Treatment of Abnormal Cortisol Levels

Hypercortisolism (Cushing Syndrome)

The National Comprehensive Cancer Network recommends surgical resection via transsphenoidal surgery as the first-line treatment for pituitary tumors (Cushing's disease) 1, 2
For ectopic ACTH-producing tumors, surgical removal of the primary tumor is recommended when possible 1
Bilateral laparoscopic adrenalectomy is an option for unresectable primary tumors 1
Medical management with adrenostatic agents, such as ketoconazole (400-1200 mg/day), is a treatment option for hypercortisolism 1, 2
Mitotane is another option for medical management, particularly for adrenal carcinoma 1
Octreotide can be considered for ectopic Cushing syndrome if the tumor is Octreoscan-positive 1

The Journal of Clinical Oncology recommends glucocorticoid replacement with hydrocortisone 15-25 mg daily in divided doses for primary adrenal insufficiency 3
Mineralocorticoid replacement with fludrocortisone (0.05-0.1 mg/day) is recommended for primary adrenal insufficiency, adjusted based on volume status, sodium level, and renin response 3
Glucocorticoid replacement with hydrocortisone 15-20 mg daily in divided doses is recommended for secondary adrenal insufficiency 4

The Journal of Clinical Oncology recommends stress dosing for illness or physical stress, with an increase in glucocorticoid dose (typically 2-3 times maintenance dose) 3
Regular follow-up of clinical symptoms and electrolytes is recommended 3
For functioning tumors, follow-up imaging and biomarkers every 3-6 months is recommended 2
A medical alert bracelet or necklace is recommended for patients with adrenal insufficiency 3
Education on steroid stress dosing and emergency injections is crucial for patients with adrenal insufficiency 3
Failure to recognize adrenal crisis can be life-threatening and requires immediate treatment with IV hydrocortisone and fluid resuscitation 3