SAT341 Even Mild Cortisol Excess Is Unsafe: Use of Mifepristone In Mild Autonomous Cortisol Secretion
Authors: Cruz Alegyari Figueroa , Torres Marina Torres , Santiago Carrion Ada Marie , Torres Yineli Ortiz , Velez Alexandra Aponte , Rivera Nazario Ivan Augusto , Mangual Garcia Michelle Marie 
Published: October 2023

Abstract
Disclosure: A. Figueroa Cruz: None. M. Torres Torres: None. A.M. Santiago Carrion: None. Y. Ortiz Torres: None. A. Aponte Velez: None. I.A. Rivera Nazario: None. M.M. Mangual Garcia: None.
Cortisol is released from the adrenal glands and works through the glucocorticoid receptor to mediate stress, metabolism, immune and inflammatory processes. Is known as our stress hormone and have manifestations in almost every system as its receptor is present in nearly every tissue. Therefore, even mild cortisol overproduction can lead to serious complications. Mild autonomous cortisol secretion (MACS) is prevalent in nearly half of adults with benign adrenal tumors and can increase the risk of hypertension and type 2 diabetes. It may go undiagnosed if not evaluated properly. There is controversial data on how we should treat this entity. Herein we present a case of MACS denoting the importance of its detection and management.
55yo female comes for evaluation after been found with bilateral adrenal masses in an MRI perform for back pain. Patient with PMHx of diabetes, hypertension, dyslipidemia, and osteopenia refers worsening hyperglycemia and blood pressure. She was previously well controlled with less medications and has needed frequent changes in therapy without achieving treatment goals. Physical exam was negative for discriminatory findings of Cushing’s syndrome. However, she recently noted increase in weight after starting sulfonylurea and insulin for blood glucose control. A CT scan confirmed the presence of adrenal masses measuring 2.5x2.9cm on the left and 2.0x2.4cm on the right with HU 10 and washout 82%. MACS was confirmed with a post Dexamethasone Suppression Test cortisol level of 10.8 ug/dL. Normal cortisol levels were found on Late Nigh Salivary Test done twice. In view of these findings, we can argue about how mild cortisol hypersecretion can be when patient A1c is 10.7% despite multiple therapies for blood glucose and uncontrolled blood pressure despite 3 medications in maximal doses. Considering surgery in this setting is controversial due to bilateral masses with minimal size difference. Since hypercortisolism needed to be addressed it was decided to start medical therapy with the glucocorticoid antagonist Mifepristone, although its use for MACS is considered off label. After mifepristone therapy A1c decreased to 8.0%, prandial insulin was discontinued, and basal insulin decreased. Current regimen for hypertension includes spironolactone to avoid hypokalemia related to mineralocorticoid stimulation of cortisol with mifepristone therapy. Patient symptoms and quality of life has improved significantly.
Benign adrenal incidentalomas can cause MACS in up to 35% of cases. Untreated hypercortisolism can lead to complications, and increased mortality risk even when is “mild”. We just need the right amount of cortisol, and minimal excess need to be identified, for which high level of suspicion is needed and more education on this entity and its available treatment options is essential.
Presentation: Saturday, June 17, 2023