This skill defines the treatment goals for patients with overt Cushing's syndrome, focusing on normalizing cortisol levels or action to eliminate symptoms and treat comorbidities. Use when a clinician asks about treatment objectives for a newly diagnosed overt Cushing's syndrome patient; triggers include "overt CS," "treatment goals for overt Cushing's," and "normalize cortisol in overt CS."
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This skill recommends unilateral resection by an experienced adrenal surgeon for all cases of benign unilateral disease causing Cushing's syndrome. Trigger when a CS patient has a unilateral adrenal lesion confirmed benign via imaging and biochemical assessment.
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This skill recommends urgent treatment (within 24–72 hours) of hypercortisolism when life‑threatening complications of Cushing's syndrome such as infection, pulmonary thromboembolism, cardiovascular events, or acute psychosis are present. Trigger phrases include sepsis, PE, chest pain with hemodynamic instability, new‑onset psychosis, or delirium in a patient with known or suspected Cushing's.
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This skill recommends using radiation therapy for corticotroph adenomas in Cushing's disease when imaging shows invasive features or mass‑effect concerns such as cavernous sinus invasion, suprasellar extension, or knobby protrusion. Consider RT when postoperative medical therapy has normalized cortisol but tumor progression or residual invasive disease is suspected.
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Adjusts intravenous bisphosphonate dosing and infusion duration for patients with hypercalcemia of malignancy and renal insufficiency (creatinine clearance <60 mL/min). Triggered when a clinician encounters renal impairment and asks how to modify zoledronic acid or pamidronate infusion rates.
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Recommends checking and managing vitamin D according to Endocrine Society guidelines to avoid hypocalcemia in patients receiving bisphosphonates or denosumab for hypercalcemia of malignancy. Use when a clinician notes risk factors for hypocalcemia (e.g., low 25‑OH vitamin D, renal insufficiency) and asks about baseline labs before antiresorptive start.
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This skill advises regular visual examination of the mouth to monitor for osteonecrosis of the jaw and other dental issues in patients receiving antiresorptive agents. Trigger phrases include initiating bisphosphonate or denosumab therapy and requesting preventive dental care guidance.
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This skill suggests using denosumab rather than an intravenous bisphosphonate for adults with hypercalcemia of malignancy. It is triggered when a clinician questions which antiresorptive to choose first or seeks guidance on drug selection for HCM.
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Recommends adding intravenous bisphosphonate or denosumab when hypercalcemia due to parathyroid carcinoma is not adequately controlled with a calcimimetic. Consider this adjunct when a clinician notes persistent HCM despite calcimimetic therapy and asks about next-step therapy.
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The skill suggests adding a calcimimetic for hypercalcemia of malignancy due to parathyroid carcinoma that persists after intravenous bisphosphonate or denosumab therapy. It is triggered when a clinician notes refractory HCM despite antiresorptive therapy and considers adding a calcimimetic.
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Determines the appropriate IV pamidronate dose (60‑90 mg) and infusion duration (2‑24 h) for adults with hypercalcemia of malignancy based on renal function. Triggered when a clinician orders pamidronate and asks how to adjust for kidney dysfunction (eGFR < 60 mL/min/1.73 m²).
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Determines whether a hypertensive patient should be screened for primary aldosteronism based on clinical features associated with higher PA prevalence. Triggered when a clinician asks 'Should I screen this hypertensive patient for PA?' or observes spontaneous hypokalemia, resistant hypertension, hypertension onset before age 40, adrenal tumor, young-onset stroke, or sleep apnea syndrome.
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Determines if PAC/PRA ratio and PAC levels indicate positive or provisionally positive screening for primary aldosteronism. Triggered when a clinician has PAC and PRA results and asks “Is this screening test positive for PA?” or needs to interpret borderline results.
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Recommends potassium supplementation for hypokalemia management in PA patients who are pregnant or planning pregnancy. Triggered when a pregnant PA patient presents with low serum potassium and asks 'How should I treat hypokalemia?' or when electrolytes are reviewed.
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Identifies safe antihypertensive options for hypertensive disorders in pregnancy applicable to PA patients, with gestational age restrictions. Triggers include when managing hypertension in a pregnant or pregnancy-planning PA patient and asking 'What BP meds are safe?' or reviewing medications.
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Recommends ACTH stimulation during AVS to improve success rate of bilateral selective catheterization, acknowledging unclear impact on diagnostic accuracy for laterality. Triggers include when setting up AVS and asking 'Should I administer ACTH?' or considering procedural optimization.
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Identifies young patients with classic primary aldosteronism features who may proceed directly to unilateral adrenalectomy without adrenal venous sampling based on high probability of unilateral disease. Triggered when a clinician sees a patient <35 years with hypokalemia, unilateral adrenal tumor on CT, and high plasma aldosterone concentration and asks whether AVS can be bypassed.
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Recommends switching specific anti-hypertensive medications to reduce false-positive and false-negative screening results for primary aldosteronism. Triggered when a clinician notes 'The patient is on ACE inhibitors/ARBs' or suspects medication interference with screening results.
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This skill recommends computed tomography (CT) as the initial imaging modality for primary aldosteronism (PA) evaluation in Japan, citing its accessibility and comparable performance to MRI. It is triggered when a clinician orders imaging for suspected PA and asks 'What imaging should I start with?' or seeks a cost-effective initial evaluation.
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Determines successful catheterization in adrenal venous sampling by applying selectivity index cut‑offs with and without ACTH stimulation. Triggered during AVS when measuring cortisol levels and asking “Is the catheter properly positioned?” or when reviewing results for technical adequacy.
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Identifies patients with a positive aldosterone-to-renin ratio screening who may proceed directly to subtype testing without confirmatory testing based on specific clinical criteria. Triggers include spontaneous hypokalemia, baseline plasma aldosterone concentration >100 pg/mL (CLEIA), renin suppression, or a clinician questioning the need for a confirmatory test after a positive screen.
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Recommends mineralocorticoid receptor antagonists for all primary aldosteronism patients to prevent target organ damage, irrespective of blood pressure control or serum potassium levels. Triggered when a clinician encounters a PA patient with well‑controlled BP and normal K and wonders, 'Do I still need to treat with MRA?' or considers stopping therapy.
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Guides choice among spironolactone, eplerenone, and esaxerenone for primary aldosteronism based on comparative efficacy, safety, and patient-specific factors. Triggers include when initiating MRA therapy and asking 'Which MRA should I prescribe?' or considering switching agents due to adverse effects, cost, or need for potassium supplementation.
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Provides evidence-based guidelines for preoperative optimization and postoperative monitoring in patients with primary aldosteronism undergoing adrenalectomy. Triggers include when planning surgery or starting treatment and asking 'What perioperative care is needed?' or managing complications such as resistant hypertension, hypokalemia, or suspected cortisol co-secretion.
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