title: A survey of clinical practice patterns in diagnosis and management of Cushing's disease in Iran.
abstract: BACKGROUND
  Cushing's disease is the most prevalent cause of endogenous adrenocorticotrophic hormone hypersecretion. The aim of this study was to document the current clinical practice pattern in the management of Cushing's disease by Iranian Endocrinologists to determine their opinions and compare them with the current clinical practice guidelines.
  
  
  METHODS
  An eight-item questionnaire dealing with diagnosis, treatment and follow up of patients with Cushing's disease was developed, piloted, and sent to the members of Iranian Endocrinology Society.
  
  
  RESULTS
  Among 90 endocrinologists invited to participate in the survey, 76 replied. Most respondents selected overnight dexamethasone suppression test (ONDST) and assessment of 24-hour urinary free cortisol (UFC) as the best screening tests followed by midnight serum cortisol and midnight salivary cortisol. Classic high dose dexamethasone suppression test and measurement of serum ACTH were selected for localization of the primary lesion by 64.5%. The primary choice of treatment was trans-sphenoidal pituitary surgery (86.8%). For the recurrence of Cushing's disease, the preferred treatment modality was medical therapy followed by bilateral adrenalectomy, and pituitary re-surgery. In case of treatment failure after the first pituitary surgery and ketoconazole treatment, 51% chose bilateral adrenalectomy, while36.8% selected pasireotide only.
  
  
  CONCLUSIONS
  ONDST and UFC are two most common tests used to screen an index case with signs and symptoms of hypercortisolism. The primary choice of treatment in Cushing's disease is pituitary surgery. However, medical treatment by ketokonazol is preferred for the recurrences. Pasireotide is the second alternative after bilateral adrenalectomy in case of treatment failure after pituitary surgery and ketoconazole.
authors.affiliation: MD, Professor of Endocrinology, Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran. malekmoj@yahoo.com.
authors.forename: Mojtaba
authors.initials: M
authors.lastname: Malek
authors.affiliation: MD, Associate Professor of Endocrinology, Department of Endocrinology, Imam Khomeini Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. fesfehanian@sina.tums.ac.ir.
authors.forename: Fatemeh
authors.initials: F
authors.lastname: Esfehanian
authors.affiliation: MD, Assistant Professor of Endocrinology, Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran. amouzegar@endocrine.ac.ir.
authors.forename: Atieh
authors.initials: A
authors.lastname: Amouzegar
authors.affiliation: MD, Associate Professor of Endocrinology, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran. f.sarvghadi@yahoo.com.
authors.forename: Farzaneh
authors.initials: F
authors.lastname: Sarvghadi
authors.affiliation: MD, Assistant Professor of Endocrinology, Endocrine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. mosaviz@mums.ac.ir.
authors.forename: Zohreh
authors.initials: Z
authors.lastname: Moossavi
authors.affiliation: MD, Assistant Professor of Endocrinology, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran. mrmohajeri@tums.ac.ir.
authors.forename: Mohammad R
authors.initials: MR
authors.lastname: Mohajeri-Tehrani
authors.affiliation: MD, Professor of Endocrinology, Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran. khamseh.m@iums.ac.ir.
authors.forename: Mohammad E
authors.initials: ME
authors.lastname: Khamseh
authors.affiliation: MD, Assistant Professor of Endocrinology, Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran. amirbaigloo@razi.tums.ac.ir.
authors.forename: Alireza
authors.initials: A
authors.lastname: Amirbaigloo
authors.affiliation: BS, Bachelor of statistics, Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran. ebrahimv86@gmail.com.
authors.forename: Ameneh
authors.initials: A
authors.lastname: Ebrahim Valojerdi
keywords: Clinical Practice; Cushing's disease; Diagnosis; Management