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In endogenous Cushing’s syndrome of any cause, there is a failure of this suppression when low doses of the syn- thetic glucocorticoid dexamethasone are given (78).
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Theovernighttestisasimpleoutpatienttest.Variousdosesof dexamethasone have been used, but 1 mg dexamethasone is usu- ally given between 2300 and 2400 h, and cortisol is measured between 0800 and 0900 h the following morning.
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Higher doses (1.5or2mg)donotsignificantlyimprovetheaccuracyofthetest (49). Researchers have used cutoff values for the suppression of serum cortisol from 3.6 to 7.2  g/dl (100–200 nmol/liter) when measured by modern RIA (79).
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A widely cited normal response is a serum cortisol less than 5  g/dl (  140 nmol/liter) (7, 80). Because some patients with Cushing’s disease demonstrate sup- pressibility to dexamethasone, use of this diagnostic criterion J Clin Endocrinol Metab, May 2008, 93(5):1526–1540 jcem.endojournals.org 1533 Downloaded from h...
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misclassified up to 15% of such patients as negative (81, 82). Therefore,toenhancesensitivity,expertshaveadvocatedrequir- ing a lower cutoff for suppression of the postdexamethasone serum cortisol to less than 1.8  g/dl (50 nmol/liter) to achieve sensitivityratesofgreaterthan95%(83).Atthe1.8  g/dlcutoff, the sensitiv...
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Given our objective of using tests with high sensitivity at this stage, we recommend use of the more stringent cutoff of 1.8  g/dl. Overall, the evidence in adults indicates that in studies with low prevalence of Cushing’s syndrome this test has similar per- formance as the others recommended for initial testing (2).
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Al- though the 1-mg overnight test is used as a screening test for pediatric patients, there are no specific data regarding its inter- pretation or performance in this population. 3.4.3 Remarks for the 1-mg DST See the earlier comments under 3.4 Remarks for dexamethasone tests .
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3.4.4 Evidence for the 48-h, 2 mg/d DST Some endocrinologists prefer to use the 48-h, 2 mg/d low-dose DST(LDDST)asaninitialtestbecauseofitsimprovedspecificity as compared with the 1-mg test.
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With adequate written instruc- tions for the patient, the LDDST is easily performed in the out- patient setting. As described above ( Section 1.0 ), certain psychiatric condi- tions (depression, anxiety, obsessive compulsive disorder), mor- bid obesity, alcoholism, and diabetes mellitus can be character- ized by overac...
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hypercortisolism is not autonomous. In these conditions, UFC measurements are less useful as an initial test. The optimal test is the LDDST. Previous studies using var- ious doses of dexamethasone and differing criteria for suppres- sion suggest that at least 2 wk of abstinence from alcohol are needed to reduce the fal...
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First described by Liddle (85) in 1960, the LDDST initially evaluated urinary 17OHCS as an indicator of cortisol suppres- sion. However, using 17OHCS or UFC, sensitivity and specific- ity rates are less than 70–80%.
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Use of a serum cortisol end point is simpler and has higher diagnostic accuracy (78). With a cutoff value for suppression of 50 nmol/liter (1.8  g/ dl), the initially reported sensitivity was greater than 95% for adultpatients(86).Withthisapproach,thesensitivityforCushing’s syndrome in 36 pediatric patients was 94% (8...
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Subsequent reports showed lower diagnostic accuracy of the LDDST (7, 88–90). Overall, in 92 patients without Cushing’s syndrome, the specificity of the LDDST was 70% (95% confi- dence interval 69–87%). In 59 patients with Cushing’s syn- drome, sensitivity was 96% for the LDDST (91).
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The reasons for this apparent decrease in specificity are unknown. Serum dexa- methasone levels were not evaluated; in healthy volunteers, dexamethasone levels 2 h after the last dose were 13.0  6.1  mol/liter (469.5  220.4  g/dl) (92).
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Consequently, the overall evidence in adults indicates that this test has similar or slightly less diagnostic accuracy than the other tests recommended here for initial testing (2). 3.4.4 Remarks for the 48-h, 2 mg/d DST In addition to the general remarks on dexamethasone tests pre- sented in the Initial testing sectio...
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at 0900, 1500, 2100, and 0300 h. Serum cortisol is measured at 0900 h, 6 h after the last dose of dexamethasone. Yanovski et al. (9) proposed a different protocol:
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administering 48 h of dexameth- asone at 6-h intervals but beginning at 1200 h and obtaining serum cortisol at 0800 h, exactl y 2 h (rather than 6 h as in the usual protocol) after the last dexamethasone dose.
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For pediatric patients weighing more than 40 kg, the initial adult protocol described above and the adult threshold for nor- mal suppression [  50 nmol/liter (1.8  g/dl)] are used.
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For pa- tients weighing less than 40 kg, the dose is adjusted to 30  g/kg  d (in divided doses) (87). 3.5 Evidence The diagnostic accuracy of various other tests previously advo- cated for the diagnosis of Cushing’s syndrome (urinary 17-ke- tosteroids,1600horotherrandomcortisollevels,andtheinsulin tolerance test) is ...
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Other tests, such as the loperamide test, have insufficient evi- dence for their diagnostic accuracy. The response to those tests used specifically to establish the cause of Cushing’s syndrome ( e.g.
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pituitary, adrenal or thoracic imaging, plasma ACTH con- centration, CRH stimulation test, 8 mg dexamethasone suppres- sion test) may be both abnormal in healthy people and normal in patients with Cushing’s syndrome and therefore are not helpful in establishing the diagnosis (78).
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3.6–3.8 Evidence Our recommendations for retesting patients with initially nor- mal test results who develop new or progressive signs or symp- toms of Cushing’s syndrome comes from the panel’s clinical ob- servations and relate to the recognition that the patient’s pretest probability of Cushing’s syndrome would be hig...
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Similarly, the recommendation to retest patients with sus- pected cyclic Cushing’s syndrome comes from the recognition that these individuals may have normal test results when the disorder is quiescent (93).
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The performance and interpretation of subsequent testing for Cushing’s syndrome requires considerable expertise (both in the clinic and in the laboratory) and may be followed by either com- plex testing to establish its cause and surgical treatments or ex- pert reassurance of patients that they do not have this conditi...
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Because of this, it is the panel’s observation that referral to en- docrinology centers with expertise and interest in Cushing’s syn- drome in patients with abnormal initial testing is likely to be associated with better patient outcomes.
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1534 Nieman et al. Guidelines for the Diagnosis of Cushing’s Syndrome J Clin Endocrinol Metab, May 2008, 93(5):1526–1540 Downloaded from https://academic.oup.com/jcem/article/93/5/1526/2598096 by University of Wisconsin System user on 20 February 2026
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The recommendation to perform additional testing in pa- tients with discordant results derives from the knowledge that some patients with Cushing’s syndrome, usually those with mild or cyclic disease, may have discordant results.
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Also, some pa- tients without Cushing’s syndrome may have only a minimally abnormal but discordant result. The distinction between these groupsisdifficult,andthereisnoonecorrectdiagnosticstrategy.
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The test results’ validity should be evaluated in light of the ca- veats mentioned for specific patient situations and for each test and assay. For example, an abnormal UFC may not be accepted if the specimen volume and creatinine suggest overcollection.
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Underlying disorders that may cause mild hypercortisolism (Ta- ble 2) should be considered and testing repeated when these are treated or resolved. Postponing additional testing to allow pro- gression of clinical and biochemical features may be useful.
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The patient should be reassured that this poses minimal risk in the setting of mild hypercortisolism. Subsequent evaluation 3.8 For the subsequent evaluation of abnormal test results from one of the high-sensitivity tests, we recommend performing an- other recommended test (Fig.
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1, 1 QEEE ). 3.8.1 We suggest the additional use of the dexamethasone- CRHtestorthemidnightserumcortisoltestinspecificsituations (Fig. 1, 1 QEEE ).
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3.8.2 We suggest against the use of the desmopressin test, exceptinresearchstudies,untiladditionaldatavalidateitsutility (2 QEEE ). 3.8.3 We recommend against any further testing for Cush- ing’s syndrome in individuals with concordantly negative results on two different tests (except in patients suspected of having the...
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3.8.4 We recommend tests to establish the cause of Cushing’s syndrome in patients with concordantly positive results from two different tests, provided there is no concern regarding pos- sible non-Cushing’s hypercortisolism (Table 2) (1 QQEE ). 3.8.5Wesuggestfurtherevaluationandfollow-upforthefew patients with concorda...
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3.8 Remarks If the initial test result is abnormal, further evaluation by an endocrinologist will ensure that the disorder is confirmed or re- futed and that the possibility of a false-positive result will be considered.
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Conversely, in cases in which there is a high pretest proba- bility of Cushing’s syndrome but a normal initial test, use of an additional alternative test has the potential benefit of disclosing those with milder disease.
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3.8.1 Evidence for the 48-h, 2 mg/d LDDST with CRH In an effort to improve the sensitivity of the 48-h, 2 mg/d test, researchers developed a combined CRH stimulation test.
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In the- ory, dexamethasone suppresses serum cortisol levels in individ- uals without Cushing’s syndrome as well as a small number of those with Cushing’s disease, but if given CRH, patients with Cushing’s disease should respond with an increase in ACTH and cortisol.
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The test is done by administering the 48-h 2 mg/d DST, followedbyadministrationofCRH(1  g/kg,iv )2hafterthelast dose of dexamethasone.
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Cortisol is measured 15 min later. The initial report of this strategy showed high diagnostic ac- curacy (92, 94). All eight of 59 patients with proven Cushing’s disease who suppressed pre-CRH cortisol to less than 1.4  g/dl (  38 nmol/liter; sensitivity 86%) were properly characterized after CRH administration.
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Subsequent reports showed lower diagnostic accuracy of both the DST and the combined test (7, 88–90). Overall, in 92 patients without Cushing’s syndrome, the specificity of the LDDST was 70% (95% confidence interval 69–87%), com- pared with a 60% specificity for the dexamethasone-CRH test (95% confidence interval 59–79...
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The reasons for the differences in the responses to the LDDST and the combined test are not clear. As discussed above, any dexamethasone test may give either false-positive or false-neg- ativeresultsinconditionsthatalterthemetabolicclearanceofthe agent; additionally, differences in the performance of cortisol assays ma...
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3.8.1 Remarks for the dexamethasone-CRH test The dexamethasone-CRH test can be useful in patients with equivocal results for UFC.
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A dexamethasone level should be measured at the time of CRH administration to exclude a false- positive result, and the serum cortisol assay must be accurate at these low levels of detection.
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Additionally, it is possible that the 2-h time interval between dexamethasone and CRH administra- tion is critical so that compliance must be assured. In the United States, ovine-sequence CRH is available com- mercially (ACTHREL; Ferring Corp., Malmo, Sweden) with Food and Drug Administration-approved labeling for the ...
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In Europe, the hu- man-sequence peptide is in widespread use (Ferring) but has lower stimulatory effect than the ovine-sequence CRH (95). 3.8.1 Evidence for the midnight serum cortisol test As noted above, the nocturnal nadir of serum cortisol values is lost in patients with Cushing’s syndrome, forming the basis of thi...
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Because the test is cumbersome to perform, we do not suggest its use in initial testing for Cushing’s syndrome. How- ever, the test may be useful in specific situations detailed below.
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Midnightserumcortisolmaybeassessedinthesleepingorawake state, using different diagnostic criteria. As with all tests, use of a higher diagnostic criterion is associated with reduced sensitiv- ity but increased specificity.
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Sleeping midnight serum cortisol In one study, a single sleeping serum cortisol greater than 1.8  g/dl (  50 nmol/liter) had high sensitivity (100%) for the di- agnosis of Cushing’s syndrome (96).
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More recent larger studies confirm the poor specificity for this criterion (20.2%), with a cutoff point of 7.5  g/dl having higher specificity (87%) (7). J Clin Endocrinol Metab, May 2008, 93(5):1526–1540 jcem.endojournals.org 1535 Downloaded from https://academic.oup.com/jcem/article/93/5/1526/2598096 by University o...
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In 105 children with Cushing’s syndrome, measurement of sleepingmidnightcortisolhadhighersensitivitythanUFC(99 vs. 88%) (30). When used in patients with a high clinical index of suspicion of Cushing’s syndrome and who had normal UFC and full sup- pression on dexamethasone testing, a sleeping midnight serum cortisol of ...
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The midnight serum cortisoltestalsohasutilityinthecontextoffailureofsuppression on dexamethasone testing due to anticonvulsant medication, in which a sleeping midnight serum cortisol less than 1.8  g/dl has been used to exclude Cushing’s syndrome (97).
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It is likely that similar values for awake measurements would have similar util- ity, but this has not been tested directly. Overall, the evidence in adult patients for the midnight serum cortisol accuracy is limited and inconsistent across studies, with at least one study showing that this test can enhance the accurac...
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Awake midnight serum cortisol Sampling for midnight serum cortisol when the patient is awake is far easier. Initial studies suggested that an awake midnight serum cortisol greater than 7.5  g/dl (  207 nmol/liter) had a sensitivity and specificity greater than 96% (98, 99).
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However, when applied to an obese cohort, the specificity was only 83% (100). In an effort to improve on specificity, higher cutoff points have been advocated, inevitably at the cost of sensitivity:
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values of serum midnight cortisol greater than 8.3–12  g/dl had 90– 92% sensitivity with specificity of 96% (63, 101). 3.8.1 Remarks for the midnight serum cortisol test The sleeping midnight cortisol requires inpatient admission for a period of 48 h or longer to avoid false-positive responses due tothestressofhospita...
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If a sleeping value is desired, the blood sample must be drawn within 5–10 min of waking the patient, or through an indwelling line, to avoid false-positive results (96).
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Young children may have their cortisol nadir earlier than midnight. In children, precatheterization is essential so that a sleeping sample for serum cortisol can be obtained. 3.8.2 Remarks for the desmopressin stimulation test The desmopressin stimulation test involves measurement of plasma ACTH just before and 10, 20,...
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In general, patients with Cushing’s disease show an increase in ACTH, but those with other causes of Cushing’s syndrome or those without Cushing’s syndrome do not respond (7, 22, 102).
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The sensitivity for patients with Cushing’s disease was 82–87%; whenotherpatientswithCushing’ssyndromewereincluded,the sensitivity was 63–75%.
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The specificity ranged from 85 to 91%. Until additional data validate the utility of the test in a larger population of patients with all causes of Cushing’s syndrome, it seems prudent to restrict this test to research studies.
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4.0 Special populations/considerations 4.1 Pregnancy: We recommend the use of UFC and against the useofdexamethasonetestingintheinitialevaluationofpregnant women (1 QQQE ).
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4.2 Epilepsy: We recommend against the use of dexamethasone testing in patients receiving antiepileptic drugs known to en- hance dexamethasone clearance and recommend instead mea- surements of nonsuppressed cortisol in blood, saliva, or urine (1 QQQE ).
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4.3 Renal failure: We suggest using the 1-mg overnight DST rather than UFC for initial testing for Cushing’s syndrome in patients with severe renal failure (2 QEEE ).
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4.4 Cyclic Cushing’s syndrome: We suggest use of UFC or mid- night salivary cortisol tests rather than DSTs in patients sus- pected of having cyclic Cushing’s syndrome (2 QEEE ).
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4.5 Adrenal incidentaloma: We suggest use of the 1-mg DST or late-night cortisol test, rather than UFC in patients suspected of having mild Cushing’s syndrome (2 QQEE ).
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4.1 Evidence for choice of tests in pregnant women Screening for hypercortisolism is more difficult in pregnancy, particularly in the second and third trimesters. UFC excretion is normal in the first trimester; however, it increases up to 3-fold by term to overlap values seen in women with Cushing’s syndrome (103).
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Thus, only UFC values in the second or third trimester greater than 3 times the upper limit of normal can be taken to indicate Cushing’s syndrome. Serum cortisol circadian variation is preserved in normal pregnancy, albeit with a higher midnight nadir. Whereas loss of circadian variation is characteristic of Cushing’s ...
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Furthermore,suppressionofserumandurinarycortisolbydexa- methasone is blunted in pregnancy (105). Thus, dexamethasone testing has an increased potential for false-positive results in pregnancy.
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4.2 Evidence for choice of tests in patients receiving anticonvulsants As discussed above (see 3.4 Remarks for dexamethasone tests ), commonly used anticonvulsant medications, including phenyt- oin, phenobarbitone, and carbamazepine, induce hepatic enzy- matic clearance of dexamethasone, mediated through CYP 3A4, and m...
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There are, however, no data to guide the length of time needed after with- drawal of such medication to allow dexamethasone metabolism to return to normal, and such a medication change may not be clinically possible.
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Switching to nonenzyme-inducing medica- tion may correct this situation, but an alternative and more prac- tical approach is to use another test, such as assessment of mid- night salivary or serum cortisol, to exclude Cushing’s syndrome in these patients (97).
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4.3 Evidence for choice of tests in chronic renal failure As noted above (see 3.4.1), excreted urine cortisol values de- creasebelowcreatinineclearanceof60ml/minandarequitelow, 1536 Nieman et al.
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Guidelines for the Diagnosis of Cushing’s Syndrome J Clin Endocrinol Metab, May 2008, 93(5):1526–1540 Downloaded from https://academic.oup.com/jcem/article/93/5/1526/2598096 by University of Wisconsin System user on 20 February 2026
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below 20 ml/min (53). Although the cortisol circadian rhythm was present in one study, neither serum nor salivary midnight cortisol concentrations have been reported in this population (106 However, serum free cortisol values measured over a 24-h period were reported to be elevated (106). As a result, a normal (low) mi...
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0dde4803c18edcb0d433fee0a17afc09bf5e608252159ddb82343bdd3c7928b7
Responses to administration of 3 and 8 mg dexamethasone were normal in some but not all patients (106, 108). In the absence of additional data, a normal response to 1 mg dexamethasone is likely to ex- clude Cushing’s syndrome, but an abnormal response is not diagnostic. 4.4 Evidence for choice of tests in cyclic Cushin...
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Because the DST results may be normal in patients who are cycling out of hyper- cortisolism, these tests are not recommended for patients sus- pected of having cyclic disease. Instead, measurement of UFC or salivary cortisol may best demonstrate cyclicity. In patients for whom clinical suspicion is high but initial tes...
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6317b5f50e9e681cc846c72460e7ac988cabb00cfc1040010c3b7a033ceb08c9
Measurement of ACTH or dehydroepi- androsteronesulfateisnotpartofinitialdiagnosticevaluationof a patient presenting with clinical features of Cushing’s syn- drome, but it may indicate subtle adrenal hyperfunction in this specific population. 5. Future directions and recommended research The evidence on which many of th...
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authorities/insurance companies for such use would be important. 3. Improved clinical outcome data and targeted clinical trials . Initial testing for hypercortisolism may be desirable to the extent that its results will favorably affect outcomes that matter to pa- tients.Thereisapressingneedtoinvestigateoutcomesinpatie...
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33ca849b11d763aea6089973e8a2b09b91ad6e1d3ce4dfd2a417210898ad38af
Services. E-mail: societyservices@endo-society.org. J Clin Endocrinol Metab, May 2008, 93(5):1526–1540 jcem.endojournals.org 1537 Downloaded from https://academic.oup.com/jcem/article/93/5/1526/2598096 by University of Wisconsin System user on 20 February 2026
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Disclaimer Statement Clinical practice guidelines are developed to be of assistance to physi- cians by providing guidance and recommendations for particular areas of practice. The guidelines should not be considered inclusive of all proper approaches or methods, or exclusive of others. The guidelines cannot guarantee a...
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Position: none declared; * Victor M. Montori , M.D.— Financial or Business/Organizational Interests: none declared, Signifi- cant Financial or Leadership Position: none declared. *Evidence-based reviews for this guideline were prepared under contract with The Endo- crine Society. References 1. Atkins D, Best D, Briss P...
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P, Schmidt K, Weeke J 2001 Incidence and late prognosis of Cushing’s syndrome: a popu- lation-based study. J Clin Endocrinol Metab 86:117–123 6. Nugent CA, Warner HR, Dunn JT, Tyler FH 1964 Probability theory in the diagnosis of Cushing’s syndrome. J Clin Endocrinol Metab 24:621–627 7. Pecori Giraldi F, Pivonello R, Am...
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12. Plotz CM, Knowlton AI, Ragan C 1952 The natural history of Cushing’s syndrome. Am J Med 13:597–614 13. Swearingen B, Biller BM, Barker 2nd FG, Katznelson L, Grinspoon S, Kli- banski A, Zervas NT 1999 Long-term mortality after transsphenoidal sur- gery for Cushing disease. Ann Intern Med 130:821–824 14. ColaoA,Pivon...
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SJ, Nieman LK 2000 Cortisolemic indices predict severe infections in Cushing syndrome due to ectopic production of adrenocortico- tropin. J Clin Endocrinol Metab 85:42–47 20. Reincke M 2000 Subclinical Cushing’s syndrome. Endocrinol Metab Clin North Am 29:43–56 21. Terzolo M, Reimondo G, Bovio S, Angeli A 2004 Subclini...
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1085 27. Samaras K, Pett S, Gowers A, McMurchie M, Cooper DA 2005 Iatrogenic Cushing’s syndrome with osteoporosis and secondary adrenal failure in hu- man immunodeficiency virus-infected patients receiving inhaled corticoste- roids and ritonavir-boosted protease inhibitors: six cases. J Clin Endocrinol Metab 90:4394–43...
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