Amir Hamrahian, MD

In this episode, ‘Screening and Diagnosis of Hypercortisolism in Type 2 Diabetes,’ the panelists explore the clinical features that should raise suspicion for underlying hypercortisolism in patients with type 2 diabetes and discuss practical approaches to screening and diagnosis in endocrinology practice. The expert faculty emphasize that many manifestations of hypercortisolism overlap with common metabolic conditions, making identification particularly challenging in this patient population. They explain how clinicians can look beyond traditional metabolic risk factors and focus on additional signs that may indicate cortisol excess.

Screening and Diagnosis of Hypercortisolism in Type 2 Diabetes

Throughout the discussion, the panel of experts highlights the importance of recognizing catabolic features such as proximal muscle weakness, sarcopenia, osteoporosis, fragility fractures, delayed wound healing, and characteristic skin findings. They also examine neurocognitive symptoms, including depression, memory impairment, and cognitive decline, as well as cardiovascular indicators such as resistant hypertension, hypokalemia, and thromboembolic events. The faculty stress that these findings may serve as important clues when evaluating patients with difficult-to-control diabetes who do not fit the expected clinical picture.

The conversation also addresses the diagnostic evaluation of suspected hypercortisolism and reviews commonly used first-line screening tests. Panelists discuss the role of the overnight dexamethasone suppression test, late-night salivary cortisol measurements, and 24-hour urinary free cortisol collection, including practical considerations for test administration and interpretation. They emphasize the importance of proper patient preparation and awareness of factors that can influence results. By combining clinical insight with practical diagnostic guidance, the panel provides a framework for identifying patients who may benefit from further evaluation and highlights the importance of maintaining a high index of suspicion for hypercortisolism in individuals with type 2 diabetes.

The next episode in this series, ‘Interpreting Screening and Diagnostic Tests in Hypercortisolism,’ features the panelists discussing how to evaluate and interpret commonly used screening tests for hypercortisolism while accounting for potential confounding factors and false-positive results. The panel of experts also explores strategies for confirmatory testing, managing discordant findings, and applying clinical judgment throughout the diagnostic process.

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Welcome back to another HCP Live Peer Exchange series. In this episode titled, ‘Prevalence and Recognition of hypercortisolism’, expert faculty discuss the growing body of evidence highlighting the prevalence of hypercortisolism in patients with type 2 diabetes (T2D) and explore why the condition may be more common than previously recognized. The panel reviews data suggesting that while overt hypercortisolism may affect a small percentage of patients with T2D, rates increase substantially when evaluating individuals with so-called hidden hypercortisolism, particularly among those with difficult-to-control diabetes despite optimized treatment.

Prevalence and Recognition of Hypercortisolism

Throughout the discussion, the panel of experts examines recent findings demonstrating abnormal dexamethasone suppression test responses in patients with poorly controlled T2D, resistant hypertension, and other metabolic complications. They explore how these observations are reshaping clinical understanding of hypercortisolism and prompting greater consideration of cortisol excess in patient populations that may not exhibit classic signs or symptoms of the disease.

The faculty also discuss which patient groups are most likely to be underrecognized in clinical practice, including individuals with refractory diabetes and resistant hypertension who continue to experience poor outcomes despite multiple therapeutic interventions. Panelists emphasize that many patients with hypercortisolism do not present with the traditional cushingoid features commonly described in medical training, making recognition particularly challenging.

By examining evolving prevalence data and discussing real-world clinical experience, the panel highlights the importance of looking beyond traditional phenotypic presentations to identify patients who may benefit from further evaluation for hypercortisolism. The discussion underscores the need for heightened awareness and consideration of cortisol excess in patients with difficult-to-manage metabolic disease.

In the next episode, ‘Screening and Diagnosis of Hypercortisolism in Type 2 Diabetes’, panelists will continue their discussion on hypercortisolism and highlight the clinical features that may raise suspicion for cortisol excess in patients with type 2 diabetes. The panel of experts will also review common screening and diagnostic approaches used in endocrinology practice and discuss practical considerations for identifying patients who may benefit from further evaluation.

Amir Hamrahian, MD

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