Navigating Hypercortisolism Management in 2026 - Episode 1
Rethinking “Rare” Cushing Syndrome: Hypercortisolism in Difficult-to-Control Diabetes
In this introductory segment, Richard Auchus, MD, and Ralph DeFronzo, MD, frame hypercortisolism as an underrecognized driver of difficult-to-control type 2 diabetes, hypertension, and osteoporosis, challenging the traditional view of Cushing syndrome as a rare disorder.
This segment opens with Richard Auchus, MD, introducing a contemporary HCP-focused discussion on hypercortisolism management and positioning Ralph DeFronzo, MD, as an expert voice at the intersection of diabetes and endocrine disease. Dr Auchus explains that, like hypothyroidism, Cushing syndrome was historically considered rare when clinicians recognized only the most florid phenotypes. With broader awareness and more sensitive testing, milder forms of hypercortisolism are now being identified more frequently, particularly in patients with complex metabolic disease. This changing landscape requires a recalibration of when and in whom to suspect cortisol excess.
Drawing on his long-standing endocrine and diabetes practice, Dr DeFronzo notes that he has seen very few patients with classic Cushing syndrome—the archetypal phenotype with a “buffalo hump,” moon facies, wide violaceous striae, and pronounced proximal muscle weakness. However, he emphasizes that current experience shows something quite different: a substantial subset of patients with very difficult-to-control type 2 diabetes, obesity, and hypertension harbor clinically important hypercortisolism that is not overtly obvious. These patients often present through metabolic, not overtly endocrine, pathways, and therefore pass under the radar unless clinicians are attuned to the possibility of cortisol excess.
Both Dr Auchus and Dr DeFronzo highlight additional features that should prompt suspicion of hypercortisolism in this context. Osteoporosis and low-trauma fractures—particularly in patients with obesity and diabetes who would not typically be expected to have poor bone density—are underscored as key red flags. Depression is also common in Cushing syndrome but is less discriminating because of its high prevalence among patients with diabetes and obesity. The faculty argue that hypercortisolism should not be reserved in clinicians’ minds for rare, extreme cases; rather, it is a practical and potentially modifiable contributor to refractory metabolic disease in 2026.
