6401 Exogenous Cushing Syndrome By Over The Counter Substance "AK Forte". Case Report

Abstract Disclosure: M.M. Eid: None. S. Gandhi: None. Introduction: Cushing syndrome is a condition of hypercortisolism, either due to excess activity of hypothalamic-pituitary-adrenal (HPA) axis or exogenous steroid intake. Case: A 36 year old, female with history of type 2 DM, HTN, HLD and arthritis. She was referred for evaluation of face and neck swelling for 3 months. No known allergy. Irrelevant family history. Daily Medications include Glipizide 2.5mg, Metformin 500mg twice, Lisinopril 2.5mg and Glargine 8 units. She reports weight gain, muscle weakness and fall, easy bruise, irregular menstruation and stretch marks for a year. Denies hirsutism. On exam: normal vital signs, BMI 47.87 with cushingoid features facial plethora, moon face, dorsocervical pad fat, violet abdominal and arm striae, proximal muscle weakness. No thyromegaly. Late night salivary cortisol 0.071ug/dl(N 0.359),24 hr urine free cortisol 1ug/dl(N 45), DHEA-S 6 ug/dl (N 61-337), 17 Hydroxyprogesterone (OH progesterone) 5ng/dl, 1 mg overnight Dexamethasone suppression test: AM cortisol 1 ug/dl, ACTH 1.7 pg/ml (N 7.2-63.3). Na 137 mmol/L , K 4.1 mmol/L,TSH 0.51mciu/ml(N 0.3-4), FT4 0.9 ng/dl(N 0.6-1.7), HBA1C 14% (was 5.1% a year ago). CT abdomen pelvis with normal adrenal glands. Endogenous hypercortisolism was excluded with low 24 urinary cortisol, and late-night salivary cortisol and adequate suppression of morning cortisol with dexamethasone. Low DHEA-S and 17 OH progesterone raises the possibility of exogenous hypercortisolism. A Thorough review of medications and substance revealed that she has been taking over the counter (OTC) AK Forte 400mg 2 tablets 2 times/day for 13 months for arthralgia. In April 2023, FDA released a public notification that AK Forte contains unspecified amount of diclofenac, dexamethasone, and methocarbamol not listed on the product label and warned against taking it (2). We recommended discontinuation of OTC substance and kept her on hydrocortisone 20mg morning and 10 mg afternoon to avoid adrenal insufficiency with plan of gradual hydrocortisone tapering till HPA axis recovers. For uncontrolled DM, dulaglutide 0.75mg/week, and premeal insulin were started and glargine dose was increased. Conclusion: We are presenting a case of exogenous Cushing’s syndrome by OTC substance that contains undeclared ingredients. Dexamethasone in AK Forte causes exogenous hypercortisolism and Cushingoid features with HPA axis suppression. We emphasize the importance of thorough medication reconciliation including OTC substances. We encourage reporting adverse events of OTC substances to FDA. Reference: 1-J.Newell-Price,X.Bertagna,A.B.Grossman,andL.K.Nieman, “Cushing’s syndrome,” Te Lancet, vol. 367, no. 9522, pp. 1605-1617, 2006. 2-https://www.fda.gov/drugs/medication-health-fraud/public-notification-ak-forte-contains-hidden-drug-ingredients. Presentation: 6/2/2024