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Cushing disease: Suspect-and-test checklist for clinicians

A one-page worksheet that turns the full Cushing disease diagnosis guide into something you can use at the point of care: what to look for, what to order, which results should not end the workup, and who else to test or refer.

Who it is forClinicians and care teams who may see Cushing disease before it is diagnosed, including primary care, the specialists named in the guide, and referral or genetics coordinators.
When to use itWhen Cushing disease is on the differential, when a patient has several red flags, or when you are preparing a referral or a second opinion.

How to use it, section by section

  1. Red flags present: Tick each finding the patient has. They are grouped by body system so you can scan quickly.
  2. Already labeled as: Tick earlier diagnoses on the chart that the sources say are often given first.
  3. Family to test: Note relatives who may need testing, and record when symptoms began and which specialists have already been seen.
  4. Testing, in order: Tick each test as you order it and write the result on its line. The order follows the published sources.
  5. Results that do not rule it out: A reminder of findings that can look reassuring but do not exclude Cushing disease.
  6. Specialists: Tick the referral, then write who it went to and any notes.
Two ways to fill it inPrint it blank and write on it, or tick boxes and type on this screen first, then print or save as a PDF. Keep it with the chart or send it with the referral.
PrivacyNothing you type is sent or saved. It stays in this browser tab and disappears when you close it. Use patient initials, not full identifiers.

What it is not: Not a diagnostic score, a protocol or coding advice. It summarizes published sources, and clinical judgment and the treating clinician govern. Every point is sourced in the full Cushing disease guide.

One Letter page. Use your browser's print or save as PDF.Full guide with sources
Suspect-and-test checklist
Cushing disease

Confirm endogenous hypercortisolism first, then find the cause. Cushing disease, a pituitary ACTH tumor, is the most common cause.

ICD-10-CME24.0, E24.9Trial Friend for Clinicians

1Red flags present

Most discriminating

Overlapping features

Children, adrenal and family

2Already labeled as

3Family to test

4Testing, in the order the sources describe

  1. Glucocorticoid drug historyFirst. Oral, inhaled, topical, rectal and injected steroids; creams, tonics, joint shots, megestrol.
    Result
  2. Late-night salivary cortisol, 2 or moreNot in night-shift workers. Licorice, smoking and steroid gels may raise it.
    Result
  3. Overnight 1mg DSTAbnormal if cortisol is above 1.8µg/dL. Oral estrogen and CYP3A4 inducers can cause false positives.
    Result
  4. Urine free cortisol, 2 or 3 24-hour collectionsAbove the assay range. Falsely low below CrCl 60mL/min.
    Result
  5. Second test after any abnormal resultEndocrinologist review. Look for the cause only after 2 concordant abnormal tests.
    Result
  6. Morning plasma ACTHSeparates ACTH-dependent from adrenal disease; levels can overlap.
    Result
  7. Pituitary MRI, 3T where availableAbout a third of scans in Cushing disease are negative.
    Result
  8. IPSS at a specialized centerLesion under 6mm: IPSS. Lesion of 10mm or more with consistent tests: not needed.
    Result

5Results the sources say do not rule it out

  • A single normal test when suspicion is high. Cyclic or mild disease can test normal.
  • A normal UFC in renal impairment. It is falsely low below CrCl 60mL/min.
  • Few clinical signs. In a registry, 28% with overt disease had 0 to 3 of 11.
  • A negative pituitary MRI. About a third of scans in Cushing disease show no tumor.

6Specialists the sources name

Diagnosis codes: E24.0 Pituitary-dependent Cushing's disease; E24.9 Cushing's syndrome, unspecifiedCodes patients often carry before diagnosis are listed in the online guide.
Full guide and sourcesEvery point here is sourced in the online guide, which also has a patient note to print.
Trial Friend, trialfriend.com/for-clinicians. Key sources: Endocrine Society guideline (2008); Pituitary Society 2021 consensus; Korean and Japanese 2026 consensus; Italian Society of Endocrinology 2026 position statement; European Registry on Cushing's syndrome (2011); Time to diagnosis meta-analysis (2020); all 10 with links in the online guide. Checked November 10, 2026. A reference checklist for licensed clinicians that summarizes published sources. It is not a diagnostic tool, a score or a protocol, and it does not replace clinical judgment, local practice or the prescribing information. Not coding advice. Trial Friend never receives anything written or typed on this sheet.