MON-011 - Evaluating Differences in Pre- and Post-Operative Management for Patients with Cushing Disease

Introduction: Cushing disease (CD) is caused by an ACTH-secreting pituitary adenoma. The first-line treatment is pituitary surgery. However, there is no consensus regarding preoperative medical management, postoperative monitoring for remission or recurrence, or postoperative glucocorticoid (GC) regimen. We aim to evaluate practitioners’ preferences for perioperative management and monitoring of patients with CD in different centers.

Methods: An anonymous survey was distributed online from July-September 2025 to Pituitary Society members who treat patients with CD. The survey included demographic questions, practice set-up, patient volume, and questions about routine medical management of these patients. Answers were collected in Qualtrics; results were analyzed in Stata 18.

Results: 126 practitioners from 28 countries (6 continents) completed the survey, 100 (79%) were endocrinologists and 22 (17.5%) neurosurgeons. Most (89%) worked at an academic practice, 43% reported to see >15 CD patients/year and 87% followed them always or most of the time beyond surgery. 84/123 (68%) practitioners start medical therapy for hypercortisolism before CD surgery if surgery is delayed or severe hypercortisolism, and most use adrenal steroidogenesis inhibitors (76/82, 93%). After surgery, 37/115 (32%) check cortisol every 6 hours for 72 hours for evaluation of postoperative remission, 29% check morning cortisol on postoperative day (POD) 1 and 29% on POD 2. A cortisol < 2 mcg/dL (55 nmol/L) is the most common cutoff used. 64/120 (53%) also use ACTH. 50% use perioperative GC, primarily hydrocortisone (94/116, 81%), followed by prednisone (15/116, 13%). There is significant variability in GC start dose and taper, but most practitioners adjust taper based on symptoms (108/115, 93.9%). Once a physiologic dose is achieved, 75/110 (68%) practitioners monitor pituitary-adrenal function every 2-3 months with ACTH and cortisol (56/113, 49.6%), and GCs are stopped once morning cortisol ≥10 mcg/dL (41/113, 36%) or peak cortisol ≥16-18 in cosyntropin stimulation test (45/113, 39.8%). Screening for recurrence is initiated 2-3 months (40/112, 35.7%) or 6 months (38/112, 33.9%) after stopping GC, and the most used test is late-night salivary cortisol (89/110, 80.9%).

Conclusions: There was significant variability in the preoperative medical management of patients with CD as well as markers used to assess for biochemical remission. Despite variation in doses, most practitioners determine GC taper based on symptoms. The screening for recurrence starts 2-6 months after discontinuation of GC, and salivary cortisol is the test that is used the most to monitor for recurrence. These results showed the lack of consensus to manage CD patients during perioperative period and underscore the need for studies to determine outcomes of different strategies and the role of individualized approach.

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