How do I install the Es Cushing Confirm Medical Therapy Effective Before Rt skill?

Run npx skillmds@latest add dromlakhani/es-cushing-confirm-medical-therapy-effective-before-rt in your terminal (requires Node.js), paste this page's agent-chat prompt into Claude, Cursor, or any MCP-connected agent, or download the SKILL.md file and copy it into your agent's skills directory.

Which AI agents work with Es Cushing Confirm Medical Therapy Effective Before Rt?

This skill is tagged as working with Claude Code, Claude.ai, OpenAI Codex. SKILL.md is an open format, so most agents that read a skills directory can load it too.

Who published Es Cushing Confirm Medical Therapy Effective Before Rt?

dromlakhani (@dromlakhani) published this skill. Their other Agent Skills are listed on their SkillMD profile.

Es Cushing Confirm Medical Therapy Effective Before Rt by dromlakhani

Name: Es Cushing Confirm Medical Therapy Effective Before Rt
Rating: 4.5 (4 reviews)
Author: dromlakhani

Es Cushing Confirm Medical Therapy Effective Before Rt

This skill confirms that medical therapy has normalized cortisol before initiating radiation therapy or radiosurgery for Cushing's syndrome to maintain disease control while awaiting radiation effect. It is triggered when planning pituitary RT/radiosurgery for a patient with persistent or recurrent Cushing's disease after transsphenoidal surgery (TSS) or when medical therapy is being used as a bridge to radiation.

dromlakhani Updated Sep 8, 2026 10 repo stars

File contents

Confirming Medical Therapy Effectiveness in Normalizing Cortisol Before Administering Radiation Therapy/Radiosurgery

STEP 1 — Gather Information

Collect baseline cortisol biomarkers (24‑h urinary free cortisol, late‑night salivary cortisol, or serum cortisol) while the patient is on medical therapy; document the specific agent(s) and dose (e.g., ketoconazole, metyrapone, pasireotide, cabergoline, mitotane, etomidate, mifepristone); assess clinical signs/symptoms of hypercortisolism (weight gain, hypertension, glucose intolerance, etc.); confirm ACTH‑dependent Cushing’s disease diagnosis and prior transsphenoidal surgery status.

STEP 2 — Rule In / Rule Out

Determine if cortisol is normalized: UFC within assay‑specific normal range, late‑night salivary cortisol ≤ laboratory upper limit, or serum cortisol within normal range, and the patient shows clinical improvement (e.g., reduced weight, better BP/glucose). If both criteria are met → rule in effective medical therapy; if cortisol remains elevated or symptoms persist → rule out ineffective medical therapy.

STEP 3 — Classify or Stratify

Classify the patient as:

Effective: normalized cortisol + clinical improvement → proceed to STEP 4.
Ineffective: elevated cortisol or lack of clinical improvement → further stratify by degree of elevation (mild: 1–2× ULN, moderate: 2–5× ULN, severe: >5× ULN) to guide therapy intensification.

STEP 4 — Decide

If effective: schedule radiation therapy or radiosurgery; continue current medical therapy until radiation effect is evident (typically 6‑12 months post‑RT). If ineffective: intensify or switch medical therapy (e.g., add a second agent, increase dose, consider alternative class), re‑measure cortisol after 2‑4 weeks, and delay radiation until normalization is achieved.

Clinical Guardrails / Mimics / Pitfalls

Do not proceed to RT/radiosurgery if cortisol remains elevated; avoid relying solely on UFC when using metyrapone or ketoconazole due to assay cross‑reactivity (prefer LC‑MS/MS or salivary cortisol); monitor for adrenal insufficiency and medication side effects (e.g., hepatotoxicity with ketoconazole, QT prolongation with pasireotide); do not delay radiation unnecessarily once cortisol is controlled, as prolonged hypercortisolism increases morbidity; ensure patient is clinically euthyroid and not pregnant when using certain agents.

Concrete Clinical Example

A 48‑year‑old woman with recurrent Cushing’s disease after transsphenoidal surgery is on pasireotide 900 µg twice daily. Late‑night salivary cortisol is normal, UFC is within normal range, and her hypertension and glucose have improved. Radiation therapy is planned for the pituitary lesion.

Source: Treatment of Cushing’s Syndrome: An Endocrine Society Clinical Practice Guideline, Nieman et al., Endocrine Society, 2015, DOI: 10.1210/jc.2015-1818

---name: es-cushing-confirm-medical-therapy-effective-before-rtdescription: This skill confirms that medical therapy has normalized cortisol before initiating radiation therapy or radiosurgery for Cushing's syndrome to maintain disease control while awaiting radiation effect. It is triggered when planning pituitary RT/radiosurgery for a patient with persistent or recurrent Cushing's disease after transsphenoidal surgery (TSS) or when medical therapy is being used as a bridge to radiation.---# Confirming Medical Therapy Effectiveness in Normalizing Cortisol Before Administering Radiation Therapy/Radiosurgery## STEP 1 — Gather InformationCollect baseline cortisol biomarkers (24‑h urinary free cortisol, late‑night salivary cortisol, or serum cortisol) while the patient is on medical therapy; document the specific agent(s) and dose (e.g., ketoconazole, metyrapone, pasireotide, cabergoline, mitotane, etomidate, mifepristone); assess clinical signs/symptoms of hypercortisolism (weight gain, hypertension, glucose intolerance, etc.); confirm ACTH‑dependent Cushing’s disease diagnosis and prior transsphenoidal surgery status.## STEP 2 — Rule In / Rule OutDetermine if cortisol is normalized: UFC within assay‑specific normal range, late‑night salivary cortisol ≤ laboratory upper limit, or serum cortisol within normal range, **and** the patient shows clinical improvement (e.g., reduced weight, better BP/glucose). If both criteria are met → rule in effective medical therapy; if cortisol remains elevated or symptoms persist → rule out ineffective medical therapy.## STEP 3 — Classify or StratifyClassify the patient as:- **Effective**: normalized cortisol + clinical improvement → proceed to STEP 4.- **Ineffective**: elevated cortisol or lack of clinical improvement → further stratify by degree of elevation (mild: 1–2× ULN, moderate: 2–5× ULN, severe: >5× ULN) to guide therapy intensification.## STEP 4 — DecideIf effective: schedule radiation therapy or radiosurgery; continue current medical therapy until radiation effect is evident (typically 6‑12 months post‑RT). If ineffective: intensify or switch medical therapy (e.g., add a second agent, increase dose, consider alternative class), re‑measure cortisol after 2‑4 weeks, and delay radiation until normalization is achieved.## Clinical Guardrails / Mimics / PitfallsDo not proceed to RT/radiosurgery if cortisol remains elevated; avoid relying solely on UFC when using metyrapone or ketoconazole due to assay cross‑reactivity (prefer LC‑MS/MS or salivary cortisol); monitor for adrenal insufficiency and medication side effects (e.g., hepatotoxicity with ketoconazole, QT prolongation with pasireotide); do not delay radiation unnecessarily once cortisol is controlled, as prolonged hypercortisolism increases morbidity; ensure patient is clinically euthyroid and not pregnant when using certain agents.## Concrete Clinical ExampleA 48‑year‑old woman with recurrent Cushing’s disease after transsphenoidal surgery is on pasireotide 900 µg twice daily. Late‑night salivary cortisol is normal, UFC is within normal range, and her hypertension and glucose have improved. Radiation therapy is planned for the pituitary lesion.**Source:** Treatment of Cushing’s Syndrome: An Endocrine Society Clinical Practice Guideline, Nieman et al., Endocrine Society, 2015, DOI: 10.1210/jc.2015-1818

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