The Role of the Pharmacist in Screening

EP: 1.Examining the Differential Diagnosis of Hypercortisolism

EP: 2.Exploring Reasons for the Underdiagnosis of Hypercortisolism

EP: 3.Selecting the Appropriate Screening Test

EP: 4.The Impact on Quality of Life and Relevant Clinical Studies

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EP: 5.The Role of the Pharmacist in Screening

This video segment discusses the crucial role pharmacists can play in identifying patients with suspected hypercortisolism based on treatment resistance patterns. Pharmacists are uniquely positioned to recognize red flags when reviewing medication lists and medical histories, particularly when patients require continuous intensification of diabetes and hypertension medications despite using powerful agents like GLP-1 receptor agonists, SGLT-2 inhibitors, or basal-bolus insulin regimens. The pattern of repeatedly adding medications without achieving glycemic or blood pressure control should prompt pharmacists to consider whether an underlying condition like hypercortisolism might be the missing piece of the puzzle in their clinical thought process.

The screening process involves identifying patients on three or more diabetes medications with hemoglobin A_1c levels still above 7.5%, which should trigger conversations about medication adherence barriers including adverse effects and cost issues. If adherence is confirmed but glucose control remains challenging, this warrants further investigation. The 1 mg overnight dexamethasone suppression test is highlighted as a relatively straightforward screening tool that pharmacists can feel comfortable recommending. Those with collaborative practice agreements may order the test directly, while others can coordinate with health care providers to recommend appropriate screening for qualifying patients.

Several barriers exist in screening for hypercortisolism, including clinical challenges from nonspecific symptoms in hidden forms of the condition, logistical limitations where pharmacists cannot independently order diagnostic tests, and systemic issues due to lack of consistent screening guidelines. There are no widely accepted criteria for determining which patients should be screened, creating uncertainty about appropriate patient selection. Addressing these gaps requires increasing clinical suspicion, strategic use of diagnostic tests with proper patient coordination and education, and establishing interprofessional collaboration for referrals when positive results are identified. The process requires careful timing coordination for the dexamethasone suppression test and subsequent referral to endocrinology specialists, though access to endocrinologists remains challenging in many areas.