scholarly journals Diagnosis of secondary adrenal insufficiency in patients with hypothalamic–pituitary disease: comparison between serum and salivary cortisol during the high-dose short synacthen test

2009 ◽  
Vol 160 (1) ◽  
pp. 9-16 ◽  
Author(s):  
Timo Deutschbein ◽  
Nicole Unger ◽  
Klaus Mann ◽  
Stephan Petersenn
Keyword(s):  
Salivary Cortisol ◽  
Serum Cortisol ◽  
Early Morning ◽  
Diagnostic Value ◽  
Tolerance Test ◽  
High Dose ◽  
Characteristic Analysis ◽  
Synacthen Test ◽  
Short Synacthen Test

ObjectiveAccurate assessment of adrenal function is essential in patients with hypothalamic–pituitary–adrenal (HPA) disease. The measurement of salivary cortisol (SaC) instead of serum cortisol (SeC) offers several advantages, such as the determination of the free hormone. We evaluated the diagnostic value of SeC and SaC both unstimulated and during a high-dose short synacthen test (HDT) in comparison to the insulin tolerance test (ITT).DesignComparative study between 2005 and 2007.MethodsFifty-five patients with HPA impairment and 21 healthy controls were enrolled. Samples were collected in the early morning and over 120 min during the HDT. Receiver operating characteristic analysis revealed individual thresholds for four HDT periods (0–30, 0–60, 0–90, and 0–120 min).ResultsThe ITT identified 30 subjects as adrenal insufficient. With respect to the four HDT periods, sensitivity and specificity were 67–79% and 71–88% for SeC, compared with 63–72% and 72–86% for SaC. If upper and lower thresholds (with specificities >95%) were applied, patients were diagnosed in 40–45% by SeC and in 25–31% by SaC. The combination of basal cortisol and HDT allowed a diagnosis in 47–49% (SeC) and in 42–45% (SaC) respectively.ConclusionWe suggest the determination of basal SeC or SaC as first-line test. In comparison to the ITT, the HDT has only limited value in screening for alterations of the HPA axis. If the HDT is performed, sampling may be limited to 30 min post-synacthen, using either SeC or SaC. Due to the ease of collection and the independence of binding proteins, SaC may be preferable.

Long-acting intramuscular ACTH stimulation test for the diagnosis of secondary adrenal insufficiency in children

2019 ◽  
Vol 32 (1) ◽  
pp. 57-63 ◽  
Author(s):  
Rajni Sharma ◽  
Shamnad Madathil ◽  
Vivek Maheshwari ◽  
Kakali Roy ◽  
Brijesh Kumar ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Serum Cortisol ◽  
Diagnostic Value ◽  
Tolerance Test ◽  
Hormone Deficiency ◽  
Cortisol Response ◽  
Acth Test ◽  
Acth Stimulation ◽  
Long Acting ◽  
Short Synacthen Test

Abstract Background The diagnosis of adrenal insufficiency (AI) is based on the basal and stimulated levels of serum cortisol in response to the short Synacthen test (SST). In patients with secondary AI (SAI) due to hypothalamic-pituitary-adrenal (HPA) axis defects, the SST has been validated against the insulin tolerance test (ITT), which is the gold standard. However, injection Synacthen is not easily available in some countries, and endocrinologists often use Acton-Prolongatum (intramuscular [IM] long-acting adrenocorticotropic hormone [ACTH]) in place of Synacthen. There are no studies validating the use of IM-ACTH in children with suspected AI. We evaluated the diagnostic value of the IM-ACTH test against the ITT for the diagnosis of SAI in children. Methods All children with suspected growth hormone deficiency (GHD) undergoing a routine ITT were evaluated using the IM-ACTH test within 1 week. Results Forty-eight patients (36 boys/12 girls, age range: 5–14 years) were evaluated using both the ITT and the IM-ACTH test. Twenty-eight patients had a normal cortisol response (≥18 μg/dL, 500 nmol/L) in the ITT and 20 had low values. In patients with a normal cortisol response on the ITT, the peak value obtained after the IM-ACTH test was higher than that on the ITT (28.7 μg/dL [± 8.8] vs. 23.8 μg/dL [± 4.54], respectively; p=0.0012). Compared to the ITT, the sensitivity and specificity of the IM-ACTH test for the diagnosis of SAI at cortisol cut-offs <18 μg/dL (500 nmol/L) and <22 μg/dL (600 nmol/L) were 57.1% and 92.8%, and 100% and 73.5%, respectively. Conclusions A peak cortisol value <18 μg/dL on the IM-ACTH test is highly suggestive of SAI, whereas a value >22 μg/dL rules out SAI.

Early morning salivary cortisol and cortisone, and adrenal responses to a simplified low-dose short Synacthen test in children with asthma

2013 ◽  
Vol 80 (3) ◽  
pp. 376-383 ◽  
Author(s):  
Joanne Blair ◽  
Gillian Lancaster ◽  
Andrew Titman ◽  
Matthew Peak ◽  
Paul Newlands ◽  
...  
Keyword(s):  
Salivary Cortisol ◽  
Low Dose ◽  
Early Morning ◽  
Children With Asthma ◽  
Synacthen Test ◽  
Short Synacthen Test

scholarly journals Can the Gold Standard Be Beaten? How Reliable Are Various Modifications of the Synacthen Test Compared to the Insulin Tolerance Test

2017 ◽  
pp. S387-S395 ◽  
Author(s):  
M. KOSAK ◽  
M. DUSKOVA ◽  
L. STARKA ◽  
H. JANDIKOVA ◽  
H. POSPISILOVA ◽  
...  
Keyword(s):  
Salivary Cortisol ◽  
Serum Cortisol ◽  
Tolerance Test ◽  
Insulin Tolerance Test ◽  
Maximum Response ◽  
Similar Response ◽  
Good Reliability ◽  
Maximum Serum ◽  
Insulin Tolerance ◽  
Synacthen Test

Criteria for the evaluation of the insulin tolerance test (ITT) and Synacthen test are still a matter of debate. The objective of the study was to make a comparison of serum and salivary cortisol during four stimulation tests. Sixty four healthy volunteers underwent the ITT, the Synacthen test with 1 (LDST), 10 (MDST) and 250 (HDST) μg dose of ACTH. Maximum serum cortisol response was observed at the 90 min of the ITT (49 %), HDST (89 %) and MDST (56 %) and at the 40 min of the LDST (44 %). Results expressed as 95 % confidence intervals: 408.0-843.6 and 289.5-868.1 nmol/l in the IIT at 60 and 90 min. In the HDST and the MDST serum cortisol reached the maximum at 90 min 542.6-1245.5 and 444.2-871.3 nmol/l. Levels of salivary cortisol followed the same pattern as serum cortisol. Salivary cortisol reached the maximum response in the HDST and the MDST at 90 min and at 40 min in the LDST. We confirmed good reliability of all tests with respect to timing of response and maximum response compared to the ITT. We proved that the MDST test can provide the similar response in serum cortisol to the HDST. Measuring either salivary cortisol or ACTH levels did not provide any additional benefit then measuring serum cortisol by itself.

Hypothalamic–pituitary–adrenal axis suppression – The value of salivary cortisol and cortisone in assessing hypothalamic–pituitary–adrenal recovery

2020 ◽  
Vol 57 (6) ◽  
pp. 456-460 ◽  
Author(s):  
Tejas Kalaria ◽  
Mayuri Agarwal ◽  
Sukhbir Kaur ◽  
Lauren Hughes ◽  
Hayley Sharrod-Cole ◽  
...  
Keyword(s):  
Salivary Cortisol ◽  
Serum Cortisol ◽  
Hypothalamic Pituitary Adrenal Axis ◽  
Adrenal Suppression ◽  
Baseline Serum ◽  
Hypothalamic Pituitary Adrenal ◽  
Adrenal Axis ◽  
Synacthen Test ◽  
Short Synacthen Test ◽  
Pituitary Adrenal Axis

Background The 0.25 mg short synacthen test is used to assess recovery from hypothalamic–pituitary–adrenal suppression due to chronic glucocorticoid administration. We assessed the potential role of salivary cortisol and cortisone in predicting hypothalamic–pituitary–adrenal function using the short synacthen test as the gold standard test. Method Between 09:00 and 10:30, salivary and blood samples were collected just prior to a short synacthen test to assess hypothalamic–pituitary–adrenal axis recovery in patients previously treated with oral glucocorticoids. The cut-off for a normal short synacthen test was a 30-min cortisol ≥450 nmol/L. Results Fifty-six short synacthen tests were performed on 47 patients. Of these, 15 were normal. The area under receiver operating characteristic curves for serum cortisol, salivary cortisone and salivary cortisol were 0.772, 0.785 and 0.770, respectively. From the receiver operating characteristic analysis, the cut-offs for baseline serum cortisol (≥365 nmol/L) and salivary cortisone (≥37.2 nmol) predicted hypothalamic–pituitary–adrenal axis recovery with 100% specificity in 26.7% of pass short synacthen tests, whereas salivary cortisol predicted none. Baseline serum cortisol (≤170 nmol/L), salivary cortisone (≤9.42 nmol/L) and salivary cortisol (≤1.92 nmol/L) predicted hypothalamic–pituitary–adrenal suppression with 100% sensitivity in 58.5%, 53.7% and 51.2% of failed short synacthen tests, respectively. Using these cut-offs, baseline serum cortisol, salivary cortisone and salivary cortisol could reduce the need for short synacthen tests by 50%, 46% and 37%, respectively. Conclusion Although marginally inferior to early morning serum cortisol, early morning salivary cortisone may be used as a first-line test for assessing hypothalamic–pituitary–adrenal function. We plan to incorporate salivary cortisone into a home-based patient pathway to identify patients with hypothalamic–pituitary–adrenal recovery, continuing hypothalamic–pituitary–adrenal suppression and those who require a short synacthen test.

scholarly journals Which serum cortisol after high dose short synacthen test, 30 or 60 min?

2014 ◽  
Author(s):  
Mansour Abbas Ali ◽  
Alhamza Ali Hussein Ali ◽  
Ammar Mohamd Saead Almomin
Keyword(s):  
Serum Cortisol ◽  
High Dose ◽  
Synacthen Test ◽  
Short Synacthen Test

The short Synacthen test: a questionnaire survey of current usage

2012 ◽  
Vol 97 (10) ◽  
pp. 870-873 ◽  
Author(s):  
Charlotte Jane Elder ◽  
Pooja Sachdev ◽  
Neil Peter Wright
Keyword(s):  
Low Dose ◽  
Inhaled Corticosteroids ◽  
British Society ◽  
High Dose ◽  
Paediatric Endocrinology ◽  
Children With Asthma ◽  
Synacthen Test ◽  
The Uk ◽  
Meta Analyses ◽  
Short Synacthen Test

BackgroundSupported by meta-analyses, the low-dose Synacthen test (LDST) has gained in popularity, with many believing it to be more sensitive than the supraphysiological standard (250 µg) short ST (SSST), particularly when assessing children prescribed high-dose inhaled corticosteroids (HDICS). However, consensus is lacking about its specific clinical application, what is considered ‘low dose’ and how that dose is made up.MethodsTo ascertain current use of the short Synacthen test (SST), a questionnaire was emailed to members of the British Society of Paediatric Endocrinology and Diabetes in the UK and Ireland (N=257), requesting a response from each department (N=92). A reminder was sent a month later to members of departments which had not responded.ResultsThe authors received 39 replies, giving a response rate of 42%. All departments use the SST: 82% use an LDST, 87% use the SSST and 69% use both. The 1 µg dose was used by 44% of hospitals, with the other 56% using seven different doses based on age, weight and body surface area. There were 14 different methods of preparing the low dose test. Additionally, variations in the timings of cortisol sampling and the diagnostic cut-offs for adrenal insufficiency were found. Increased requests for SSTs in children with asthma prescribed HDICS were noted by 44% of respondents, with 67% reporting the detection of adrenal suppression in this group.ConclusionStandardisation of the SST is required to address the considerable variation in the methodology and application of this test in the UK and Ireland.

scholarly journals Predictive Accuracy of Delta Cortisol on Recovery of Adrenal Function in Patients With Drug Induced Cushing’s Syndrome With Secondary Adrenal Insufficiency

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A91-A91
Author(s):  
Bo Bo San
Keyword(s):  
Cushing’S Syndrome ◽  
Cushing Syndrome ◽  
Serum Cortisol ◽  
Cushing's Syndrome ◽  
Adrenal Function ◽  
Drug Induced ◽  
Basal Serum ◽  
Synacthen Test ◽  
Short Synacthen Test

Abstract There is a growing concern upon the finding of many drug induced Cushing’s syndrome because of inadvertent use of glucocorticoids (GC) either prescribed or as alternative medicine in Myanmar. These patients are presenting with diversity of clinical problems ranging from hypertension, diabetes to acute adrenal crisis due to hypothalamic-pituitary-adrenal (HPA) axis suppression and secondary adrenal insufficiency (AI). The present study aimed to assess the delta cortisol (the degree of cortisol increments) during the first short Synacthen test (SST) as a factor predictive of adrenal function recovery in patients with drug induced Cushing’ syndrome with secondary AI and to determine the proportion of patients who recovered from AI within six-month follow-up. This was a hospital based prospective analytical study that enrolled a total of 52 patients with drug induced Cushing’s syndrome with secondary AI from January 2018 to June 2019. Secondary AI is defined by morning basal serum cortisol ≤ 400 nmol/L with Synacthen stimulated peak cortisol level ≤ 550 nmol/L and serum ACTH &lt; 60 pg/ml. The follow-up SSTs were performed at three-month and six-month after first SST, and the patients with morning basal serum cortisol &gt; 400 nmol/L (or) Synacthen stimulated peak serum cortisol &gt; 550 nmol/L during follow-up SSTs are defined as recovered adrenal function group. In this study, a total of 52 patients were treated with modified regimen of physiological dose of prednisolone with tapering schedule or stress dose GC based on the basal serum cortisol levels up to six months. Among them, nearly half (n=25 / 48.1%) of the patients with drug induced Cushing’s syndrome with secondary AI achieved normal adrenal function within six-month follow-up. It was found that mean values for delta cortisol were not statistically significant between recovered and non-recovered groups, 118.6 nmol/L (SD 72.3) and 97.2 nmol/L (SD 64.2) respectively. The delta cortisol during the first SST could not predict strongly (AUC - 0.6, 95% CI - 0.44 to 0.76, P = 0.2) the recovery of adrenal function in patients with drug induced Cushing’s syndrome with secondary AI and it was inconsistent with previous studies. The older age of the patients, oral route of administration of drugs causing Cushing’s syndrome and comorbid hypertension were found to be more significant in the non-recovered group. In conclusion, the present study did not support the evidence that the delta cortisol during the first SST could predict adrenal function recovery in patients with drug induced Cushing’ syndrome with secondary AI. Reference: (1) Baek et al., 2016; Recovery of Adrenal Function in Patients with Glucocorticoids Induced Secondary AI. Endocrinol Metab.31, pp. 153–160. (2) Pofi et al., 2018; The Short Synacthen Test Can Be Used to Predict Recovery of HPA Axis Function. J Clin Endocrinol Metab.103(8), pp. 3050–3059.

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