Fell, Vanessa

Abstract Disclosure: S. Ahmadian: None. C.A. Villavicencio Torres: None. V.M. Fell: None. K.L. Moehnke: None. Y. Chai: None. R.L. Taylor: None. S.K. Grebe: None. A.D. Maus: None. I. Bancos: None. Background: Salivary cortisol (SalF), and cortisone (SalE) interpretation can be influenced by intra-individual variability arising from cortisol secretion cyclicity, assay performance, and sampling techniques. No studies to date have examined the impact of sampling on intra-individual variability. Methods: We conducted a single-center cross-sectional study of adults evaluated with total serum cortisol measurements as a part of the overnight dexamethasone suppression test (DST) or cosyntropin stimulation test (CST), November 2024- January 2025. Participants were provided with two cotton swabs (salivettes) and asked to collect two consecutive saliva samples immediately after the venipuncture for total cortisol. Each cotton swab was kept in the mouth for 2-2.5 minutes. Saliva was tested for SalF and SalE by mass spectrometry. Variability was examined based on cortisol tertiles. Results: A total of 78 paired saliva samples were obtained from 60 participants (45 [75%] women; median age 55 years [IQR 39-66]), who were undergoing either DST (42 [70%]) or CST (18 [30%]). A total of 10 (17%) saliva samples did not contain a sufficient sample for analysis during the first or second saliva collection (7 [12%] from DST group, and 3 [5%] from CST group).Among 53 patients undergoing DST, the median serum total cortisol was 1.3 mcg/dL [IQR 0.9-3], the median first SalF was 20 ng/dL [IQR 7-28], the median second SalF was 12 ng/dL [IQR 6-23], and the median variability was 11% [IQR 3-22%]. The median first SalE was 69 ng/dL [IQR 54-185], while the median second SalE was 63 ng/dL [IQR 56-178], with a median variability of 6% [IQR 4-10].In patients undergoing CST, peak median serum total cortisol was 20 mcg/dL [IQR 18-24], median first SalF was 809 ng/dL [IQR 536-1227], and median second SalF was 1063 ng/dL [IQR 667-1503], with the median variability of 14% [IQR 8-22]. The median first SalE was 2507 ng/dL [IQR1697-2966], while the median second SalE was 2485 ng/dL [IQR 1530-2976], with a median variability of 9% [IQR 3-12].When examining intra-individual variability of SalF, the variability was lowest in the middle tertile, corresponding to serum cortisol of 1.8-8.9 mcg/dL, at 9% [IQR 5-16]. Variability was higher in the lowest tertile (14% [IQR 0-52]) and the highest tertile (12% [IQR 6-16]). Overall, the variability of SalE was lower than that of SalF: 7% [IQR 4-13] in the lowest tertile, 5% [IQR 2-9] in the middle tertile, and 10% [IQR 4-12] in the highest tertile. Conclusion: We show that saliva sampling may impact the results, with 17% patients providing insufficient sample for analysis, and variability of 9-14% for SalF and 5-10% for SalE. Same time-point sampling-related variability should be considered in interpretation of SalF and SalE measurements. Presentation: Sunday, July 13, 2025

Abstract Disclosure: M. Salehi: None. K. Yu: None. C.A. Villavicencio Torres: None. V. Fell: None. I. Bancos: None. Context: The use of the 1 mg overnight dexamethasone suppression test (1 mg-DST) is considered the standard-of-care test for the assessment of hypercortisolism. Scarce data are available on the utility of 8 mg-DST in distinguishing adrenal from pituitary hypercortisolism. Objective: To determine the value of 8 mg-DST in diagnosing hypercortisolism subtype. Methods: We conducted a single-center retrospective cohort study (2005-2024) of consecutive adults who underwent both the 1 mg-DST and the 8 mg-DST within a 6-month period. Only patients with optimal reference standard confirming the type of hypercortisolism were included. Patients were excluded if they had an abnormal DST and dexamethasone concentration <100 ng/dL or were receiving oral estrogen therapy. Delta cortisol [(post 1 mg-DST cortisol- post 8 mg-DST cortisol) x100/post 1 mg-DST cortisol)] was calculated for each patient. Results: A total of 61 patients (50, 82% women, median age 60 years, interquartile range, IQR 47-67) underwent both 1- and 8 mg-DST at least once, with 8 (13%) patients undergoing the 1 mg-DST and 8 mg-DST twice, and 1 (1.6%) patient undergoing both tests thrice. Adrenal hypercortisolism was diagnosed in 44 (72%) patients and pituitary hypercortisolism in 17 (28%) patients. Median post 1 mg-DST cortisol was 4.6 mcg/dL (IQR 2.8-7.2) in adrenal and 13.7 mcg/dL (IQR 7.3-21.7) in pituitary hypercortisolism. Median post 8 mg-DST cortisol was 3.2 mcg/dL (IQR 2.5-6.3) in adrenal and 3.6 mcg/dL (IQR 2.2-7.5) in pituitary hypercortisolism. Median delta cortisol was higher in pituitary hypercortisolism when compared to adrenal hypercortisolism (69%, IQR 25-83 vs 5 %, IQR -20-16, P<0.001). Delta cortisol demonstrated a good discrimination in distinguishing adrenal from pituitary hypercortisolism with a median area under receiver operator of 82% (95%CI 69-92). A cut-off of 25% provided a specificity of > 85%, while a cut-off of -1% yielded a sensitivity of > 85% in diagnosing adrenal hypercortisolism. Conclusion: In this study, we show that performing 8 mg-DST in addition to 1 mg-DST in selected patients with hypercortisolism and calculating delta cortisol is a valuable in distinguishing hypercortisolism subtype. Presentation: Sunday, July 13, 2025

Abstract Disclosure: S. Sharma Sharma: None. J. Saini: None. S.R. Chacko: None. S. Ahmadian: None. V. Fell: None. S.J. Achenbach: None. E.J. Atkinson: None. W.F. Young: None. I. Bancos: None. Context: The impact of active hypercortisolism on sleep is incompletely characterized. Several studies report impaired sleep in patients with Cushing syndrome (CS). Patients with mild autonomous cortisol secretion (MACS) demonstrate an abnormal circadian cortisol secretion with mild nocturnal hypercortisolism that could also impact sleep. Objectives: To characterize sleep abnormalities and to identify factors associated with impaired sleep in patients with CS and MACS. Methods: We conducted a single-center cross-sectional study of prospectively enrolled adults with active CS and MACS evaluated between August 31, 2020, and December 2, 2024. Clinical and biochemical severity scores for hypercortisolism were calculated. Quality of life (QoL) was assessed using 1) Short Form-36 (SF-36), physical (PCS) and mental (MCS) component summaries, and 2) Cushing QOL survey, with psychosocial and physical domains. Sleep quality was assessed using Pittsburgh Sleep Quality Index (PSQI), a global score of ≥5 was considered abnormal. Pearson correlations and linear regression models were used to explore associations with PSQI scores. Results: In 285 patients (226 [79%] women, 259 [91%] White, median age of 54 [IQR 44-64] years), MACS was diagnosed in 147 (52%) and CS in 138 (48%). Patients reported abnormal sleep (median PSQI of 12 (IQR 8-16) in CS vs 10 (IQR 7-15) in MACS (P=0.086). Most prevalent sleep abnormalities included report of “fairly bad” or “very bad” overall sleep quality (73% in CS and 54% in MACS) and report of severe day dysfunction due to sleepiness (70% in CS and 56% in MACS). In an age-, sex- and BMI- adjusted univariable analysis of patients with hypercortisolism, higher clinical hypercortisolism severity score (r=0.13, P=0.024) and worse QoL, as measured by SF-36 and Cushing QoL (P=<0.001 for all), were associated with higher PSQI scores, a reflection of poor sleep. In a multivariable analysis of patients with hypercortisolism, we found that younger age (est -0.08, P=<0.001), female sex (est 1.95, P=0.004), lower BMI (est -0.07, P=0.041), and higher clinical severity score (est 0.12, P=0.024) were associated with higher PSQI scores, indicating impaired sleep. In a multivariable analysis of only patients with MACS, female sex (est 2.17, P=0.012), lower BMI (est -0.12, P=0.017), and higher clinical severity score (est 0.24, P=0.003), but not age were associated with higher PSQI scores, indicating impaired sleep. In patients with CS, only younger age (est -0.12, P=<0.001), but not other variables were associated with higher PSQI scores. Conclusion: We found that patients with MACS have impaired sleep, possibly due to nocturnal hypercortisolism. In patients with MACS, but not CS, clinical hypercortisolism severity score was associated with more impaired sleep. Presentation: Sunday, July 13, 2025

Abstract Disclosure: S. Sharma Sharma: None. J. Saini: None. S.R. Chacko: None. S. Ahmadian: None. V. Fell: None. S. Achenbach: None. A. Peersen: None. E. Atkinson: None. W.F. Young: None. I. Bancos: None. Context: Patients with MACS demonstrate an abnormal circadian cortisol secretion with mild nocturnal hypercortisolism that could impact sleep. Objectives: 1) To characterize sleep abnormalities and to identify factors associated with impaired sleep in patients with MACS. 2) To compare sleep abnormalities between patients with MACS and referent subjects. Methods: We conducted a single-center cross-sectional study of prospectively enrolled adults with MACS evaluated between August 31, 2020, and April 03, 2025. In parallel, we conducted a referent subject study between May 15, 2019, and May 02, 2023. Referent subjects were eligible if they had abdominal cross-sectional imaging without evidence of an adrenal mass. For patients with MACS, clinical and biochemical severity scores for hypercortisolism were calculated. In both groups, quality of life was assessed using Short Form-36 (SF-36), physical (PCS) and mental (MCS) component summaries. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), a global score of ≥5 was considered abnormal. Pearson correlations and linear regression models were used to explore associations with PSQI scores. Results: The total cohort included 167 patients with MACS and 89 referent subjects. No differences in age (median 60 vs 56 years, P= 0.122) and sex (71% vs 67% females, P= 0.523) were observed between patients with MACS and referents. However, median BMI was higher in patients with MACS (32 28 kg/m2 [IQR 28-38] vs 28 kg/m2 [IQR 24-32], P= < 0.001). Patients with MACS had more impaired sleep than referent subjects (median PSQI 11 [IQR 7-15] vs 5 [IQR 3-7], P= <0.001). In an age-, sex- and BMI- adjusted univariable analysis, lower PCS and MCS scores were associated with poor sleep in both referents (r= -0.45, P= <0.001 and r= -0.29, P= 0.008) and patients with MACS (r= -0.36 and -0.38, P= <0.001), however, the presence of obstructive sleep apnea (OSA) was not. In patients with MACS, both higher clinical and biochemical severity scores were associated with poor sleep (r=0.20, P=0.012) and (r= 0.15, P= 0.050). Multivariable analysis of age, sex, BMI, clinical severity and OSA demonstrated that women (est 2.35, P= 0.004), lower BMI (est -0.13, P= 0.014) and higher clinical severity score (est 0.17, P=0.026), but not OSA were associated with impaired sleep in patients with MACS. All PSQI subcomponents were higher in patients with MACS vs referents, indicating poor sleep-most significantly, sleep quality score (OR 3.93, 95% CI: 2.58-6.29), sleep disturbance score (OR 3.73, 95% CI: 2.28-6.37) and daytime dysfunction score (OR 4.74, 95% CI: 2.29-10.75). Conclusion: Patients with MACS report impaired sleep, and women with lower BMI and higher clinical hypercortisolism severity scores are more affected. Reversing abnormal nocturnal hypercortisolism may improve sleep. Presentation: Saturday, July 12, 2025

Abstract Disclosure: S.R. Chacko: None. C. Powell: None. B. Ndovu: None. E.Y. Ferreira: None. R. Rosenberg: None. J. Saini: None. S. Nevin: None. K. Yu: None. V. Fell: None. J.J. Larson: None. E. Atkinson: None. I. Bancos: Funding for investigator-initiated research from Esteve. Context: Mild autonomous cortisol secretion (MACS), found in about 50% of patients with adrenal incidentalomas, is associated with increased cardiovascular morbidity. While adrenalectomy improves outcomes in unilateral MACS, safe and effective medical therapy is needed for bilateral MACS. Objectives: To evaluate the tolerability and safety of overnight metyrapone in adults with MACS. Methods: Study design: Open-Label, Phase 2, Clinical Trial (NCT06106295) Participants: Patients >18-years-old with MACS and benign adrenal imaging phenotype were prospectively enrolled between December 2023 and January 2025. MACS was diagnosed based on 1 mg post-dexamethasone suppression test serum cortisol >1.8 mcg/dL. Eligibility required at least one MACS-associated comorbidity (obesity, dysglycemia, dyslipidemia, hypertension, osteopenia or osteoporosis). Intervention: Metyrapone was administered at an initial dose of 250 mg each evening with up titration in 250 mg increments every 2-4 weeks based on tolerance, to a maximum of 1000 mg. Outcomes: The primary endpoint was assessment of treatment-related adverse events (AE), categorized by CTCAE grade. Adrenal insufficiency (AI) was considered an AE, assessed on biochemistry and AddiQoL survey. Sample size: 30 patients projected Results: Twenty-six patients with MACS [median age 66 years (IQR 61-68), 69% women] were enrolled. At the time of analysis, median metyrapone dose was 1000 mg (IQR 750-1000). At median follow-up of 3 months (IQR 2-6), 22 patients (85%) developed at least one AE. None were serious, aside from one patient with an acute kidney injury (AKI), unlikely related to metyrapone. All other AEs were CTCAE Grade 1-2, including dizziness 12%, nausea 6% and fatigue 5%. Of all 90 AEs, 12 (13%) occurred at a dose of 250 mg, 10 (11%) at 500 mg, 20 (22%) at 750 mg and 48 (53%) at 1000 mg. One (1%) was definitely related to metyrapone (hypokalemia), 16 (18%) probably related, 20 (22%) possibly related, 35 (39%) unlikely to be related, and 18 (20%) unrelated to metyrapone. Dose was reduced in 5 patients (19%) due to an AE. Two discontinued metyrapone, one because of AKI, while the other withdrew from the study. Morning serum cortisol was not significantly changed between baseline [11.5 (IQR 9.2-14.8)], 3 months [12.0 (IQR 11.0-15.0)], and 6 months [9.7 (IQR 7.9-12.5)] (normal: 4.8-20 mcg/dL). No patient developed AI (morning serum cortisol <10 mcg/dL and ACTH >60 pg/ml), but plasma ACTH significantly increased from baseline to 3 months [8.0 (IQR 5.4-20.8) vs. 18.0 (IQR 14.0-28.0), P=0.021] (normal: 10-60 pg/ml). Between 3 and 6 months, no significant change occurred in ACTH. AddiQol survey scores did not change significantly between baseline, 3 and 6 months. Conclusion: Metyrapone therapy in patients with MACS demonstrated a favorable safety profile with no occurrence of AI. Further investigation into efficacy and MACS-associated outcomes is warranted. Presentation: Sunday, July 13, 2025

ABSTRACT Objective Data on bone health in patients with mild autonomous cortisol secretion (MACS) are limited and heterogenous. We sought to assess the prevalence of osteoporosis and symptomatic fragility fractures in patients with adrenal adenomas and hypercortisolism, and explore associations with the degree of cortisol excess and frailty. Design This multicenter cross ‐sectional study involved prospective enrollment of adults with nonfunctioning adrenal adenomas (NFA), MACS, Cushing syndrome (CS) and referent subjects without adrenal disorders during the study period (January 2019–September 2022). All participants completed a bone health questionnaire at enrollment and had dual‐energy X ‐ray absorptiometry bone mineral density assessment within 12‐months. Final analyses were adjusted for age, sex, body mass index, smoking status, alcohol use. Results Participants included 117 with NFA (median age 62 years, 80% women), 191 with MACS (median age 63 years, 74% women), 62 with CS (median age 50 years, 92% women), and 101 referent subjects (median age 59 years, 47% women). Both patients with CS (OR: 3.0, 95% CI: 1.1–8.3) and MACS (OR: 2.2, 95% CI: 1.9–4.9) had a higher prevalence of osteoporosis when compared to referents. Among patients with MACS, only those with post 1‐mg dexamethasone suppression test (post‐1mg‐DST) cortisol > 83 nmol/L had a higher prevalence of osteoporosis when compared to referents (OR: 3.2, 95% CI: 1.4–7.5) and NFA (OR: 2.2, 95% CI: 1.1–4.4). For clinical fragility fractures, only patients with CS showed an increased prevalence when compared to referents (OR: 6.1, 95% CI: 1.7–26.4) and NFA (OR: 3.8, 95% CI: 1.3–11.2). Prevalence of clinical fragility fractures was similar to referents in patients with MACS (OR: 1.8, 95% CI: 0.6–6.9) and NFA (OR: 1.5, 95% CI: 0.4–6.1), and was not associated with post‐1mg‐DST cortisol or frailty in the MACS and NFA groups. Conclusion Patients with CS, and those with MACS and post‐1mg‐DST cortisol > 83 nmol/L, exhibited a higher burden of osteoporosis. However, only CS was associated with an elevated risk of symptomatic fragility fractures.

Abstract Context The impact of active hypercortisolism on sleep is incompletely characterized. Studies report impaired sleep in patients with Cushing syndrome (CS). Patients with mild autonomous cortisol secretion (MACS) demonstrate mild nocturnal hypercortisolism that could impact sleep. Objectives To characterize sleep abnormalities in patients with CS and MACS using the Pittsburgh Sleep Quality Index (PSQI), identify factors associated with poor sleep, and compare sleep abnormalities in patients with MACS vs referent subjects. Methods We conducted a single-center cross-sectional study of adults with active CS and MACS. Clinical and biochemical severity scores for hypercortisolism were calculated. Parallelly, we enrolled referent subjects. Quality of life was assessed using (1) the Short Form-36 (SF-36) in all participants and (2) the CushingQoL in patients with active hypercortisolism. Sleep quality was assessed using PSQI. Results PSQI was assessed in 154 patients with CS (mean 12, SD ±4.5), 194 patients with MACS (mean 11, SD 4.6), and 89 referents (mean 5, SD ±3.4). Patients with MACS exhibited shorter sleep duration, longer sleep latency, more severe daytime dysfunction, lower sleep efficiency, and a higher sleep medication use compared to referent subjects (P = <.001 for all). Age-, sex, and body mass index-adjusted analysis demonstrated no differences in PSQI or its subcomponents between patients with CS and MACS (P > .05 for all). In a multivariable analysis of patients with MACS, younger age, female sex, and higher clinical hypercortisolism severity score were associated with impaired sleep. In patients with CS, only younger age was associated with poor sleep. Conclusion Patients with MACS demonstrate sleep impairment that is similar to patients with CS. Younger women with higher clinical severity of MACS are more likely to have impaired sleep.

Abstract Context Patients with endogenous hypercortisolism experience glucocorticoid withdrawal syndrome (GWS) after surgery. Meditation may be an effective intervention to alleviate the severity of GWS. Objective To determine the acceptability of a portable, wearable electroencephalography device for guided meditation (MUSE headband) and the impact of MUSE use on GWS and quality of life 12 weeks postsurgery. Methods We conducted a single-center prospective cohort study of adults with endogenous hypercortisolism undergoing curative surgery from 2019 to 2024. Patients had baseline and postsurgical assessments over 12 weeks. The study comprised patients using MUSE for ≥ 6 weeks (MUSE cohort) and patients matched by age, sex, BMI, hypercortisolism type, and glucocorticoid type at 1:4 ratio. Quality of life and GWS symptoms were assessed with AddiQoL, CushingQoL, and 36-item Short Form Health Survey mental and physical component (SF-36 MCS and PCS) questionnaires. Results MUSE was offered to 52 patients, and 22 (42%) used MUSE for ≥ 6 weeks within 12 weeks after surgery. At baseline, compared to 88 matched subjects, 22 MUSE participants demonstrated similar prevalence of comorbidities and clinical and biochemical hypercortisolism severity, but lower AddiQoL (mean 73 vs 66, P = .031) and SF-36 MCS (mean 39 vs 33, P = .022). At 12 weeks, these differences in quality of life were no longer present. After adjusting for age, sex, BMI, clinical severity score, and baseline quality of life, MUSE use was an independent predictor of improved SF-36 PCS at 12 weeks postsurgery (beta 4.2, 95% CI: 0.5-7.9, P = .026). Conclusion Postsurgical meditation intervention may improve physical symptoms and accelerate recovery.

Abstract Objective Glucocorticoid withdrawal syndrome (GWS) may develop in patients following successful surgery for endogenous hypercortisolism. Effective strategies to minimize GWS and improve quality of life (QoL) are currently lacking. We aimed to determine the impact of hydrocortisone vs prednisone therapy on GWS and QoL during the first 12 weeks postsurgery. Methods Single-center prospective cohort study (2019-2024) of adults with endogenous hypercortisolism who developed postoperative adrenal insufficiency and treated with either prednisone or hydrocortisone. Quality of life was assessed with Short Form-36 (SF-36) and Cushing QoL questionnaires at baseline and at 12 weeks postsurgery. GWS was assessed using weekly AddiQoL questionnaires for the first 12 weeks postsurgery. Results Of 165 patients, 101 (61%) were treated with hydrocortisone and 64 (39%) with prednisone. At baseline, no group differences were found in the hypercortisolism subtype, comorbidities, or QoL assessments. At follow-up, no group differences in final total daily hydrocortisone equivalent dose were seen. When adjusting for the baseline QoL assessment, patients treated with prednisone demonstrated a higher degree of improvement in their QoL, particularly in the SF-36 mental component score (estimate 0.33, 95% CI, 0.04-0.63), SF-36 role-emotional limitation (estimate 0.52, 95% CI, 0.2-0.84), and SF-36 body pain (estimate 0.31, 95% CI, 0.07-0.56) subcomponents. In the multivariable analysis of age, sex, body mass index, glucocorticoid type, baseline clinical severity score, and baseline QoL assessment, prednisone therapy was an independent predictor of better SF-36 mental component at 12 weeks postsurgery. Conclusions Prednisone therapy was associated with better mental health QoL than hydrocortisone at 12 weeks postsurgery in patients with hypercortisolism.

Abstract Objectives The impact of mild autonomous cortisol secretion (MACS) on cognition is incompletely characterized. We aimed to assess cognition in patients with MACS, identify factors associated with lower cognition, and determine the impact of adrenalectomy on cognition. Methods We conducted a cross-sectional study (4/2019 to 10/2022) and a longitudinal cohort study (10/2021 to 9/2023) of adults with MACS and referent subjects. Cognition was assessed with National Institute of Health Toolbox Cognition Battery and reported as standardized T scores (adjusted for age, sex, race/ethnicity, and education) for fluid, crystallized, and total composite cognition. Participants were assessed with urine steroid profiling (liquid chromatography-tandem mass spectrometry), frailty index, Beck’s Depression Inventory (BDI), and Short Form-36 (SF-36). Results A total of 84 patients (median age 57 years, 67% women) and 201 referent subjects (median age 63 years, 58% women) were included. Patients with MACS demonstrated lower mean (SD) total composite (50.9 [9.3] vs 55.4 [8.9], P < .001) and fluid composite T score (49.3 [10.6] vs 55.2 [10.2], P < .001), but not crystallized composite T score (52.3 [8.4] vs 54.0 [8.4], P = .130) when compared with referent subjects. Multivariable analysis adjusted for age, sex, BDI, SF-36, frailty index, total glucocorticoids, and androgens demonstrated that MACS status was associated with lower cognition. When cognition was reassessed in 37 patients post-adrenalectomy and 31 referent subjects, adjusted group differences of cognition change were similar except for a higher comparative increase in attention and executive functioning in patients with MACS. Conclusion Patients with MACS demonstrate lower cognition than referent subjects. Adrenalectomy for MACS had a minor positive impact on cognition.