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Ectopic ACTH Management — SCE Medical Oncology MCQ

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HardOncological EmergenciesEctopic ACTH ManagementSCE Medical Oncology

A patient with metastatic ectopic-ACTH syndrome has life-threatening hypercortisolism, sepsis, severe hypokalaemia and ileus. Cortisol remains markedly raised despite prior oral metyrapone, which can no longer be absorbed reliably. What is the best rapid bridge while definitive treatment is planned?

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Correct answer: C — Use a titrated intravenous etomidate infusion with intensive-care cortisol monitoring

Intravenous etomidate rapidly inhibits adrenal steroidogenesis and is suited to severe hypercortisolism when enteral absorption is unreliable; cortisol must be monitored closely to titrate or use block-and-replace treatment. Nasogastric metyrapone remains unreliable in ileus. Combining two oral steroidogenesis inhibitors does not solve absorption. Mifepristone is oral and serum cortisol cannot monitor its receptor-blocking effect. Emergency adrenalectomy may ultimately be needed but operative treatment before stabilising sepsis, potassium and cortisol is hazardous.

Reference: Endocrine Society clinical practice guideline for treatment of Cushing syndrome (Published August 2015): https://pubmed.ncbi.nlm.nih.gov/26222757/; Etomidate 2 mg/mL UK summary of product characteristics (Current UK SmPC, accessed July 2026): https://www.medicines.org.uk/emc/product/15214/smpc