Is There Value in Routine Screening for Cushing's Syndrome in Patients with Diabetes?

Journal of Clinical Endocrinology & Metabolism , doi:10.1210/jc.2009-2453

K. Mullan, N. Black, A. Thiraviaraj, P. M. Bell, C. Burgess, S. J. Hunter, D. R. McCance, H. Leslie, B. Sheridan,  and A. B. Atkinson*

Regional Centre for Endocrinology and Diabetes (K.M., N.B., A.T., P.M.B., S.J.H., D.R.M., A.B.A.), and Regional Endocrine Laboratory (C.B., H.L., B.S.), Royal Victoria Hospital, Belfast BT12 6BA, United Kingdom

* To whom correspondence should be addressed. E-mail: brew.atkinson@belfasttrust.hscni.net..

Context: Subclinical Cushing's syndrome has been described among diabetic populations in recent years, but no consensus has emerged about the value of screening.

Methods: We enrolled 201 consecutive patients attending our diabetes clinic and 79 controls. Patients with at least two of the following three criteria were offered screening using a 2300 h salivary cortisol test: glycosylated hemoglobin of at least 7%, body mass index of at least 25 kg/m2, and a history of hypertension or blood pressure of at least 140/90 mm Hg. Results are expressed as mean ± SEM.

Results: Mean nighttime salivary cortisol levels were similar in the two groups (8.5 ± 1.0 nmol/liter for diabetic patients vs. 5.8 ± 1.0 nmol/liter for controls). Forty-seven patients (23%) had a value of at least 10 nmol/liter, which was set as a conservative threshold above which further investigation would be performed. Thirty-five (75%) agreed to further testing with a 1-mg overnight dexamethasone test. Of the remaining 12 patients, 10 were followed up clinically for at least 1 yr, and no evidence was found of the syndrome evolving. In 28 patients, serum cortisol suppressed to 60 nmol/liter or less. Of the seven patients who failed this test, four agreed to a 2 mg/d 48-h dexamethasone test, with serum cortisol suppressing to 60 nmol/liter or less in all four. Three declined this test but had normal 24-h urinary free cortisol levels. No patient had clinical features of hypercortisolism.

Conclusions: The 1–3% detection rates of three recently published series have not been realized at our center where we studied a group using criteria making patients more likely to have hypercortisolism. Our results do not support the validity of screening patients without clinical features of Cushing's syndrome in the diabetes clinic.

http://jcem.endojournals.org/cgi/content/abstract/jc.2009-2453v1