Section 3 Online Certification

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You will be provided with 3 videos and 3 quizzes grouped into 3 sections. You have to complete a quiz to move to the next video and its quiz (you will receive a link to a new section). After completion of 2 first two quizzes, you will receive partial certifications. After successful completion of the 3rd quiz, you will be able to download the full certificate (with the total hours) and KTA Reflection Tool.

Online Certification Objectives

Online certification aims to:

Provide participants with a process to record their answers
Provide detailed feedback to participants on their performance to enable the identification of any areas requiring improvement through the development of a future learning plan
Provide participants with an opportunity to evaluate the overall program and each individual module

Section 3 Online Certification - step 3

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Quiz 2 Explanation

The effective dose range for ketoconazole is 400-1200mg/d in divided doses and liver enzyme elevation is frequent and can be tolerated up to 3x the upper normal limit. In this case, the patient is responding partially to the minimal dose of 400mg with almost no side effects other than slight liver enzyme elevation. Ketoconazole is the first choice because it is available immediately and relatively safe in this context.

Mitotane should never be used before we have confirmation of very high suspicion of adrenocortical cancer (for example if androgen levels were elevated).

Cabergoline is only effective in Cushing disease (pituitary directed therapy).

Metyrapone would be effective but needs to be approved by Health Canada SAP which usually need paperwork and a delay of ~5-7 days to be available, if not more.

Etomidate is only safe in a high monitoring setting as the patient can experience sedation (even at lower doses) and acute adrenal insufficiency. It is a very effective treatment but should only be used in intensive care setting. In our case, the patient is responding to ketoconazole and is not in a critical condition, so the risks of etomidate outweighs the benefits.

References

Fleseriu M and al. Consensus on diagnosis and management of Cushing's disease: a guideline update. Lancet Diabetes Endocrinol. 2021 Dec;9(12):847-875. doi: 10.1016/S2213-8587(21)00235-7. Epub 2021 Oct 20.

Feelders RA, Newell-Price J, Pivonello R, Nieman LK, Hofland LJ, Lacroix A. Advances in the medical treatment of Cushing's syndrome. Lancet Diabetes Endocrinol. 2019 Apr;7(4):300-312. doi: 10.1016/S2213-8587(18)30155-4. Epub 2018 Jul 20.

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Demystifying Cushing’s Polling Questions

Question 3 (Brandon Galm)

Please watch the full video to unlock the quiz question below.

Case Description

A 71-year-old male from a remote community is seen for recurrence of Cushing syndrome. He had a partial distal pancreatectomy 10 years ago for a pancreatic neuroendocrine tumour causing ectopic Cushing syndrome. He had a preoperative lower extremity DVT. He had a complicated postoperative course in hospital for several months, but achieved remission of his Cushing syndrome. Unfortunately, he was lost to follow-up.

He now presents to his local clinic with muscle weakness and arrhythmias, and is found to have a potassium of 2.5 mmol/L (reference 3.5 to 5.0). He has a 24-hour urine cortisol of 3981 nmol/d (reference 10 to 166). Imaging shows bone and liver lesions that are concerning for metastases. Given this, you discuss the need for bilateral adrenalectomy.

You decide that this patient is at high risk of VTE. While awaiting further investigations, you recommend VTE prophylaxis. According to the recent 2025 consensus statement on VTE prophylaxis in Cushing syndrome, what do you recommend?(Required)

A) Ambulation & mechanical prophylaxis; no chemoprophylaxis

B) Enoxaparin, starting now

C) Enoxaparin, starting 24 hours after bilateral adrenalectomy

D) Apixaban, starting now

E) Apixaban, starting 24 hours after bilateral adrenalectomy

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