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Doctors’ Response to June News Linking Cortisol Level to Death Risk with COVID-19

On June 18, 2020, online medical journal The Lancet Diabetes and Endocrinology published a report about the association between high cortisol and death rate with COVID-19. Numerous news outlets picked this up and ran with it, and it’s caused some confusion and alarm in our community. Click the link below for the report.

Association between high serum total cortisol concentrations and mortality from COVID-19.  Tricia Tan, Bernard Khoo, Edouard G Mills, Maria Phylactou, Bijal Patel, Pei C Eng, Layla Thurston, Beatrice Muzi, Karim Meeran, A Toby Prevost, Alexander N Comninos, Ali Abbara, Waljit S Dhillo.  The Lancet Diabetes & Endocrinology (June 18, 2020) published online. https://doi.org/10.1016/S2213-8587(20)30216-3

We asked a few members of our Medical Advisory Board to weigh in on this article and its ramifications for patients with Cushing’s and other forms of hypercortisolism:

Dr. Adriana Ioachimescu, Emory (Atlanta, GA): In general, cortisol responds to acute illness with a significant increase. In severely ill patients, the cortisol levels can be quite high. Multiple studies looked at cortisol levels in patients in the intensive care unit. Research has shown that those with low and very high cortisol levels are at higher risk of death compared to those with a mild to moderate increase above normal. The exact threshold varies across studies. Our current understanding of this laboratory abnormality is that cortisol levels are responding to the degree of systemic illness with either “adrenal insufficiency of the critically ill” or with hypercortisolism. Hence, measuring cortisol levels can serve as a prognosis of bad outcome. How this applies specifically to Cushing’s syndrome patients who already have elevated cortisol levels at baseline has not been studied. I expect a lot of research will be done on this topic now that a study suggested administration of dexamethasone in Covid-19 patients may improve outcomes.

Dr. Maria Fleseriu, Oregon Health and Science University (Portland, OR):  The study mentioned in the article and published in Lancet looked at cortisol values in patients with no known history of either adrenal insufficiency or Cushing’s, thus does not apply directly to patients with Cushing’s. Data is relatively similar with previous studies in non-COVID-related severe diseases in ICU; very high cortisol, when present, is a marker of severe disease in ICU patients.

A lot is still unknown for patients with Cushing’s and COVID, however based on data from other infectious diseases and prevalence of diabetes and hypertension, risk of infection could be higher and complications can be more frequent theoretically in patients with Cushing’s.

Even more important, patients with adrenal insufficiency after treatment of Cushing’s might need higher doses of stress dose steroid /glucocorticoid if infected and every 6 hours, based on other studies from the UK.

Dr. Eliza Geer, Memorial Sloan Kettering Cancer Center (NYC):   I agree with my colleagues and don’t have much more to add, other than to reiterate that for the patients in this study, their high cortisol levels are a reflection of their sickness/stress levels – this is a very different situation that someone with Cushing’s who has a tumor causing high cortisol.

Although with active/untreated Cushing’s, the high cortisol levels suppress the immune system, so active Cushing’s patients are likely at higher risk to get sick if exposed to this virus (or other viruses). And as Maria mentioned, Cushing’s comorbidities like diabetes and  high blood pressure especially now need to be strictly managed since these are risk factors for getting sicker if exposed to SARS-CoV-2.

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