Is Hypercortisolism Treatable? Which Patients Should Be Treated and How-A Practical Guide for Clinicians

Area of Science:

• Endocrinology
• Internal Medicine
• Metabolic Disorders

Background:

• Endogenous hypercortisolism is an endocrine disorder characterized by excessive cortisol production.
• It is associated with significant cardiometabolic morbidity, including hypertension and type 2 diabetes.
• Adrenal incidentalomas are common and may harbor autonomous cortisol secretion.

Purpose of the Study:

• To guide clinicians on suspecting and diagnosing endogenous hypercortisolism.
• To outline the appropriate use of the overnight 1-mg dexamethasone suppression test (DST) for case-finding.
• To identify patient groups most likely to benefit from treatment.

Main Methods:

• A narrative review synthesizing evidence from clinical practice guidelines, prevalence studies, RCTs, systematic reviews, and meta-analyses.
• Focus on patients with treatment-resistant type 2 diabetes, resistant hypertension, and adrenal incidentalomas.
• Analysis of diagnostic strategies and management options.

Main Results:

• Endogenous hypercortisolism confirmed in 0.6%-3.4% of type 2 diabetes cohorts; higher in selected high-risk groups (approx. 25%).
• Mild autonomous cortisol secretion (MACS) is linked to increased hypertension, diabetes, adiposity, and mortality.
• Routine screening is not recommended; testing should target specific high-risk phenotypes and adrenal incidentalomas.

Conclusions:

• Accurate interpretation of diagnostic tests requires attention to timing, drug interactions, and physiological variations.
• Surgical resection offers the best chance for remission; medical therapies are available for non-surgical candidates.
• Management requires multidisciplinary follow-up to monitor for adrenal insufficiency and treatment side effects.