Re: Adding the evaluation of Cushing's to the schema for PA. Seems like it should be added esp if there is an adrenal bump. or bumps.

[Guest guest]

I thought I posted this but I have been having trouble w/. I sent Dr.

Moraitis a message and here is his response. (His answer followed by my

question.):

In adrenal Cushing's, urine free cortisol is usually normal. It 's elevated only

in the advanced cases.

Have a good day

Dr Moraitis

On Mon, Apr 30, 2012 at 10:49 AM, <jclark24p@...> wrote:

So, I hope you are done goofing off and ready to go back to work! (No rush, I

have all DAY! )

I was looking through some of my prior tests from the VA this morning and found

a 24hr urine test done on Jan. 14, 2011:

CORTISOL FREE = 26.3, range 4.0-50.0 VOLUME = 2600 ML

Does this shed any light on the " masked cortisol " ? (I'm not sure if that

indicates it appeared in the last 15 months or not, but you're the doctor!)

> > >

> > > As our discussions of cortisol production have been stimulated by

> > the

> > > NIH experience I did a lit search and just found

> > >

> > > http://www.jabfm.org/content/25/2/199.full.pdf+html

> > >

> > > This article on subclinical Cushing's suggests that we need to add

> > the

> > > screening for CS to all with an adrenal adenoma or any suggestion

> > of ld > Cushig's: HTN,obesity, glucose intolearance etc etc.

> > >

> > > In other words everyone with HTN should be screened.

> > >

> > > So in my protocol for easy diagnosis I am adding to the 24 hr

> > urine a

> > > urinary free cortisol testing-which have have done in many but never

> > > found (or at last recognized) a subclinical Cushing's. These authors

> > > suggest that a UFC at the upper limit of normal should have further

> > > testing for Cushing's. Again I have never seen this in at least 100

> > > pts with Conn's I have tested over the years. But did not have ACTH

> > > levels then.

> > >

> > > It seems like we should also add a plasma cortisol and ACTH to the

> > > blood testing on the aldo day.

> > >

> > > They do not suggest doing a P aldo or a renin in every suspected

> > > Cushing's but I just sent them an email adding this to their

> > schema if

> > > the BP is above 120/80.

> > >

> > > If one looks at the evolution of PA the evolution of adrenal

> > Cushing's

> > > would be similar using urinary cortisol as the illustrative plot for

> > > urine changes in cortisol and the stages of Cushings would be the

> > same

> > > as I have for Conn's but the instead of renin going down we would be

> > > seeing ACTH going down and obesity/glucose intolerance increasing

> > over

> > > time.

> > >

> > > More later.

> > >

> > > CE Grim MD

> > >

> >

> >

>

[Guest guest]

And in a system that will pay for the testing.Val does a good job of finding labs locally that will do tests and she pays.This is always an option but have not costed out the Ideal Testing scheme cost.Perhaps someone can do this online at a lab site. So we would need the following:1. 24 hr urine for Na, K, creat, aldo, UFC and catecholamines What we do not know is the lower limit of UFC that we can say there is no possibility of Cushing's.2. Plasma renin, aldosterone, cortisol (time to do all of these best is not the same but has not been well studied) and ACTH.I am going to review data on using cortisol/ACTH ratio as a screen as we do aldo/renin. Makes good sense but may be no data published.3. Plasma electrolytes properly drawn and processed.Then figure cost of repeating any that are "abnormal" or inappropriate.Unfortunately now the on one we can medically Rx easily is PA. CE Grim MDOn Apr 30, 2012, at 2:22 PM, lvasiliu@... wrote: Yeap, Dr. Grim!! Kudos to you in seeing the similarities between these sister diseases (btw you've been doing this for, what 40y ..?)! But good luck to any PT comunicating with their young unexperienced endo about doing PA and Cushing's testing in parallel. I have tried, they say PA is very rare, Cushing's more so and they only go for the $$$$ making procedures not a simple 24h UFC for diagnosys. And I have also tried to convince my endo to do a saliva cortisol sampled 3-4 times/day to see the diurnal cortisol cycle, they would not do-it, NOT DONE HERE, blah-blah, we would have to order the saliva cortisol kits from the lab blah-blah and this was a research oriented institution (University of California). I've ended up doing couple of 24h UFC and one was wayyyy out of range (like 50% higher then the upper limit). You know what they said? This is OK, you were probably stressed, blah-blah, you don't have the other signs of Cushing's (btw like that paper pointed out this is SUBCLINICAL adrenal Cushing's). So it will take much longer until the PA and Cushing's will get their correct diagnosis workup unless you are working with Dr. Grim or the NIH doctors which truly understand test results and interpret clinical signs correctly. > > > Well Dr. Grim, so much for that idea. I sent Dr. Moraitis a message and here is his answer followed by my question: > > > > In adrenal Cushing's, urine free cortisol is usually normal. It 's elevated only in the advanced cases. > > Will touch base with you on Friday to discuss the final plan > > Have a good day > > Dr Moraitis

[Guest guest]

Yes and the other problem is that surgery seems the only treatment now.CE Grin MDOn Apr 30, 2012, at 2:57 PM, lvasiliu@... wrote: Hi Dr. Grim, Could that be "Subclinical Cushing's" == "Cyclical Cushing's" ? One could have Cyclical Cushing and be subclinical at the time of evaluation because cortisol cycle is bottoming out. There isn't much out there about cyclical Cushing's .... Your comments appreciated. tiu > > As our discussions of cortisol production have been stimulated by > the NIH experience I did a lit search and just found > > http://www.jabfm.org/content/25/2/199.full.pdf+html > > This article on subclinical Cushing's suggests that we need to add > the screening for CS to all with an adrenal adenoma or any > suggestion of Cushig's: HTN,obesity, glucose intolearance etc etc.

[Guest guest]

Is that because adenal is also making Aldo which increases BP AND LOWERS k or is he talking about tumors that make only excess. Would be good to ask if there is any urine cortisol level below which one does not need to worry about Cushing's. Does he mean in patients who look Cushingoid or look normal?Also not clear why Spiro is bad if you have excess cortisol and aldo. As both can occupy MCR and waste k and increase BP and these aspects of cortisol should be blocked by MCB. May your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertensionOn May 1, 2012, at 12:10, <jclark24p@...> wrote:

I thought I posted this but I have been having trouble w/. I sent Dr. Moraitis a message and here is his response. (His answer followed by my question.):

In adrenal Cushing's, urine free cortisol is usually normal. It 's elevated only in the advanced cases.

Have a good day

Dr Moraitis

On Mon, Apr 30, 2012 at 10:49 AM, <jclark24p@...> wrote:

So, I hope you are done goofing off and ready to go back to work! (No rush, I have all DAY! )

I was looking through some of my prior tests from the VA this morning and found a 24hr urine test done on Jan. 14, 2011:

CORTISOL FREE = 26.3, range 4.0-50.0 VOLUME = 2600 ML

Does this shed any light on the "masked cortisol"? (I'm not sure if that indicates it appeared in the last 15 months or not, but you're the doctor!)

> > >

> > > As our discussions of cortisol production have been stimulated by

> > the

> > > NIH experience I did a lit search and just found

> > >

> > > http://www.jabfm.org/content/25/2/199.full.pdf+html

> > >

> > > This article on subclinical Cushing's suggests that we need to add

> > the

> > > screening for CS to all with an adrenal adenoma or any suggestion

> > of ld > Cushig's: HTN,obesity, glucose intolearance etc etc.

> > >

> > > In other words everyone with HTN should be screened.

> > >

> > > So in my protocol for easy diagnosis I am adding to the 24 hr

> > urine a

> > > urinary free cortisol testing-which have have done in many but never

> > > found (or at last recognized) a subclinical Cushing's. These authors

> > > suggest that a UFC at the upper limit of normal should have further

> > > testing for Cushing's. Again I have never seen this in at least 100

> > > pts with Conn's I have tested over the years. But did not have ACTH

> > > levels then.

> > >

> > > It seems like we should also add a plasma cortisol and ACTH to the

> > > blood testing on the aldo day.

> > >

> > > They do not suggest doing a P aldo or a renin in every suspected

> > > Cushing's but I just sent them an email adding this to their

> > schema if

> > > the BP is above 120/80.

> > >

> > > If one looks at the evolution of PA the evolution of adrenal

> > Cushing's

> > > would be similar using urinary cortisol as the illustrative plot for

> > > urine changes in cortisol and the stages of Cushings would be the

> > same

> > > as I have for Conn's but the instead of renin going down we would be

> > > seeing ACTH going down and obesity/glucose intolerance increasing

> > over

> > > time.

> > >

> > > More later.

> > >

> > > CE Grim MD

> > >

> >

> >

>

[Guest guest]

Dr. Grim, unfortunately most doctors I've seen went to a " different " medical

school then you did ;-) (sarcasm here ...)

When I tried to talk my endo into adding a cortisol test to my 24 h urine

metanephrines and cathecolamines (chasing a pheo) she literally said to me:

" this is not possible because these are different lab protocols " .

Last week I tried to get my PCP to do a spot urine check for K, Na, and

creatinine (to see how I'm DASHing) she said " it's of no use because they vary

through the day and from day to day " (which is true but showing that she doesn't

really understand the Na-K relation in PA and DASHing).

>

> But if we are getting a 24 hr urine for Na, K and aldo and creat

> anyway seems we should always add cortisol and cats. They we are done.

[Guest guest]

Dr. Grim, unfortunately most doctors I've seen went to a " different " medical

school then you did ;-) (sarcasm here ...)

When I tried to talk my endo into adding a cortisol test to my 24 h urine

metanephrines and cathecolamines (chasing a pheo) she literally said to me:

" this is not possible because these are different lab protocols " .

Last week I tried to get my PCP to do a spot urine check for K, Na, and

creatinine (to see how I'm DASHing) she said " it's of no use because they vary

through the day and from day to day " (which is true but showing that she doesn't

really understand the Na-K relation in PA and DASHing).

>

> But if we are getting a 24 hr urine for Na, K and aldo and creat

> anyway seems we should always add cortisol and cats. They we are done.

[Guest guest]

Dr. Grim, unfortunately most doctors I've seen went to a " different " medical

school then you did ;-) (sarcasm here ...)

When I tried to talk my endo into adding a cortisol test to my 24 h urine

metanephrines and cathecolamines (chasing a pheo) she literally said to me:

" this is not possible because these are different lab protocols " .

Last week I tried to get my PCP to do a spot urine check for K, Na, and

creatinine (to see how I'm DASHing) she said " it's of no use because they vary

through the day and from day to day " (which is true but showing that she doesn't

really understand the Na-K relation in PA and DASHing).

>

> But if we are getting a 24 hr urine for Na, K and aldo and creat

> anyway seems we should always add cortisol and cats. They we are done.

[Guest guest]

Hmm ACTH would have kicked cortisol very high.Used to be used to treat arthritis.CE Grim MDOn Apr 30, 2012, at 7:08 PM, Valarie wrote: , this is all very interesting. I salute your research skills. I went to a U of CO endo in 2006. She was convinced that I had Cushings and said she'd dig until she got to the bottom of what was wrong with me. Cushing's tests didn't pan out as the urinary value always came in the high-normal range. Once she couldn't prove Cushing's, she lost interest. I went on my (un)merry way with BP = ~180/100. My ARR ranged from 21 - 35. I ought to go back and find those tests and see where urinary sodium was, assuming she even did it. I remember ACTH being off but don't remember whether it was high or low. Dopamine was low. I had a totally normal ACTH-stim test and after the injection of ACTH, I felt more calm than I had in years. That didn't pique any interest and of course, it didn't last. In 1999, I had high PTH and high calcium and had a parathyroidectomy. I'd had the high calcium for 14 years and my bones were trashed. That's why I say they will pry my estrogen out of my cold, dead hands. I have since had saliva cortisol tests and they have been sky-high but gradually falling as I've progressed with Lyme treatment. The rhythm is good but results are 3 - 4 x normal. Val From: hyperaldosteronism [mailto:hyperaldosteronism ] On Behalf Of , with this "11 deoxycortisol 99 ng/dl (<=62) HIGH" I would suggest it would be worth further checking for cushing's or "masked cushing". Dr. Stratakis at NIH (protocol 00-CH-0160) could give you some ideas I would think. Actually I just looked back and with an ARR of 27 you might have PA masking excess cortisol - CALL HIM:http://clinicalstudies.info.nih.gov/detail/A_2000-CH-0160.htmlWhat's this? "High PTH, high bone ALK phos, need high doses of vit d and Magnesium to stay in normal range" Did she check calcium? NIH was surprised my bone density test was so good (they said excess estrogen and I added 3 glasses of milk/day for 64 years and 1 year of "momma's milk"!) They did put me on 8-weeks of vit-B suppl and will test again. .<image001.gif>