Adrenal Hyperfunction (Cushing Syndrome) Testing

Click here for topics associated with this algorithm INDICATIONS FOR TESTING Suspected Cushing Syndrome (Central obesity, muscle weakness, refractory hypertension)

Rule out Metabolic Syndrome or Polycystic Ovarian Syndrome

Cortisol Urine Free by LC-MS/MS

OR

Cortisol, Saliva (tested at midnight)

no

>60 g/day male >45 g/day female

yes

0.112 g/dL

<0.112 g/dL

normal

Repeat Cortisol Urine Free by LC-MS/MS

Repeat Cortisol, Saliva (tested at midnight)

normal

normal

>60 g/day male >45 g/day female Cushing Syndrome likely

0.112 g/dL

normal Cushing Syndrome unlikely; no further testing

Cushing Syndrome unlikely; no further testing

Low dose dexamethasone suppression test (DST) protocol: 1 mg dexamethasone PO (taken between 11 pm and 12 am) Then measure at 8 am the following morning: Cortisol, Serum or Plasma (or Cortisol Urine Free by LC-MS/MS)

no Adrenocorticotropic Hormone <5 pg/mL <200 pg/mL

Urine cortisol <7.2 g/day or serum cortisol <10 g/day

yes, (normal)

Cushing Syndrome unlikely; however, If high suspicion, repeat with high dose DST (4 mg taken between 11 p.m. and midnight) over 2 days AND Cortisol, Serum or Plasma

200 pg/mL

Serum Cortisol <10 g/day

ACTH independent Cushing Syndrome, adrenal MRI of adrenal glands

ACTH dependent Cushing Syndrome, pituitary

Ectopic ACTH

no

yes (normal) Cushing Syndrome unlikely, no further testing

MRI of pituitary gland

Tumor visualized

No tumor visualized

Bilateral inferior petrosal sinus sampling; petrosal ACTH ratio to serum ACTH after administering corticotropin stimulation (obtain samples pre and post) pre >2:1 post >3:1 Cushing Syndrome, pituitary No gradient in pre and post samples

Pituitary adenoma

Ectopic ACTH producing tumor

www.arupconsult.com

2006-2009 ARUP Laboratories. All Rights Reserved. Revised 11/2/2009