When the Cure Becomes the Cause: Adrenal Insufficiency in Cushing's Management

The document discusses a case of a 69-year-old woman with severe hypercortisolism who developed adrenal insufficiency after starting ketoconazole for Cushing’s disease management. Despite initial treatment to reduce cortisol levels, the patient experienced hypotension and altered mental status due to a significant drop in cortisol. This case highlights the risk of acute adrenal insufficiency when using ketoconazole, especially in patients with prior glucocorticoid exposure. The conclusion emphasizes the importance of careful dose titration and monitoring of adrenal function, suggesting strategies like starting at the lowest dose or using a block and replace approach with hydrocortisone to prevent iatrogenic adrenal insufficiency.