SUN-484 Levoketoconazole Use Prior to Adrenalectomy

Abstract Disclosure: I. Hulinsky: None. J. Crean: Xeris Pharmaceuticals. J. Hantrakul: Xeris Pharmaceuticals, Inc. Background: a patient presented with mild hypercortisolism and a 2.6 cm adrenal adenoma was scheduled for adrenalectomy. Patient was given Recorlev® pre-operatively to minimize surgical complications related to elevated cortisol levels, a use not previously reported. Clinical Case: A 35-year-old female presented in December 2020 complaining of a four-year history of 40 lbs. weight gain. Her medical history included hyperlipidemia, metabolic syndrome consisting of central obesity, and asthma. At presentation, her weight was 191 lbs. Due to rising fasting blood glucose levels, metformin 850 twice daily was initiated in March 2021 alongside Trulicity®, 0.75 titrated to 3mg weekly. At follow-up in March 2023, imaging identified a 1.9 × 1.9 cm adrenal tumor. Biochemical workup showed no initial abnormalities. However, repeat tests in June 2023 revealed an elevated aldosterone to renin activity ratio of 42 (reference: 0.9-28.9), plasma renin of 0.19 ng/mL/h (reference: 0.25-5.82 ng/mL/h), aldosterone of 8.0 ng/dL (reference: ≤ 28 ng/dL). A one milligram overnight dexamethasone suppression test was abnormal at 2.0 µg/dL. The LNSC test was 0.16 µg/dL (reference: ≤ 0.09 µg/dL) and morning cortisol was 0.72 µg/dL (reference: 0.04-0.56 µg/dL). A repeat CT scan showed a 1.9 cm low attenuation lesion in the right adrenal gland, consistent with an adenoma producing aldosterone and cortisol. Recorlev®, 150 mg daily was started in December 2023 with Trulicity and metformin discontinued. At a January 2024 follow-up, the Recorlev® dose was increased to 150 twice daily. By March 2024, all biochemical parameters, including DHEAS, cortisol, aldosterone, plasma renin activity, and aldosterone-to-renin ratio were within normal ranges. By July 2024, six months after starting Recorlev®, the patient weighed 162 lbs., representing a 34 lb. weight loss. A repeat CT scan revealed a 2 cm adenoma with -2HU. Given the patient’s age and tumor progression, surgery was chosen. Recorlev® was continued, laparoscopic adrenalectomy was performed in December 2024. The final pathology was of an adrenal cortical adenoma measuring 2.6 cm confirming the interval growth of the tumor. Recorlev® was discontinued immediately prior to surgery. Postoperative testing on day one showed: undetectable ACTH, baseline cortisol of 1.2 µg/dL (reference: 4.0-22.0 µg/dL), and a 30- and 60-minute Cosyntropin stimulated cortisol level of 20.5 µg/dL and 26.5 µg/dL (reference: >18 µg/dL) respectively. Outpatient post-operative biochemical follow-up showed all labs within normal range. Conclusion: This is the first documented case of pre-operative use of Recorlev® in a patient undergoing adrenalectomy. The tumor was found to secrete both cortisol and aldosterone. Pre-operative administration of Recorlev® successfully attenuated these hormones, facilitating a smooth surgical procedure and favorable postoperative outcome. Presentation: Sunday, July 13, 2025