Richard Pratley, MD; Vivian Fonseca, MD, FRCP; Ralph DeFronzo, MD; Richard Auchus, MD, PhD; and Natalie Bellini, DNP, FNP, BC-ADM, CDCES, discuss how the groundbreaking CATALYST trial results revealed that approximately 25% of patients with difficult-to-control diabetes despite optimal medical management have hypercortisolism, representing a treatable cause of treatment-resistant diabetes that can be identified through simple dexamethasone suppression testing and managed with targeted therapies such as mifepristone or surgical intervention for adrenal adenomas.
Panelists discuss how the CATALYST trial results revealed a surprisingly high 25% prevalence of hypercortisolism in patients with difficult-to-control diabetes, fundamentally changing their approach to screening and recognizing this previously underdiagnosed condition affecting an estimated 1.2 million Americans.
Panelists discuss how hypercortisolism differs from classic Cushing syndrome and how 35% of patients in the CATALYST study had adrenal imaging abnormalities, emphasizing the importance of distinguishing between pituitary-dependent and adrenal-independent sources to guide appropriate treatment strategies.
Panelists discuss how the 1-mg dexamethasone suppression test has become the simple, first-line screening tool for hypercortisolism, replacing more complex tests such as salivary cortisol or 24-hour urine collections, with practical tips for implementation and patient education.
Panelists discuss how surgical removal of adrenal adenomas remains first-line treatment when feasible but that many patients require medical therapy due to bilateral disease, surgical ineligibility, or the chronic nature of pituitary Cushing syndrome, with high recurrence rates even after successful surgery.
Panelists discuss how medical management options include steroidogenesis inhibitors and glucocorticoid receptor antagonists such as mifepristone, with particular emphasis on managing the complex withdrawal symptoms and coordinating care across multiple comorbidities including diabetes, hypertension, and osteoporosis.
Panelists discuss how monitoring effectiveness requires tracking clinical parameters such as glucose and blood pressure rather than cortisol levels when using receptor antagonists while carefully managing expected adverse effects such as hypokalemia and the need for close glucose monitoring, especially in insulin-dependent patients.
Panelists discuss how the CATALYST study’s treatment phase results demonstrated that mifepristone significantly reduced hemoglobin A1C (HbA1C) level by 1.45% in patients with hypercortisolism and difficult-to-control diabetes while also reducing waist circumference and managing blood pressure effects.
Panelists discuss how the CATALYST study results can be applied to clinical practice by identifying patients on multiple diabetes medications who have poor control, emphasizing that this represents precision medicine for a specific population with an identifiable underlying cause.
Panelists discuss how new data show osilodrostat’s expanded FDA approval for Cushing syndrome demonstrates long-term efficacy in maintaining normal urinary-free cortisol levels, though careful dosing is required to avoid overtreatment and withdrawal symptoms.
Panelists discuss how monitoring patients on hypercortisolism treatments requires balancing safety (morning cortisol to avoid overtreatment) with efficacy (late-night salivary cortisol) while acknowledging the practical challenges and evolving best practices in this field.
Panelists discuss how future research should focus on understanding why hypercortisolism is becoming more prevalent, developing more specific treatments with fewer adverse effects, and determining optimal thresholds for circadian rhythm dysfunction and treatment duration.
Panelists discuss how their key takeaways emphasize the importance of having a high index of suspicion for hypercortisolism, implementing routine screening in appropriate patients and educating primary care physicians to recognize the “big 4” symptoms of difficult-to-treat diabetes, hypertension, obesity, and bone disease.
