Approach to the Patient with Cushing's Syndrome: Use of Anticoagulation Therapy

There is an increased awareness on the higher hypecoagulability risks in patients with Cushing's syndrome (CS), but management remains controversial. Here, we present 4 illustrative cases of CS that exemplify some "grey areas" on venous thromboembolism (VTE) prevention-when to start, how long to continue, what to use, and when to stop. The cases span the initiation of prophylaxis at diagnosis of active CS, periprocedural management around inferior petrosal sinus sampling, perioperative prophylaxis after transsphenoidal surgery (TSS), and discontinuation decisions in medically controlled disease. We synthesize current evidence and expert practice and recommend considering low-molecular-weight heparin at diagnosis of active CS, continuing through surgery, and extending for approximately 3 months after biochemical remission in selected patients to address the highest-events risk window. Based on recent data, we discourage routine use of graduated compression stockings (GCS) for VTE prevention. Though bleeding complications appear uncommon, they need to be carefully considered on an individualized basis. Finally, scenarios where prophylaxis can be safely discontinued once eucortisolaemia is achieved are outlined. This case-anchored framework translates heterogeneous data into actionable guidance and highlights priorities for prospective evaluation.