What is the patient's cortisol level?

From the Guidelines

Elevated cortisol levels are indicative of Cushing's syndrome, and testing cortisol levels can be done through blood, saliva, or 24-hour urine collection, with 24-hour urine collection recommended if cortisol levels are elevated 1.

Importance of Cortisol Testing

Cortisol is a steroid hormone produced by the adrenal glands that helps regulate metabolism, reduce inflammation, and assist with stress response. Normal cortisol levels typically follow a diurnal pattern, being highest in the morning and lowest at night.

Diagnostic Approach

Abnormally high cortisol may indicate Cushing's syndrome, while low levels could suggest Addison's disease.

• Testing cortisol levels can be done through:
  • Blood
  • Saliva
  • 24-hour urine collection
• 24-hour urine collection is recommended if cortisol levels are elevated 1

Treatment and Management

Lifestyle factors like chronic stress, poor sleep, and certain medications can affect cortisol levels. Managing stress through regular exercise, adequate sleep, mindfulness practices, and a balanced diet can help maintain healthy cortisol levels.

• If diagnosed with a cortisol imbalance, treatment will depend on the underlying cause and may include:
  • Medication
  • Lifestyle changes
  • Surgery in some cases
• For patients with primary adrenal insufficiency, the recommended daily dose of hydrocortisone is 15-25 mg, taken in split doses, with the first dose immediately after waking and the last dose not less than 6 hours before bedtime 1

Recent Guidelines

Recent guidelines suggest that the high-dose (250-μg) ACTH stimulation test is superior to other existing diagnostic tests to establish the diagnosis of primary adrenal insufficiency, with peak cortisol levels below 18 μg/dl indicating adrenal insufficiency 1

From the FDA Drug Label

Approximately 8 hours after administration of Metopirone, evaluate the values of ACTH and 11-desoxycortisol Normal values will depend on the method used to determine ACTH and 11‑desoxycortisol levels. An intact HPA axis function is generally indicated by an increase in 11‑desoxycortisol to over 70 mcg/L.

The cortisol level is not directly measured by the Metopirone test, but rather the level of 11-desoxycortisol, a precursor to cortisol.

• The test evaluates the ability of the adrenal glands to respond to the blockage of cortisol production by Metopirone.
• An increase in 11-desoxycortisol to over 70 mcg/L indicates an intact HPA axis function 2. However, the test does not provide a direct measurement of cortisol levels.

From the Research

Cortisol Level Overview

• Cortisol is a hormone that plays a vital role in the body's response to stress, regulating blood sugar levels, and aiding in the metabolism of fat, protein, and carbohydrates.
• Abnormal cortisol levels can lead to various health issues, including Cushing's syndrome and adrenal insufficiency.

Cushing's Syndrome and Cortisol Levels

• Cushing's syndrome is a condition characterized by excess cortisol levels in the body, which can be caused by a variety of factors, including prolonged use of corticosteroid medications, a benign tumor on the pituitary gland, or a tumor on the adrenal gland 3.
• The estimated incidence of Cushing's syndrome due to endogenous overproduction of cortisol ranges from 2 to 8 per million people annually 3.
• Studies have shown that metyrapone, a steroidogenesis inhibitor, can be an effective treatment for Cushing's syndrome, reducing cortisol levels and improving clinical symptoms 4, 5.

Diagnosing Adrenal Insufficiency

• Adrenal insufficiency is a condition where the adrenal glands do not produce enough cortisol, which can be life-threatening if left untreated.
• A morning serum cortisol level >13 mcg/dL can reliably rule out adrenal insufficiency, while levels ≤13 mcg/dL require further evaluation with the cosyntropin stimulation test (CST) 6.

Treatment Options for Cushing's Syndrome

• Treatment for Cushing's syndrome typically involves surgery to remove the source of excess cortisol production, followed by medication to control cortisol levels 3.
• Combination therapy with mitotane, metyrapone, and ketoconazole can be an effective alternative to bilateral adrenalectomy in patients with severe ACTH-dependent Cushing's syndrome 7.
• Metyrapone has been shown to be effective in reducing cortisol levels and improving clinical symptoms in patients with Cushing's syndrome, with a rapid onset of action and sustained efficacy over time 4, 5.