Filed under: adrenal crisis, Cushing's, Meetings and Conferences, pituitary, symptoms, Treatments | Tagged: adrenal insufficiency, arginine, Barbara Craven, cortisol, cortrosyn, Cushing's Awareness Challenge 2016, Dr. Mary Lee Vance, Dr. Roberto Salvatori, fatigue, growth hormone, heart attack, insulin tolerance test, insurance, ITT, Johns Hopkins, MaryO, NIH, pituitary, surgery, weight | 3 Comments »

Endocrine Society experts call for expanded screening for primary aldosteronism

Posted on April 30, 2016 by MaryO

Washington, DC–The Endocrine Society today issued a Clinical Practice Guideline calling on physicians to ramp up screening for primary aldosteronism, a common cause of high blood pressure.

People with primary aldosteronism face a higher risk of developing cardiovascular disease and dying from it than other people with high blood pressure. As many as one in ten people with high blood pressure may have primary aldosteronism. Uncontrolled high blood pressure can put these individuals at risk for stroke, heart attack, heart failure or kidney failure.

The guideline, entitled “The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline,” was published online and will appear in the May 2016 print issue of The Journal of Clinical Endocrinology & Metabolism (JCEM), a publication of the Endocrine Society. The guideline updates recommendations from the Society’s 2008 guideline on primary aldosteronism.

“In the past eight years, we have come to recognize that primary aldosteronism, despite being quite common, frequently goes undiagnosed and untreated,” said John W. Funder, MD, PhD, of the Hudson Institute of Medical Research in Clayton, Australia, and chair of the task force that authored the guideline. “This is a major public health issue. Many people with primary aldosteronism are never screened due to the associated costs. Better screening processes are needed to ensure no person suffering from primary aldosteronism and the resulting risks of uncontrolled high blood pressure goes untreated.”

Primary aldosteronism occurs when the adrenal glands — the small glands located on the top of each kidney – produce too much of the hormone aldosterone. This causes aldosterone, which helps balance levels of sodium and potassium, to build up in the body. The resulting excess sodium can lead to a rise in blood pressure.

The Endocrine Society recommends primary aldosterone screening for people who meet one of the following criteria:

Those who have sustained blood pressure above 150/100 in three separate measurements taken on different days;
People who have hypertension resistant to three conventional antihypertensive drugs;
People whose hypertension is controlled with four or more medications;
People with hypertension and low levels of potassium in the blood;
Those who have hypertension and a mass on the adrenal gland called an adrenal incidentaloma;
People with both hypertension and sleep apnea;
People with hypertension and a family history of early-onset hypertension or stroke before age 40; and
All hypertensive first-degree relatives of patients with primary aldosteronism.

Other recommendations from the guideline include:

The plasma aldosterone-to-renin ratio (ARR) test should be used to screen for primary aldosteronism.
All patients diagnosed with primary aldosteronism should undergo a CT scan of the adrenal glands to screen for a rare cancer called adrenocortical carcinoma.
When patients choose to treat the condition by having one adrenal gland surgically removed, an experienced radiologist should take blood samples from each adrenal vein and have them analyzed. This procedure, called adrenal vein sampling, is the gold standard for determining whether one or both adrenal glands is producing excess aldosterone.
For people with primary aldosteronism caused by overactivity in one adrenal gland, the recommended course of treatment is minimally invasive surgery to remove that adrenal gland.
For patients who are unable or unwilling to have surgery, medical treatment including a mineralocorticoid receptor (MR) agonist is the preferred treatment option.

###

The Hormone Health Network offers resources on primary aldosteronism athttp://www.hormone.org/questions-and-answers/2012/primary-aldosteronism.

Other members of the Endocrine Society task force that developed this guideline include: Robert M. Carey, of the University of Virginia Health System in Charlottesville, VA; Franco Mantero of the University of Padova in Padua, Italy; M. Hassan Murad of the Mayo Clinic in Rochester, MN; Martin Reincke of the Klinikum of the Ludwig-Maximilians-University of Munich in München, Bavaria, Germany; Hirotaka Shibata of Oita University in Oita, Japan; Michael Stowasser of the University of Queensland in Brisbane, Australia; and William F. Young, Jr. of the Mayo Clinic in Rochester, MN.

The Society established the Clinical Practice Guideline Program to provide endocrinologists and other clinicians with evidence-based recommendations in the diagnosis and treatment of endocrine-related conditions. Each guideline is created by a task force of topic-related experts in the field. Task forces rely on evidence-based reviews of the literature in the development of guideline recommendations. The Endocrine Society does not solicit or accept corporate support for its guidelines. All Clinical Practice Guidelines are supported entirely by Society funds.

The Clinical Practice Guideline was co-sponsored by the American Heart Association, the American Association of Endocrine Surgeons, the European Society of Endocrinology, the European Society of Hypertension, the International Association of Endocrine Surgeons, the International Society of Hypertension, the Japan Endocrine Society and The Japanese Society of Hypertension.

The guideline was published online at http://press.endocrine.org/doi/10.1210/jc.2015-4061, ahead of print.

Endocrinologists are at the core of solving the most pressing health problems of our time, from diabetes and obesity to infertility, bone health, and hormone-related cancers. The Endocrine Society is the world’s oldest and largest organization of scientists devoted to hormone research and physicians who care for people with hormone-related conditions.

The Society, which is celebrating its centennial in 2016, has more than 18,000 members, including scientists, physicians, educators, nurses and students in 122 countries. To learn more about the Society and the field of endocrinology, visit our site at http://www.endocrine.org. Follow us on Twitter at @TheEndoSociety and @EndoMedia.

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.

From http://www.eurekalert.org/pub_releases/2016-04/tes-ese042616.php

Filed under: adrenal | Tagged: adrenal glands, heart attack, heart failure, high blood pressure, kidney failure, primary aldosteronism, stroke | Leave a comment »

Day Eleven, Cushing’s Awareness Challenge 2015

Posted on April 11, 2015 by MaryO

Cushing’s Conventions have always been special times for me – we learn a lot, get to meet other Cushies, even get referrals to endos!

As early as 2001 (or before) my pituitary function was dropping. My former endo tested annually but did nothing to help me with the symptoms.

Fast forward 2 years to 2004. I had tried for awhile to get my records from this endo. He wouldn’t send them, even at doctors’ or my requests.

I wanted to go see Dr. Vance at UVa but I had no records so she would’t see me until I could get them.

In April of 2004, many of us from the message boards went to the UVa Pituitary Days Convention. That’s where the picture above comes in. Other pictures from that convention are here.

By chance, we met a wonderful woman named

Read Barbara Craven. She sat at our table for lunch on the last day and, after we learned that she was a dietitian who had had Cushing’s, one of us jokingly asked her if she’d do a guest chat for us. I didn’t follow through on this until she emailed me later. In the email, she asked how I was doing. Usually I say “fine” or “ok” but for some reason, I told her exactly how awful I was feeling.

My new doctor was wonderful. Understanding, knowledgeable. He never once said that I was “too fat” or “depressed” or that all this was my own fault. I feel so validated, finally.

He looked through my records, especially at my 2 previous Insulin Tolerance Tests. From those, he determined that my growth hormone has been low since at least August 2001 and I’ve been adrenal insufficient since at least Fall, 1999 – possibly as much as 10 years! I was amazed to hear all this, and astounded that my former endo not only didn’t tell me any of this, he did nothing. He had known both of these things – they were in the past records that I took with me. Perhaps that was why he had been so reluctant to share copies of those records. He had given me Cortef in the fall of 1999 to take just in case I had “stress” and that was it.

The new endo took a lot of blood (no urine!) for cortisol and thyroid stuff. I went back on Sept. 28, 2004 for arginine, cortrosyn and IGF testing.

He said that I would end up on daily cortisone – a “sprinkling” – and some form of GH, based on the testing the 28th.

For those who are interested, my new endo is Roberto Salvatori, M.D.
Assistant Professor of Medicine at Johns Hopkins

Clinical Interests: Neuroendocrinology, pituitary disorders, adrenal disorders

Research Interests: Control of growth hormone secretion, genetic causes of growth hormone deficiency, consequences of growth hormone deficiency.

The new GH company assigned a rep for me, submitted info to pharmacy, and waited for insurance approval, again.

I finally started the Growth Hormone December 7, 2004.

Was the hassle and 3 year wait worth it?

Stay tuned for tomorrow, April 12, 2015 when all will be revealed.

Read

Read Dr. Barbara Craven’s Guest Chat, October 27, 2004

Thanks for reading 🙂

Filed under: Cushing's, Interview, Meetings and Conferences, pituitary, Treatments | Tagged: adrenal insufficiency, arginine, cortisol, cortrosyn, Cushing's Awareness Challenge 2015, Dr. Mary Lee Vance, Dr. Roberto Salvatori, fatigue, growth hormone, heart attack, insurance, Johns Hopkins, MaryO, NIH, pituitary, surgery, weight | Leave a comment »

	38 Years Cushing… on In Memory: Edward H. Oldfield,…
	Voices from the Past… on Looking at your Doctor’s…
	Basics: Meds: Recorl… on FDA Approval for Endogenous Cu…
	What’s on Your Med… on Medical ID Jewelry Often Lacks…
	Day 26, Cushing’s Aw… on Day 6: Cushing’s Awareness Cha…

CushieBlog

Translate to…

Recent Posts

Enjoying the Free Content?

Recent Comments

Categories

Cushings on Facebook

Meta

A More Accurate Diagnosis of Cushing’s Syndrome

The symptoms of Cushing’s syndrome