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Diabetes, Endocrine and Obesity Branch, The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD, USA.
Copyright © 2018 Korean Endocrine Society
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
CONFLICTS OF INTEREST: HRA Pharma provided research funding to National Institutes of Health for investigation of metyrapone and mifepristone under a Cooperative Research and Development Agreement.
Test | Caveat | When can the test be used despite the caveat? | Verifying the result |
---|---|---|---|
All tests | May be falsely normal in a patient with cyclic Cushing's syndrome [1011] | If the pre-test probability is high based on history and physical examination, repeat testing at intervals or when patient feels worst. | Review caveats for each test below |
UFC | May be falsely increased with fluid intake >5 L/day [12] | If subjects reduce intake | Measure volume; if volume is high, ask about intake |
May be falsely increased or decreased with incorrect collection | Measure creatinine, which should be ± 15% from day to day; check volume | ||
Will be decreased in the setting of renal impairment [13] | Use with caution with GFR 30–50 mL/min: accept as valid only elevated values. | ||
1 mg DST | May be falsely normal in Cushing's disease patients, presumably because of slow drug metabolism [14] | Measure dexamethasone; if in range expected of an 8 mg dose, consider Cushing's disease | |
May be falsely abnormal in patients with elevated CBG (2° oral estrogen) or in those with fast metabolism of dexamethasone [8] | Fewest false positive results in patients not taking medications that interact with CYP3A4 [15] | Measure dexamethasone level; if low, increase dose to achieve correct level | |
Measure CBG; if high discontinue estrogen for 4–6 weeks | |||
Salivary cortisol | May be falsely abnormal in older men and women, and in hypertensive or diabetic patients [1617] | If used in these populations, consider accepting only normal results | |
May be falsely abnormal in individuals with variable sleeping times (e.g., shift workers) | If used in this population, consider accepting only normal results |
Condition | Factors affecting hypercortisolism |
---|---|
Exercise | Described in individuals exercising nearly daily at close to maximal VO2 [18] |
Hypothalamic amenorrhea | Described in women under stress or after weight loss [19] |
Pregnancy | Occurs in late second and third trimester [20] |
Uncontrolled diabetes | |
Sleep apnea | Seen in untreated subjects; remits with treatment [21] |
Pain | |
Alcoholism | Associated with increased UFC and abnormal DST [22] |
Psychiatric disorders | |
Stress | |
Extreme obesity |