Figure 2.

Medical management by ‘Block and Replace’. These recommendations for block and replace regime are ‘expert advice’ rather than being evidence based. Telephone consultations should evaluate symptomatology, weight, BP and capillary blood glucose to assist judging the effectiveness of the replacement glucocorticoid dose. Patients should be instructed to follow ‘sick day rules’ for glucocorticoid replacement (see text). Note: when using metyrapone any assay that has cross-reactivity with 11-deoxycortisol will read falsely high – where possible – LC-MS/MS assays are recommended; *doses may be increased further if needed and ketoconazole and metyrapone may be used in combination; with monitoring, it may also be possible to reduce the dose while maintaining blockade – collaboration with expert in Cushing's is recommended.