chronic

Cushing's Syndrome (Referral)

Treatment options, dosing, cautions and Egyptian brands from the shipped Dawaa Reference card.

Evidence status

Checked against the sources named below

Sources3 sources

Endocrine Society Guideline on Diagnosis of Cushing's Syndrome 2008 · Egyptian National Drug Formulary - Antimicrobial 2023 (ketoconazole monograph) · Cushing Disease - StatPearls - NCBI Bookshelf (NBK448184) - disease-level clinical article

Verified against2 documents

Egyptian National Drug Formulary - Antimicrobial 2023 (ketoconazole monograph)
Cushing Disease - StatPearls - NCBI Bookshelf (NBK448184) - disease-level clinical article

Verified date2026-08

Presentation reference

Is it this?

Reference only, to read alongside your own examination.

Symptoms — what the patient reports (12)

Steady weight gain, usually centred on the trunk, is the commonest complaint [weight gain]
Headache, dizziness and blurred vision from the raised blood pressure [blurred vision · dizziness · headache · hypertension]
Passing much urine, thirst, and either a big appetite or none, as sugar climbs
Women: scanty or absent periods, difficulty conceiving or outright infertility [absent periods · infertility]
Men: reduced libido, low energy, tiredness, vague weakness and erectile difficulty [fatigue]
Bruising with little provocation is one of the more telling complaints [bruising]
Weak shoulder and hip muscles: trouble on stairs, rising from a low chair, or squatting
In a child, weight climbing across the centiles while height stalls is the giveaway
Disturbed sleep, with vivid dreams and nightmares
Depression and mood swings, from elation to sudden low, and sometimes psychosis with no prior history [low mood]
Women: excess hair growth and heavy acne; frank virilisation instead suggests adrenal cancer [acne · excess hair · virilisation]
Long-standing disease thins bone: chronic back pain, lost height from collapsed vertebrae, fractures on trivial impact [back pain · collapse]

Signs — what you find (12)

Most patients do not look like the textbook picture, so suspicion has to be kept high
No single sign clinches it, and the vague ones lead to both over- and under-diagnosis
A rounded, moon-shaped face
Flushed cheeks with prominent small vessels across them
Fat pad at the back of the neck and above the collarbones; the collarbone pads are the more telling
Raised blood pressure [hypertension]
Thin skin bearing broad purple stretch marks over abdomen, thighs or breasts, and bruises after trivial knocks [bruising · stretch marks]
Hair loss in women [hair loss]
Skin darkened all over points to the ACTH-driven forms
The blood pressure can be severe and drug-resistant at presentation, with heart failure or a dilated heart
Screen young adults with thin bone, early hypertension, high sugar, a plethoric face or weak proximal muscles [hypertension]
Also screen for pigmented, palpable stretch marks over 1 cm wide, easy bruising in the young, or an adrenal lesion found by chance [bruising · stretch marks]

Tests (11)

Ask hard about steroid exposure, creams and inhalers included, and about recreational or covert use
Screening is built to catch cases, so it is deliberately sensitive and less specific
It is confirmed when two different first-tier screening tests come back plainly high
Salivary cortisol, at least twice, early morning and late at night, to see whether the daily rhythm survives
A 24-hour urine for free cortisol: throw away the first morning sample, then collect everything
Too little urine gives a false negative, too much a false positive, and poor kidney function lowers the reading
Prove the tablet was taken and absorbed by measuring the dexamethasone level the same morning
Repeat screening when suspicion stays high despite a negative result, or where the disease may be cyclical
Results are skewed by other medicines, dexamethasone metabolism, night shifts, binding globulin changes and sleep disorders
ACTH is pulsed and varies through the day, so it usually has to be repeated before it can be trusted
ACTH persistently under 5 pg/mL means the adrenal or an outside steroid; above 20 pg/mL means ACTH is driving it

If not this — what else fits (12)

Pregnancy, severe obesity, or melancholic depression can raise cortisol without the disease
Long-term heavy drinking, or diabetes that is badly controlled
Eating disorders, bulimia nervosa and night eating among them
Chronic lymphoedema, lipoedema, partial lipodystrophy or Dercum disease
Hypothalamic obesity syndromes: Prader-Willi, Frohlich and Bardet-Biedl
In children also POMC or leptin deficiency obesity, and Sotos syndrome
Generalised swelling from severe malnutrition, heart failure, cirrhosis with ascites, or nephrotic syndrome
Abnormal bloods without the physical picture: steroids taken from outside, or covert self-administration
Severe physical stress, severe undernutrition or anorexia nervosa
Excessive exercise, including the athlete triad of disordered eating, absent periods and thin bone
Hypothalamic amenorrhoea, or a state of resistance to glucocorticoids
Rarely, cortisol made outside the adrenal, or high cortisol with none of the Cushingoid features

SourceStatPearls "Hypercortisolism (Cushing Syndrome)" - disease-level clinical article

Presentation findings are traced to the source above.

KETOCONAZOLE

1st line

Strength200 mg

Formoral.solid

Adult dose and duration

Oral: 200 mg once daily; may increase to 400 mg once daily if response is insufficient. - pre-operative bridge / specialist management

Paediatric dose

Specialist pediatric endocrinology management

Dose source

Egyptian National Drug Formulary - Antimicrobial 2023 (ketoconazole monograph)

Why

All oral forms are cancelled in Egypt, but kept as the guideline medical bridge to surgery; specialist sourcing required.

Cautions

Requires urgent endocrinology referral for diagnostic workup (late-night salivary cortisol, 24h urinary free cortisol, dexamethasone suppression test).
Black box warning for severe hepatotoxicity; check baseline and regular LFTs.
Ketoconazole is a potent CYP3A4 inhibitor with an extensive drug interaction profile.

Egyptian brands

Egyptian brand	Manufacturer	Indicative price
KIZOL 200MG 10 TAB. (CANCELLED)discontinued	RAMEDA	21.60 EGP (2.16/unit)
FUNGIZOLE 200MG 10 TAB. (CANCELLED)discontinued	ALEXANDRIA	22.00 EGP (2.20/unit)
KETOZOLE 200MG 10 TAB. (CANCELLED)discontinued	MEMPHIS	22.00 EGP (2.20/unit)
NIZORAL 200MG 10 TAB. (CANCELLED)discontinued	JANSSEN CILAG	33.90 EGP (3.39/unit)
ZAKAN 2GM/100ML SHAMPOO 60 ML? strength differs? different route - not oral solid	SIGMA	18.30 EGP

Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy.