Etomidate lowers cortisol before surgery in Cushing’s syndrome case

The procedure was performed to remove a tumor in the adrenal glands

Patricia Inácio, PhD avatar

by Patricia Inácio, PhD |

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Etomidate helped normalize dangerously high cortisol levels in a woman with Cushing’s syndrome who had an adrenal gland tumor before she having surgery to remove it, a recent case report shows.

“In its severe form, Cushing’s syndrome is a medical emergency that must be rapidly controlled. Etomidate is both safe and effective, and has shown promising results in the treatment of severe [high cortisol levels],” the researchers wrote in “Etomidate in the treatment of Cushing syndrome,” which was published in the Spanish Journal of Anesthesiology and Resuscitation.

Cushing’s syndrome features excessive levels of cortisol, called hypercortisolism. The hormone is normally produced by the adrenal glands atop the kidneys. In most cases, the disease progresses relatively slowly, but in some patients a rapid increase in cortisol levels can be life-threatening.

Etomidate, an anesthetic agent marketed as Amidate, can rapidly lower cortisol levels and may help manage severe cases of hypercortisolism.

Researchers in Spain described the case of a 27-year-old woman with severe Cushing’s syndrome who was given etomidate to normalize dangerously high cortisol levels.

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Elevated cortisol levels

The woman had no history of allergies, but had shown anxious-depressive symptoms. She developed paranoid ideation, along with confusion and mistrust, and had excessive hair growth (hirsutism), and low potassium levels in her blood (hypokalemia).

Her blood cortisol levels were elevated and didn’t drop after an overnight dexamethasone suppression test. Also known as a Nugent test, it can confirm hypercortisolism. It measures cortisol levels in the blood in the morning after a dexamethasone tablet is taken. Cushing’s is signaled when cortisol fails to drop in response to dexamethasone, which is a corticosteroid that normally blocks its production.

The woman’s urine cortisol levels were also elevated and she was eventually diagnosed with Cushing’s syndrome. A CT scan revealed a large mass in the right adrenal gland, suggesting a tumor.

She was referred for surgery to remove the right adrenal gland along with part of the liver. Before surgery she was admitted to the intensive care unit (ICU) where she received a continuous etomidate infusion to rapidly lower her cortisol levels and ease her symptoms.

Etomidate was given at a dose of 5 mg and then at an infusion rate of 0.04 mg per kg of body weight per hour. The rate was adjusted according to cortisol levels, measured every six hours. During treatment, she was closely monitored for potential blood-related complications and alterations in consciousness.

Four days of treatment with etomidate normalized her cortisol, potassium, and phosphate levels. After that, she had the surgery, which was conducted under general anesthesia.

Blocking cortisol production can also lead to adrenal insufficiency, a condition wherein the adrenal glands are unable to produce sufficient amounts of steroid hormones, including cortisol.

To prevent acute adrenal insufficiency, she was treated with the steroid hydrocortisone. It was initiated before surgery and maintained after the procedure then tapered off.

The woman’s paranoia and emotional instability were still present after surgery, along with signs of liver dysfunction. All her symptoms gradually resolved with therapy.

Four days after the surgery, she was discharged from the ICU with a good prognosis. Her neurological symptoms eased after her medication was adjusted. An analysis of the removed tumor tissue was consistent with the presence of adrenal cancer.