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cardio.hypertensive-emergency.cushing-syndrome.v1

Cushing syndrome HTN crisis (cortisol-excess–driven severe HTN with hypokalemic alkalosis)

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Detailed

Cushing syndrome HTN crisis = supraphysiologic cortisol → mineralocorticoid receptor activation (saturates 11β-HSD2) + RAAS + α-adrenergic upregulation → severe HTN + hypokalemia + metabolic alkalosis + hyperglycemia. Pharmacology pivot: MR-blockade FIRST (spironolactone or eplerenone) + K replacement; nicardipine for acute crisis; AVOID isolated ACEi acutely (often borderline K + RAAS-driven); cortisol-lowering medical bridge (ketoconazole, metyrapone, osilodrostat, mifepristone, mitotane) if surgery delayed. Definitive: transsphenoidal pituitary adenectomy for Cushing disease (most common ACTH-dependent); adrenalectomy for adrenal source; ectopic resection for ectopic ACTH (most often SCLC / bronchial carcinoid). Route to parent engine for shared HTN-emergency arc; this dossier owns cortisol-specific pharmacology + biochemical dx + perioperative pathway.

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Cushing phenotype identified (clinical + biochemical screen positive)

Patient inputs (13)

Differentiates ACTH-dependent (Cushing disease pituitary, ectopic) vs ACTH-independent (adrenal); suppressed ACTH <5 pg/mL = adrenal source

Localization — pituitary MRI for ACTH-dependent (60-70% identifiable), CT/MRI adrenal for ACTH-independent

Younger Cushing more often pituitary (Cushing disease, F:M ~3:1); older with rapid onset + cachexia suggests ectopic ACTH (SCLC) or adrenal carcinoma

Hypokalemia (K <3.5, often <3.0) is hallmark of severe cortisol excess — drives MR-blockade + replacement strategy; also drives AVOID-ACEi caution

Metabolic alkalosis (HCO3 >28) from K wasting + H+ secretion — supports MR activation

Cortisol → insulin resistance + gluconeogenesis → hyperglycemia, often DKA-like presentations in ectopic Cushing

24h urinary free cortisol — primary screening test (Endocrine Society 2008 PMID 18334580); 2 measurements ≥3× ULN diagnostic

Loss of diurnal rhythm — high midnight salivary cortisol confirms; sensitive screen

1 mg overnight DST — failure to suppress cortisol <1.8 mcg/dL confirms autonomous cortisol secretion

Renal function for nicardipine, MRA, K replacement, contrast for imaging

Defines crisis threshold; cortisol-driven HTN often sustained 200+ with diastolic prominence

Sustained DBP >110 typical in cortisol excess due to RAAS + MR activation

α-adrenergic upregulation may produce mild tachy; bradycardia rare

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Severity triggers (5)

5 need judgement
  • informationallife_threateningcushing_with_opportunistic_infection_PJP_or_fungal
    Cushing patient with severe hypercortisolism (UFC >1000 mcg/24h or 4× ULN) develops fever, hypoxia, infiltrate — opportunistic infection (PJP, CMV, aspergillosis, candidemia) from cortisol immunosuppression
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcushing_with_HHS_or_severe_hyperglycemic_emergency
    Cushing crisis + glucose >600 mg/dL + osmolality >320 + altered mental status → hyperglycemic hyperosmolar state from cortisol-induced extreme insulin resistance
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningectopic_ACTH_secreting_tumor_with_metastatic_disease
    Ectopic ACTH from SCLC, bronchial carcinoid, MTC, pheo — metastatic at presentation with severe Cushing crisis + hypokalemia <2.5 + cachexia
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpituitary_apoplexy_in_known_adenoma
    Cushing disease patient with known pituitary macroadenoma develops sudden severe headache + visual field defect + altered mental status + hypopituitarism — pituitary apoplexy (hemorrhagic infarct of adenoma)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_cushing_psychiatric_crisis_suicide_risk
    Cushing patient with new psychosis, severe depression, mania, or suicidal ideation — psychiatric symptoms in 50-80% Cushing, suicide risk elevated
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Cushing syndrome HTN crisis — MR-blockade FIRST (spironolactone or eplerenone) + K replacement + nicardipine; cortisol-lowering bridge (ketoconazole, metyrapone, osilodrostat, mifepristone, mitotane) for surgical bridge
axis: cushing_syndrome_MR_blockade_and_cortisol_lowering
Selected axis "Cushing syndrome HTN crisis — MR-blockade FIRST (spironolactone or eplerenone) + K replacement + nicardipine; cortisol-lowering bridge (ketoconazole, metyrapone, osilodrostat, mifepristone, mitotane) for surgical bridge" by default fallback (first axis)
  • nicardipine
    first line
    DHP_CCB
    5 mg/h IV titrate by 2.5 mg/h q5-15 min, max 15 mg/h • IV • continuous
    triggers: cushing_crisis_acute_HTN
    ACC/AHA 2025 — predictable titration; safe in Cushing with renal involvement; CCB preferred acute
    rxcui 7396
  • spironolactone
    first line
    mineralocorticoid_receptor_antagonist
    25-50 mg PO daily, titrate to 100-400 mg/d • PO • daily
    triggers: cushing_crisis_with_hypokalemia, cushing_HTN_with_MR_activation
    Endocrine Society 2008/2015 (PMID 18334580/26222757) — blocks MR activation by cortisol; addresses K wasting + HTN simultaneously; gynecomastia limit (use eplerenone if concern)
    rxcui 9997
  • eplerenone
    first line
    mineralocorticoid_receptor_antagonist_selective
    25-50 mg PO daily, titrate to 100-200 mg/d • PO • daily or BID
    triggers: cushing_HTN_with_gynecomastia_concern, spironolactone_intolerant
    Selective MR antagonist — no androgen receptor blockade → no gynecomastia; less potent than spironolactone, requires higher doses; PATHWAY-2 PMID 26414968 demonstrated MRA efficacy in resistant HTN
    rxcui 298869
  • potassium chloride
    first line
    electrolyte_replacement
    KCl IV 10-20 mEq/h via central line if K <3 (peripheral max 10 mEq/h); KCl PO 40-80 mEq divided • IV + PO • continuous IV or QID PO
    triggers: cushing_crisis_with_hypokalemia_K_below_3.5
    Severe hypokalemia from cortisol-driven K wasting; replace to ≥3.5 with continuous ECG monitoring
    rxcui 8591
  • magnesium sulfate
    add on
    electrolyte_replacement
    2-4 g IV load + 1-2 g/h infusion • IV • continuous
    triggers: cushing_crisis_with_hypomagnesemia, arrhythmia_risk_torsades
    Mg almost always coexisting low; refractory hypokalemia without Mg correction; Torsades prophylaxis
    rxcui 6585
  • ketoconazole
    second line
    cortisol_synthesis_inhibitor_imidazole
    200 mg PO TID, titrate to 400-1200 mg/d divided • PO • TID-QID
    triggers: cushing_medical_bridge_to_surgery, cushing_refractory_or_unresectable
    Endocrine Society 2015 (PMID 26222757) — CYP17 + CYP11B inhibitor; rapid cortisol-lowering; HEPATOTOXICITY (monitor LFTs weekly initial then monthly); QT prolongation; CYP3A4 interactions
    rxcui 6135
  • metyrapone
    second line
    cortisol_synthesis_inhibitor_11beta
    250 mg PO QID, titrate to 500-1000 mg q6h • PO • QID
    triggers: cushing_medical_bridge, ketoconazole_intolerant_or_hepatic
    Endocrine Society 2015 — 11β-hydroxylase inhibitor; rapid effect; can cause hirsutism + hypoadrenalism; alternative when ketoconazole hepatic concern
    rxcui 6923
  • osilodrostat
    second line
    cortisol_synthesis_inhibitor_11beta_aldosterone
    2 mg PO BID, titrate q2 wk to max 30 mg BID • PO • BID
    triggers: cushing_disease_medical_bridge, cushing_refractory_after_pituitary_surgery
    LINC-3 trial (Fleseriu Lancet Diabetes Endocrinol 2019 PMID 31523029) — newer 11β-hydroxylase inhibitor + aldosterone synthase inhibitor; FDA approved Cushing disease 2020; hyperandrogenism + adrenal insufficiency monitor
    rxcui 2286252
  • mifepristone
    second line
    glucocorticoid_receptor_antagonist
    300 mg PO daily, titrate to 600-1200 mg/d • PO • daily
    triggers: cushing_with_hyperglycemia_or_diabetes_T2D, cushing_unresectable
    FDA approved (Korlym) for Cushing-induced hyperglycemia; SEEKING-2 trial; cortisol levels rise (GR antagonism not synthesis inhibition) — cannot use cortisol to titrate; symptom-based + glucose-based titration; HYPOKALEMIA worsens (need MRA + K)
    rxcui 6964
  • mitotane
    second line
    adrenolytic
    0.5 g PO BID titrate to 4-8 g/d (target plasma 14-20 mg/L) • PO • BID-TID
    triggers: adrenocortical_carcinoma, refractory_cushing_pre-bilateral-adrenalectomy
    Endocrine Society 2015 — adrenolytic agent specific for adrenocortical carcinoma; slow onset (weeks); GI + neuro toxicity; mandatory cortisol replacement during therapy; long terminal half-life
    rxcui 7004
  • AVOID isolated ACEi/ARB acutely
    contraindication substitute
    do_not_use
    AVOID • N/A • N/A
    triggers: cushing_with_borderline_potassium_below_3.5
    Cushing patients have aldosterone-like activity but renin-suppressed RAAS → ACEi alone less effective; coexisting hypokalemia + risk of hyperK if MRA also added → start MRA + K replacement first, then ACEi/ARB once K stable
  • STOP exogenous glucocorticoid (taper if iatrogenic)
    first line
    discontinue_offending_agent
    Taper (do not stop abruptly — adrenal suppression risk) • PO/inhaled/topical • taper
    triggers: exogenous_cushing_iatrogenic
    Iatrogenic Cushing from chronic supraphysiologic GC — taper with stress-dose coverage during illness; CRH-stim or AM cortisol to confirm HPA recovery before full stop

outpatient playbook — drug actions (5)

  1. 1. continue physiologic GC if HPA not recovered
    rxcui 5492
    Hydrocortisone 15-25 mg/d divided BID (or prednisone 5 mg AM) • PO • BID
    trigger: HPA suppression (failed ACTH stim)
    Endocrine Society 2015 — physiologic until HPA recovery confirmed
  2. 2. BP regimen if essential HTN persists
    rxcui 17767
    Amlodipine 5-10 mg ± lisinopril 10-20 mg ± chlorthalidone 12.5 mg • PO • daily
    trigger: Persistent HTN
    ACC/AHA 2025 — legacy CV risk Pivonello 2016 PMID 26142020
  3. 3. statin for ASCVD risk reduction
    rxcui 83367
    Atorvastatin 40-80 mg PO daily • PO • daily
    trigger: Elevated ASCVD risk post-Cushing
    AHA/ACC 2018 lipid guideline; Cushing legacy increases ASCVD
  4. 4. metformin for residual insulin resistance
    rxcui 6809
    500-2000 mg/d divided BID • PO • BID
    trigger: A1c >7 or insulin resistance persists
    ADA 2026 first-line for T2D
  5. 5. bisphosphonate for osteoporosis
    rxcui 40790
    Alendronate 70 mg PO weekly OR zoledronate 5 mg IV yearly • PO/IV • weekly/yearly
    trigger: T-score ≤-2.5 OR fragility fracture
    Cushing-induced osteoporosis often persists post-cure

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Cushingoid phenotype (moon facies, dorsocervical fat pad, central obesity, purple striae, proximal myopathy, easy bruising) + severe HTN (Newell-Price Lancet 2006 PMID 16713505); Severe hypokalemia (K <3.0) + metabolic alkalosis + HTN — high-cortisol or ectopic ACTH suspicion; Chronic supraphysiologic glucocorticoid exposure (prednisone ≥7.5 mg ≥3 wk, dexamethasone, megestrol, intra-articular/inhaled high-dose) — exogenous Cushing.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cushing syndrome HTN crisis (cortisol-excess–driven severe HTN with hypokalemic alkalosis)** (cardio.hypertensive-emergency.cushing-syndrome.v1).
Scope: Cushing syndrome HTN crisis = supraphysiologic cortisol → mineralocorticoid receptor activation (saturates 11β-HSD2) + RAAS + α-adrenergic upregulation → severe HTN + hypokalemia + metabolic alkalosis + hyperglycemia. Pharmacology pivot: MR-blockade FIRST (spironolactone or eplerenone) + K replacement; nicardipine for acute crisis; AVOID isolated ACEi acutely (often borderline K + RAAS-driven); cortisol-lowering medical bridge (ketoconazole, metyrapone, osilodrostat, mifepristone, mitotane) if surgery delayed. Definitive: transsphenoidal pituitary adenectomy for Cushing disease (most common ACTH-dependent); adrenalectomy for adrenal source; ectopic resection for ectopic ACTH (most often SCLC / bronchial carcinoid). Route to parent engine for shared HTN-emergency arc; this dossier owns cortisol-specific pharmacology + biochemical dx + perioperative pathway.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cushing syndrome HTN crisis — MR-blockade FIRST (spironolactone or eplerenone) + K replacement + nicardipine; cortisol-lowering bridge (ketoconazole, metyrapone, osilodrostat, mifepristone, mitotane) for surgical bridge**.
1. nicardipine 5 mg/h IV titrate by 2.5 mg/h q5-15 min, max 15 mg/h IV continuous (DHP_CCB, first line) — ACC/AHA 2025 — predictable titration; safe in Cushing with renal involvement; CCB preferred acute
2. spironolactone 25-50 mg PO daily, titrate to 100-400 mg/d PO daily (mineralocorticoid_receptor_antagonist, first line) — Endocrine Society 2008/2015 (PMID 18334580/26222757) — blocks MR activation by cortisol; addresses K wasting + HTN simultaneously; gynecomastia limit (use eplerenone if concern)
3. eplerenone 25-50 mg PO daily, titrate to 100-200 mg/d PO daily or BID (mineralocorticoid_receptor_antagonist_selective, first line) — Selective MR antagonist — no androgen receptor blockade → no gynecomastia; less potent than spironolactone, requires higher doses; PATHWAY-2 PMID 26414968 demonstrated MRA efficacy in resistant HTN
4. potassium chloride KCl IV 10-20 mEq/h via central line if K <3 (peripheral max 10 mEq/h); KCl PO 40-80 mEq divided IV + PO continuous IV or QID PO (electrolyte_replacement, first line) — Severe hypokalemia from cortisol-driven K wasting; replace to ≥3.5 with continuous ECG monitoring
5. magnesium sulfate 2-4 g IV load + 1-2 g/h infusion IV continuous (electrolyte_replacement, add on) — Mg almost always coexisting low; refractory hypokalemia without Mg correction; Torsades prophylaxis
6. ketoconazole 200 mg PO TID, titrate to 400-1200 mg/d divided PO TID-QID (cortisol_synthesis_inhibitor_imidazole, second line) — Endocrine Society 2015 (PMID 26222757) — CYP17 + CYP11B inhibitor; rapid cortisol-lowering; HEPATOTOXICITY (monitor LFTs weekly initial then monthly); QT prolongation; CYP3A4 interactions
7. metyrapone 250 mg PO QID, titrate to 500-1000 mg q6h PO QID (cortisol_synthesis_inhibitor_11beta, second line) — Endocrine Society 2015 — 11β-hydroxylase inhibitor; rapid effect; can cause hirsutism + hypoadrenalism; alternative when ketoconazole hepatic concern
8. osilodrostat 2 mg PO BID, titrate q2 wk to max 30 mg BID PO BID (cortisol_synthesis_inhibitor_11beta_aldosterone, second line) — LINC-3 trial (Fleseriu Lancet Diabetes Endocrinol 2019 PMID 31523029) — newer 11β-hydroxylase inhibitor + aldosterone synthase inhibitor; FDA approved Cushing disease 2020; hyperandrogenism + adrenal insufficiency monitor
9. mifepristone 300 mg PO daily, titrate to 600-1200 mg/d PO daily (glucocorticoid_receptor_antagonist, second line) — FDA approved (Korlym) for Cushing-induced hyperglycemia; SEEKING-2 trial; cortisol levels rise (GR antagonism not synthesis inhibition) — cannot use cortisol to titrate; symptom-based + glucose-based titration; HYPOKALEMIA worsens (need MRA + K)
10. mitotane 0.5 g PO BID titrate to 4-8 g/d (target plasma 14-20 mg/L) PO BID-TID (adrenolytic, second line) — Endocrine Society 2015 — adrenolytic agent specific for adrenocortical carcinoma; slow onset (weeks); GI + neuro toxicity; mandatory cortisol replacement during therapy; long terminal half-life
11. AVOID isolated ACEi/ARB acutely AVOID N/A N/A (do_not_use, contraindication substitute) — Cushing patients have aldosterone-like activity but renin-suppressed RAAS → ACEi alone less effective; coexisting hypokalemia + risk of hyperK if MRA also added → start MRA + K replacement first, then ACEi/ARB once K stable
12. STOP exogenous glucocorticoid (taper if iatrogenic) Taper (do not stop abruptly — adrenal suppression risk) PO/inhaled/topical taper (discontinue_offending_agent, first line) — Iatrogenic Cushing from chronic supraphysiologic GC — taper with stress-dose coverage during illness; CRH-stim or AM cortisol to confirm HPA recovery before full stop

Setting playbook (outpatient) — Lifelong endocrine surveillance — annual UFC + ACTH for recurrence (10-15% Cushing disease at 10 y); cardiovascular risk reassessment (legacy CV risk persists); bone density q1-2 y; HPA recovery monitoring with ACTH stim test until physiologic; mood/psych follow-up; diabetes/lipid management
13. continue physiologic GC if HPA not recovered Hydrocortisone 15-25 mg/d divided BID (or prednisone 5 mg AM) PO BID — HPA suppression (failed ACTH stim) (Endocrine Society 2015 — physiologic until HPA recovery confirmed)
14. BP regimen if essential HTN persists Amlodipine 5-10 mg ± lisinopril 10-20 mg ± chlorthalidone 12.5 mg PO daily — Persistent HTN (ACC/AHA 2025 — legacy CV risk Pivonello 2016 PMID 26142020)
15. statin for ASCVD risk reduction Atorvastatin 40-80 mg PO daily PO daily — Elevated ASCVD risk post-Cushing (AHA/ACC 2018 lipid guideline; Cushing legacy increases ASCVD)
16. metformin for residual insulin resistance 500-2000 mg/d divided BID PO BID — A1c >7 or insulin resistance persists (ADA 2026 first-line for T2D)
17. bisphosphonate for osteoporosis Alendronate 70 mg PO weekly OR zoledronate 5 mg IV yearly PO/IV weekly/yearly — T-score ≤-2.5 OR fragility fracture (Cushing-induced osteoporosis often persists post-cure)

Non-pharmacologic actions:
- Annual endocrine visit
- Cardiology if cardiomyopathy or persistent HTN
- Mental health follow-up (mood + cognition)
- Genetics if young/syndromic (MEN1, Carney complex, McCune-Albright)
- Family screening if syndromic
- Pre-anesthesia alert (stress-dose GC if HPA suppressed)
- Patient education on recurrence symptoms

AVOID / contraindication checks:
- Spironolactone_avoid_eGFR_below_30_or_K_above_5 (KDIGO 2024)
- Eplerenone_avoid_eGFR_below_30_or_K_above_5_or_severe_hepatic
- Ketoconazole_monitor_LFTs_weekly_initially_then_monthly (FDA black box hepatotoxicity)
- Ketoconazole_QT_prolongation_check_baseline_ECG_avoid_with_other_QT_drugs
- Mifepristone_pregnancy_category_X (abortifacient — contraception mandatory)
- Mifepristone_cortisol_levels_uninterpretable_for_titration (use clinical + glucose)
- Mitotane_adrenal_insufficiency_mandatory_GC_replacement_during_therapy
- K_replacement_via_central_line_if_above_10_mEq_per_hour_peripheral_max
- Avoid_thiazide_alone_in_cushing (worsens hypokalemia)

Monitoring

Regimen monitoring:
- continuous ECG during acute crisis and K replacement (Torsades risk)
- q4-6h K Mg glucose during acute crisis (hourly during IV K replacement)
- q12-24h BMP during oral titration
- weekly LFTs first month then monthly on ketoconazole or osilodrostat
- q6-12h cortisol during metyrapone osilodrostat titration (target mid-normal)
- daily weight BP during admission
- morning cortisol postop day 1-3 (remission marker if <1.8 mcg/dL)
- hydrocortisone replacement postop with taper to physiologic 15-25 mg per day
- annual UFC for recurrence (10-15% at 10 yr Cushing disease)
- annual ACTH stim test until HPA recovery (6-18 mo typical)
- DEXA bone density yearly + osteoporosis treatment
- annual cardiovascular risk reassessment (legacy CV risk persists years after cure — Pivonello 2016 PMID 26142020)

Setting (outpatient) monitoring:
- Annual UFC + ACTH + AM cortisol
- Annual cardiometabolic + BP + glucose + lipid
- DEXA q1-2 y
- Pituitary MRI annual × 2-3 y then per indicators

Follow-up plan: Postop morning cortisol day 1-3 (suppression to <1.8 mcg/dL = remission); if <5 — physiologic hydrocortisone replacement 15-25 mg/d divided BID (or 10/5 split); follow ACTH stim test annually until HPA recovery (usually 6-18 mo); annual UFC + ACTH for recurrence (10-15% recurrence at 10 years for Cushing disease); cardiovascular risk reassessment (cardiometabolic legacy effect persists years after cure); bone density DEXA + osteoporosis treatment; psychiatric follow-up (mood symptoms slow recovery); diabetes management (often resolves but chronic GI insulin resistance may persist)
- Close-out criterion: biochemical remission confirmed + glucocorticoid replacement plan + lifelong endocrine surveillance booked

Monitoring phase: Continuous ECG (hypokalemia Torsades risk); q4-6h K, Mg, glucose during acute crisis; daily LFTs if on ketoconazole; q6-12h cortisol if on metyrapone or osilodrostat (titrate to mid-normal); daily weight + BP; postop monitoring for ADRENAL INSUFFICIENCY (after pituitary or unilateral adrenal surgery — contralateral often suppressed) → IV hydrocortisone 100 mg IV → 50 mg q6h taper; monitor glucose normalization

Disposition

Current setting: outpatient — Lifelong endocrine surveillance — annual UFC + ACTH for recurrence (10-15% Cushing disease at 10 y); cardiovascular risk reassessment (legacy CV risk persists); bone density q1-2 y; HPA recovery monitoring with ACTH stim test until physiologic; mood/psych follow-up; diabetes/lipid management

Disposition criteria:
- Long-term continuation; cross-link to cardio.htn.core.v1 if persistent essential HTN; cross-link to endo.osteoporosis if bone disease

Escalation triggers (move to higher acuity):
- Recurrent symptoms → urgent UFC + DST + imaging
- Adrenal crisis intercurrent illness → IV hydrocortisone + ED
- New cushingoid changes → re-eval for recurrence

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Cushing patient with severe hypercortisolism (UFC >1000 mcg/24h or 4× ULN) develops fever, hypoxia, infiltrate — opportunistic infection (PJP, CMV, aspergillosis, candidemia) from cortisol immunosuppression
- [LIFE_THREATENING] Cushing crisis + glucose >600 mg/dL + osmolality >320 + altered mental status → hyperglycemic hyperosmolar state from cortisol-induced extreme insulin resistance
- [LIFE_THREATENING] Ectopic ACTH from SCLC, bronchial carcinoid, MTC, pheo — metastatic at presentation with severe Cushing crisis + hypokalemia <2.5 + cachexia

Citations

- Endocrine Society 2008 Cushing Syndrome Diagnosis CPG (Nieman JCEM 2008 PMID 18334580) + 2015 Treatment CPG (Nieman JCEM 2015 PMID 26222757) + 2025 ACC/AHA HTN (Whelton) [PMID:18334580](https://pubmed.ncbi.nlm.nih.gov/18334580/)
- Cited evidence (PMID 26222757) [PMID:26222757](https://pubmed.ncbi.nlm.nih.gov/26222757/)
- Cited evidence (PMID 26142020) [PMID:26142020](https://pubmed.ncbi.nlm.nih.gov/26142020/)
- Cited evidence (PMID 26004339) [PMID:26004339](https://pubmed.ncbi.nlm.nih.gov/26004339/)
- Cited evidence (PMID 16713505) [PMID:16713505](https://pubmed.ncbi.nlm.nih.gov/16713505/)

Last reconciled with current guidelines: 2026-05-15.
References
  • Endocrine Society 2008 Cushing Syndrome Diagnosis CPG (Nieman JCEM 2008 PMID 18334580) + 2015 Treatment CPG (Nieman JCEM 2015 PMID 26222757) + 2025 ACC/AHA HTN (Whelton) — PMID:18334580
  • Cited evidence (PMID 26222757) — PMID:26222757
  • Cited evidence (PMID 26142020) — PMID:26142020
  • Cited evidence (PMID 26004339) — PMID:26004339
  • Cited evidence (PMID 16713505) — PMID:16713505