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Okutan S, Jørgensen NT, Pedersen LE, Borresen SW, Hilsted L, Hansen LF, Feldt-Rasmussen U, Klose M. Determination of cortisol cut-off limits and steroid dynamics in the ACTH stimulation test: a comparative analysis using Roche Elecsys Cortisol II immunoassay and LC-MS/MS. Endocrine 2024; 85:321-330. [PMID: 38460071 PMCID: PMC11246257 DOI: 10.1007/s12020-024-03752-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 02/12/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE Measurement of cortisol concentrations is method dependent. The study aimed to establish assay-specific cut-off limits for cortisol after adrenocorticotropic hormone (ACTH) stimulation, comparing Roche Elecsys Cortisol II immunoassay to liquid chromatography-mass spectrometry (LC-MS/MS), and to assess the impact of patient characteristics, estrogen containing oral contraceptives as well as relation to other adrenocortical steroid hormone dynamics. METHODS One hundred healthy participants underwent a 250 μg ACTH-test, with plasma samples analyzed using ElecsysCortI, ElecsysCortII, and LC-MS/MS. Cortisone, corticosterone, 17-OH-progesterone, dehydroepiandrosterone sulfate (DHEAS), androstenedione, and testosterone were additionally analyzed with LC-MS/MS. Cut-off limit for a normal cortisol response to the ACTH-test was defined as: 2.5th percentile-1.96 × SE. RESULTS ElecsysCort II measured cortisol concentrations 21% (95% CI: 19-22%) lower than ElecsysCort I. Cut-off limits for cortisol 30 and 60 min after ACTH were 426 and 485 nmol/L (ElecsysCort II) and 411 and 470 nmol/L (LC-MS/MS). Cut-offs were unaffected by gender, or body-composition. The ACTH-test resulted in significantly increased adrenocortical steroid hormones, except for decreased cortisone concentrations (both sexes), and decreased testosterone in men (1.9 nmol/L, 95% CI: 1.3-2.5). Testosterone was increased in women (0.07 nmol/L, 95% CI: 0.02-0.13). CONCLUSION ElecsysCort II has high analytical performance and yields significantly lower cortisol concentrations than prior polyclonal immunoassays. This clinically relevant difference underscores the necessity for revised cut-off limits for improved diagnostic precision. Suggested 30-minute cortisol cutoff limits are 411 nmol/L (LC-MS/MS) and 426 nmol/L (ElecsysCort II). Adrenocortical steroids increased upon ACTH stimulation, except for cortisone in both sexes and testosterone in men, both of which decreased.
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Affiliation(s)
- Sema Okutan
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nanna Thurmann Jørgensen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Lars Engers Pedersen
- Department of Clinical Biochemistry, Næstved, Slagelse and Ringsted Hospitals, Slagelse, Denmark
| | - Stina Willemoes Borresen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Linda Hilsted
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lennart Friis Hansen
- Department of Clinical Biochemistry, Næstved, Slagelse and Ringsted Hospitals, Slagelse, Denmark
- Department of Clinical Biochemistry, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Marianne Klose
- Department of Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
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Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M. Iatrogenic adrenal insufficiency in adults. Nat Rev Endocrinol 2024; 20:209-227. [PMID: 38272995 DOI: 10.1038/s41574-023-00929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
Iatrogenic adrenal insufficiency (IAI) is the most common form of adrenal insufficiency in adult patients, although its overall exact prevalence remains unclear. IAI is associated with adverse clinical outcomes, including adrenal crisis, impaired quality of life and increased mortality; therefore, it is imperative that clinicians maintain a high index of suspicion in patients at risk of IAI to facilitate timely diagnosis and appropriate management. Herein, we review the major causes, clinical consequences, diagnosis and care of patients with IAI. The management of IAI, particularly glucocorticoid-induced (or tertiary) adrenal insufficiency, can be particularly challenging, and the provision of adequate glucocorticoid replacement must be balanced against minimizing the cardiometabolic effects of excess glucocorticoid exposure and optimizing recovery of the hypothalamic-pituitary-adrenal axis. We review current treatment strategies and their limitations and discuss developments in optimizing treatment of IAI. This comprehensive Review aims to aid clinicians in identifying who is at risk of IAI, how to approach screening of at-risk populations and how to treat patients with IAI, with a focus on emergency management and prevention of an adrenal crisis.
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Affiliation(s)
- Julie Martin-Grace
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Maria Tomkins
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Michael W O'Reilly
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Mark Sherlock
- Department of Endocrinology, Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland.
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El-Farhan N, Tennant S, Rees SE, Evans C, Rees DA. Salivary Cortisol Response to ACTH Stimulation Is a Reliable Alternative to Serum Cortisol in Evaluating Hypoadrenalism. J Clin Endocrinol Metab 2024; 109:e579-e588. [PMID: 37768151 PMCID: PMC10795914 DOI: 10.1210/clinem/dgad576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 09/29/2023]
Abstract
CONTEXT The serum total cortisol response to the ACTH stimulation test is widely used to assess adrenocortical function but is affected by changes in cortisol-binding globulin (CBG) concentration. Salivary cortisol reflects free cortisol concentrations and may offer a reliable alternative. OBJECTIVES (1) To establish the salivary cortisol response to ACTH stimulation in healthy volunteers and patients with altered CBG concentrations; (2) to evaluate the performance of a lower reference limit (LRL) determined in healthy volunteers in patients with suspected hypoadrenalism (SH-patients). DESIGN A 250 µg ACTH stimulation test was undertaken in 139 healthy volunteers, 24 women taking an estradiol-containing oral contraceptive pill (OCP-females), 10 patients with low serum protein concentration (LP-patients), and 30 SH-patients. Salivary cortisol was measured by liquid chromatography-tandem mass spectrometry. Mean and LRL of the 30-minute salivary cortisol response (mean-1.96 standard deviation) were derived from log-transformed concentrations. The LRL was applied as a diagnostic cut-off in SH-patients, with comparison to the serum response. RESULTS Mean CBG concentrations (range) were 58 (42-81) mg/L, 64 (43-95) mg/L, 41 (28-60) mg/L, and 116 (84-159) mg/L in males, females, LP-patients, and OCP-females, respectively. The mean 30-minute salivary cortisol concentration was 19.3 (2.5th-97.5th percentile 10.3-36.2) nmol/L in healthy volunteers. Corresponding values were not different in OCP-females [19.7 (9.5-41.2) nmol/L; P = .59] or LP-patients [19.0 (7.7-46.9) nmol/L; P = .97]. Overall diagnostic agreement between salivary and serum responses in SH-patients was 79%. CONCLUSION Salivary cortisol response to ACTH stimulation offers a reliable alternative to serum and may be especially useful in conditions of altered CBG concentration.
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Affiliation(s)
- Nadia El-Farhan
- Department of Medical Biochemistry, Royal Gwent Hospital, Newport NP20 2UB, UK
| | - Sarah Tennant
- Department of Medical Biochemistry, Immunology and Toxicology, University Hospital of Wales, Cardiff CF14 4XW, UK
| | - Seren E Rees
- Birmingham Medical School, University of Birmingham, Birmingham B15 2TT, UK
| | - Carol Evans
- Department of Medical Biochemistry, Immunology and Toxicology, University Hospital of Wales, Cardiff CF14 4XW, UK
| | - D Aled Rees
- Neuroscience and Mental Health Innovation Institute, School of Medicine, Cardiff University, Cardiff CF14 4XN, UK
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Nickler M, Stampf S, Bernasconi L, Segerer S, Blum CA, Kim MJ. Performance of synacthen test in chronic hemodialysis patients. BMC Nephrol 2023; 24:330. [PMID: 37936106 PMCID: PMC10631216 DOI: 10.1186/s12882-023-03347-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/23/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Adrenal function tests (Synacthen test) in chronic hemodialysis (HD) patients are currently performed off dialysis. The study aimed to demonstrate equivalence of serum cortisol concentrations pre- and during HD, each for standard-dose (250 µg) and low-dose (1 µg) Synacthen test. METHODS In a single-center cross-over diagnostic equivalence study, Synacthen tests were performed in four settings, in standard- and low-dose as well as pre- and during HD. Serum cortisol concentration was measured at 30 and 60 min after Synacthen administration, and additionally at 20 min in low dose test. Based on a multivariable linear mixed model the means of cortisol concentration on log-scale were estimated in each dose and test time combination. Differences in means were calculated and the TOST approach was applied to test for equivalence. Equivalence was proven if the 90% confidence interval of the difference of two cortisol means was entirely between - 0.22 and 0.22. RESULTS In 28 chronic HD patients, serum cortisol concentrations at 30 and 60 min after Synacthen administration in both standard- and low-dose were shown to be equivalent pre- and during HD. In 10 of 56 low-dose tests, the cortisol peak was already reached after 20 min. However, cortisol concentrations at 20 and 30 min after low-dose Synacthen test pre- and during HD showed no significant difference. CONCLUSION These results suggest that the adrenal function test may be carried out during an ongoing HD session, leading to a more patient-friendly performance of the test, less organizational effort and potentially earlier diagnosis of adrenal insufficiency.
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Affiliation(s)
- Manuela Nickler
- Medical University Department, Division of Nephrology, Kantonsspital Aarau, Aarau, Switzerland
| | - Susanne Stampf
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Luca Bernasconi
- Center for Laboratory Medicine, Institut of Immunology & Clinical Chemistry, Kantonsspital Aarau, Aarau, Switzerland
| | - Stephan Segerer
- Medical University Department, Division of Nephrology, Kantonsspital Aarau, Aarau, Switzerland
| | - Claudine A Blum
- Hormonpraxis Aarau, Aarau, Switzerland
- University of Basel, Basel, Switzerland
| | - Min Jeong Kim
- Medical University Department, Division of Nephrology, Kantonsspital Aarau, Aarau, Switzerland.
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Flowers KC, Shipman KE. Pitfalls in the Diagnosis and Management of Hypercortisolism (Cushing Syndrome) in Humans; A Review of the Laboratory Medicine Perspective. Diagnostics (Basel) 2023; 13:diagnostics13081415. [PMID: 37189516 DOI: 10.3390/diagnostics13081415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/28/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Biochemical confirmation of a diagnosis of hypercortisolism (Cushing syndrome) is vital to direct further investigations, especially given the overlap with non-autonomous conditions, such as pseudo-Cushing, and the morbidity associated with missed diagnoses. A limited narrative review was performed focusing on the laboratory perspective of the pitfalls of making a biochemical diagnosis of hypercortisolism in those presenting with presumed Cushing syndrome. Although analytically less specific, immunoassays remain cheap, quick, and reliable in most situations. Understanding cortisol metabolism can help with patient preparation, specimen selection (e.g., consideration of urine or saliva for those with possible elevations of cortisol binding globulin concentration), and method selection (e.g., mass spectrometry if there is a high risk of abnormal metabolites). Although more specific methods may be less sensitive, this can be managed. The reduction in cost and increasing ease of use makes techniques such as urine steroid profiles and salivary cortisone of interest in future pathway development. In conclusion, the limitations of current assays, particularly if well understood, do not impede diagnosis in most cases. However, in complex or borderline cases, there are other techniques to consider to aid in the confirmation of hypercortisolism.
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Affiliation(s)
- Kade C Flowers
- Department of Clinical Chemistry, University Hospitals Sussex NHS Trust, Worthing BN11 2DH, UK
| | - Kate E Shipman
- Department of Clinical Chemistry, University Hospitals Sussex NHS Trust, Worthing BN11 2DH, UK
- Department of Medical Education, Brighton and Sussex Medical School, University of Sussex, Falmer Campus, Brighton BN1 9PX, UK
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Borresen SW, Klose M, Glintborg D, Watt T, Andersen MS, Feldt-Rasmussen U. Approach to the Patient With Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab 2022; 107:2065-2076. [PMID: 35302603 DOI: 10.1210/clinem/dgac151] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Indexed: 11/19/2022]
Abstract
Glucocorticoid-induced adrenal insufficiency is caused by exogenous glucocorticoid suppression of the hypothalamic-pituitary-adrenal axis and is the most prevalent form of adrenal insufficiency. The condition is important to diagnose given the risk of life-threatening adrenal crisis and impact on patients' quality of life. The diagnosis is made with a stimulation test such as the ACTH test. Until now, testing for glucocorticoid-induced adrenal insufficiency has often been based on clinical suspicion rather than routinely but accumulating evidence indicates that a significant number of cases will remain unrecognized. During ongoing oral glucocorticoid treatment or initially after withdrawal, ~50% of patients have adrenal insufficiency, but, outside clinical studies, ≤ 1% of patients have adrenal testing recorded. More than 70% of cases are identified during acute hospital admission, where the diagnosis can easily be missed because symptoms of adrenal insufficiency are nonspecific and overlap those of the underlying and intercurrent conditions. Treatment of severe glucocorticoid-induced adrenal insufficiency should follow the principles for treatment of central adrenal insufficiency. The clinical implications and thus indication to treat mild-moderate adrenal deficiency after glucocorticoid withdrawal has not been established. Also, the indication of adding stress dosages of glucocorticoid during ongoing glucocorticoid treatment remains unclear. In patients with established glucocorticoid-induced adrenal insufficiency, high rates of poor confidence in self-management and delayed glucocorticoid administration in the acute setting with an imminent adrenal crisis call for improved awareness and education of clinicians and patients. This article reviews different facets of glucocorticoid-induced adrenal insufficiency and discusses approaches to the condition in common clinical situations.
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Affiliation(s)
- Stina Willemoes Borresen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
| | - Dorte Glintborg
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, DK-5000 Odense, Denmark
| | - Torquil Watt
- Department of Endocrinology and Internal Medicine, Herlev and Gentofte Hospital, DK-2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Marianne Skovsager Andersen
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, DK-5000 Odense, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, DK-2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
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Abstract
Adrenal insufficiency (AI), first described by Thomas Addison in 1855, is characterised by inadequate hormonal production by the adrenal gland, which could either be primary, due to destruction of the adrenal cortex, or secondary/tertiary, due to lack of adrenocorticotropic hormone or its stimulation by corticotropin-releasing hormone. This was an invariably fatal condition in Addison's days with most patients dying within a few years of diagnosis. However, discovery of cortisone in the 1940s not only improved the life expectancy of these patients but also had a dramatic effect on their overall quality of life. The diagnosis, easily confirmed by demonstrating inappropriately low cortisol secretion, is often delayed by months, and many patients present with acute adrenal crisis. Sudden withdrawal from chronic glucocorticoid therapy is the most common cause of AI. Currently, there remains a wide variation in the management of this condition across Europe. As primary AI is a relatively rare condition, most medical specialists will only manage a handful of these patients in their career. Despite many advances in recent years, there is currently no curative option, and modern cortisol replacement regimens fail to adequately mimic physiological cortisol rhythm. A number of new approaches including allograft of adrenocortical tissue and stem cell therapy are being tried but remain largely experimental.
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Affiliation(s)
- Rajeev Kumar
- Diabetes and Endocrinology, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - W S Wassif
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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Zha L, Li J, Krishnan SM, Brennan MR, Zhang YV, Povse P, Kerlin R, Shively K, Oleksik F, Williams J, Sykes E, Sun Q. New Diagnostic Cutoffs for Adrenal Insufficiency after Cosyntropin Stimulation using Abbott Architect Cortisol Immunoassay. Endocr Pract 2022; 28:684-689. [PMID: 35487459 DOI: 10.1016/j.eprac.2022.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/14/2022] [Accepted: 04/06/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Accurate interpretation of the cosyntropin (ACTH) stimulation test requires method and assay-specific cutoffs of cortisol. Compared with the historical cutoff (18 μg/dL) from polyclonal antibody-based immunoassays, lower thresholds were proposed for the Roche Elecsys II assay that uses a monoclonal antibody. However, cutoffs for other commonly adopted monoclonal antibody-based cortisol assays were not yet available. Here we established the cortisol thresholds specific to the Abbott Architect immunoassay by comparing cortisol measurements on three immunoassays. METHODS The ACTH stimulation test was performed in patients with suspected adrenal insufficiency (AI) (n=50). Serum cortisol was measured with Abbott Architect, Roche Elecsys II, and Siemens Centaur assays. Results from Abbott were also compared with those from liquid chromatography-tandem mass spectrometry (LC-MS/MS). Receiver operating characteristic (ROC) analysis was performed to derive new diagnostic thresholds for the Abbott assay using polyclonal antibody-based Siemens assay as the reference method. RESULTS Cortisol measurements on Abbott were similar to those from LC-MS/MS and Roche Elecsys II, but significantly lower than Siemens. The optimized cortisol thresholds on Abbott were 14.6 μg/dL at 60 minutes after stimulation (sensitivity 92%; specificity 96%) and 13.2 μg/dL at 30 minutes (sensitivity 100%; specificity 89%). CONCLUSION We recommend a cortisol threshold of 14.6 μg/dL at 60 minutes post ACTH stimulation for the Abbott assay. In comparison to the historical threshold of 18 μg/dL, applying the new cutoff may significantly decrease false positive results from ACTH stimulation testing. Using assay-specific cutoffs will be essential to reduce misclassification and overtreatment in patients with suspected AI.
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Affiliation(s)
- Li Zha
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Jieli Li
- Department of Pathology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | | | - Michael R Brennan
- Endocrine Center, Beaumont Health, Royal Oak, Michigan, USA; Department of Pathology and Laboratory Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan, USA
| | - Y Victoria Zhang
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Patrick Povse
- Department of Pathology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Rae Kerlin
- Department of Pathology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Kevin Shively
- Department of Pathology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Felicia Oleksik
- Department of Pathology and Laboratory Medicine, Beaumont Health, Royal Oak, Michigan, USA
| | - JoAnna Williams
- Department of Pathology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Elizabeth Sykes
- Department of Pathology and Laboratory Medicine, Beaumont Health, Royal Oak, Michigan, USA; Department of Pathology and Laboratory Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan, USA
| | - Qian Sun
- Department of Pathology and Laboratory Medicine, Beaumont Health, Royal Oak, Michigan, USA; Department of Pathology and Laboratory Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan, USA.
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Genere N, Kaur RJ, Athimulam S, Thomas MA, Nippoldt T, Van Norman M, Singh R, Grebe S, Bancos I. Interpretation of Abnormal Dexamethasone Suppression Test is Enhanced With Use of Synchronous Free Cortisol Assessment. J Clin Endocrinol Metab 2022; 107:e1221-e1230. [PMID: 34648626 PMCID: PMC9006975 DOI: 10.1210/clinem/dgab724] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Interpretation of dexamethasone suppression test (DST) may be influenced by dexamethasone absorption and metabolism and by the altered cortisol binding. OBJECTIVE We aimed to determine the normal ranges of free cortisol during DST in participants without adrenal disorders and to identify the population of patients where post-DST free cortisol measurements add value to the diagnostic workup. DESIGN AND SETTING Cross-sectional study conducted in a tertiary medical center. PARTICIPANTS Adult volunteers without adrenal disorders (n = 168; 47 women on oral contraceptive therapy [OCP], 66 women not on OCP, 55 men) and patients undergoing evaluation for hypercortisolism (n = 196; 16 women on OCP). MEASUREMENTS Post-DST dexamethasone and free cortisol (mass spectrometry) and total cortisol (immunoassay). MAIN OUTCOME MEASURES Reference range for post-DST free cortisol, diagnostic accuracy of post-DST total cortisol. RESULTS Adequate dexamethasone concentrations (≥0.1 mcg/dL) were seen in 97.6% volunteers and 96.3% patients. Only 25.5% of women volunteers on OCP had abnormal post-DST total cortisol (>1.8 mcg/dL). In volunteers, the upper post-DST free cortisol range was 48 ng/dL in men and women not on OCP, and 79 ng/dL in women on OCP. When compared with post-DST free cortisol, diagnostic accuracy of post-DST total cortisol was 87.3% (95% CI, 81.7-91.7); all false-positive results occurred in patients with post-DST cortisol between 1.8 and 5 mcg/dL. OCP use was the only factor associated with false-positive results (21.1% vs 4.9%, P = 0.02). CONCLUSIONS Post-DST free cortisol measurements are valuable in patients with optimal dexamethasone concentrations and post-DST total cortisol between 1.8 and 5 mcg/dL.
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Affiliation(s)
- Natalia Genere
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine; Saint Louis, MO 63130, USA
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Ravinder Jeet Kaur
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Shobana Athimulam
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
- Department of Medicine, Division of Endocrinology, Diabetes, Bone and Mineral Disorders, Henry Ford Health System, Detroit, MI 48202, USA
| | - Melinda A Thomas
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Todd Nippoldt
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Molly Van Norman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Ravinder Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Stefan Grebe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Irina Bancos
- Correspondence: Irina Bancos, MD, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Sivapalan P, Borresen SW, Eklöf J, Klose M, Holm FS, Feldt-Rasmussen U, Rossing M, Jørgensen NR, Marvig RL, Saeed MI, Wilcke T, Seersholm N, Mathioudakis AG, Vestbo J, Jensen JUS. Adrenal suppression in patients with chronic obstructive pulmonary disease treated with glucocorticoids: Role of specific glucocorticoid receptor polymorphisms. PLoS One 2022; 17:e0262898. [PMID: 35120172 PMCID: PMC8815987 DOI: 10.1371/journal.pone.0262898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 01/07/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Single-nucleotide polymorphisms (SNPs) of the glucocorticoid receptor (GR) gene NR3C1 have been associated with an altered sensitivity to glucocorticoids, and thus may alter the therapeutic effects of glucocorticoids. We investigated the prevalence of adrenal suppression after treatment with glucocorticoids and evaluated whether GR SNPs were associated with altered risks of adrenal suppression and metabolic disorders in patients with chronic obstructive pulmonary disease (COPD). METHODS In an observational prospective cohort study, we recruited 78 patients with severe COPD receiving 5 days glucocorticoid treatment for an exacerbation of COPD. In total, 55% of these patients were also receiving regular inhaled corticosteroids (ICS). Adrenal function was evaluated with a corticotropin test 30 days after the exacerbation. Patients were genotyped for Bcl1, N363S, ER22/23EK, and 9β SNPs. RESULTS The prevalence of adrenal suppression (corticotropin-stimulated plasma-cortisol ≤ 420 nmol/L) 30 days after glucocorticoid treatment was 4/78 (5%). There was no difference between carriers and non-carriers of the polymorphisms (Bcl1, 9β, ER22/23K, and N363S) in corticotropin stimulated plasma-cortisol concentrations. In the haplotype analyses, we included the 50 patients who had a high-sensitivity (76%), a low-sensitivity (4%), or a wild-type (20%) GR haplotype. There was no difference in the frequency of adrenal suppression or metabolic disorders between the two stratified groups: (a) high-sensitivity (Bcl1 and/or N363S) haplotypes vs. (b) low-sensitivity (9β and/or ER22/23K) plus wild-type haplotypes (p > 0.05). Carriers of the high-sensitivity GR gene haplotype exhibited a steeper decline in stimulated P-cortisol with increased ICS dose (slope, -1.35 vs. 0.94; p = 0.17), compared to the group with low-sensitivity or wild-type haplotypes, respectively. CONCLUSIONS In total, 5% of patients exhibited insufficient adrenal function. The Bcl1 and N363S polymorphisms did not seem to increase the risk of glucocorticoid suppression or metabolic disorders in adults treated with glucocorticoids for COPD exacerbations.
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Affiliation(s)
- Pradeesh Sivapalan
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Internal Medicine, Zealand Hospital, University of Copenhagen, Roskilde, Denmark
| | - Stina Willemoes Borresen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital
| | - Josefin Eklöf
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital
| | - Freja S. Holm
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maria Rossing
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niklas R. Jørgensen
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Rasmus L. Marvig
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mohamad Isam Saeed
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Torgny Wilcke
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Niels Seersholm
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Alexander G. Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Jens-Ulrik Stæhr Jensen
- Section of Respiratory Medicine, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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11
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Hemmingsen SD, Jensen NA, Larsen PV, Sjögren JM, Lichtenstein MB, Støving RK. Cortisol, Depression, and Anxiety Levels Before and After Short-Term Intensive Nutritional Stabilization in Patients With Severe Anorexia Nervosa. Front Psychiatry 2022; 13:939225. [PMID: 35903636 PMCID: PMC9314772 DOI: 10.3389/fpsyt.2022.939225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/15/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Depression and anxiety are well-known comorbid conditions in patients with anorexia nervosa (AN). Hypercortisolemia in patients with AN may be pathogenic and contribute to depression and anxiety symptomatology. OBJECTIVE The aim of this study was to investigate short-term changes in cortisol levels and depression and anxiety symptomatology following intensive re-nutrition in patients with severe AN and hospitalized in a specialized unit. Furthermore, we investigated the potential association between cortisol levels and psychometric parameters. METHODS A total of 36 patients with AN were enrolled in the study. Nine dropped out before follow-up. Patients underwent paraclinical and psychometric examinations at admission and discharge. Measurements included plasma cortisol, cortisol binding globulin (CBG), 24-h urine cortisol, and self-report questionnaires regarding eating disorder, depression, anxiety, and stress symptoms. Patients were hospitalized in the unit for somatic stabilization and intensive re-nutrition. Mean admission length was 41 days. The study was registered at ClinicalTrials.gov (NCT02502617). RESULTS Cortisol levels in blood and urine did not change from admission to discharge in patients with severe AN. Symptoms of depression, anxiety, stress, and eating disorder remained elevated at discharge. There were no associations between changes in cortisol levels and changes in psychometrics. DISCUSSION Our results suggest that short-term intensive re-nutrition did not alter hypothalamic-pituitary-adrenal axis activity or mental health in patients with severe AN. Long-term stabilization and longer follow-up after hospital discharge may be needed to detect changes in cortisol levels and whether these changes are associated with depression and anxiety symptomatology. Greater knowledge about cortisol levels and mental health in patients with severe AN may help in the development of new treatment choices for the chronically ill patients. Future studies could investigate whether cortisol-lowering drugs have a therapeutic effect on mental health in AN.
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Affiliation(s)
- Simone Daugaard Hemmingsen
- Center for Eating Disorders, Odense University Hospital, Mental Health Services in the Region of Southern Denmark, Odense, Denmark.,Research Unit for Medical Endocrinology, Department of Clinical Research, Open Patient Data Explorative Network (OPEN), University of Southern Denmark, Odense, Denmark
| | - Nikolai Arndal Jensen
- Center for Eating Disorders, Odense University Hospital, Mental Health Services in the Region of Southern Denmark, Odense, Denmark.,Research Unit for Medical Endocrinology, Department of Clinical Research, Open Patient Data Explorative Network (OPEN), University of Southern Denmark, Odense, Denmark
| | - Pia Veldt Larsen
- Mental Health Services in the Region of Southern Denmark, Vejle, Denmark
| | - Jan Magnus Sjögren
- Psychiatric Center Ballerup, Copenhagen, Denmark.,Department of Clinical Sciences, Umeå University, Umeå, Sweden
| | - Mia Beck Lichtenstein
- Centre for Telepsychiatry, Region of Southern Denmark, Vejle, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - René Klinkby Støving
- Center for Eating Disorders, Odense University Hospital, Mental Health Services in the Region of Southern Denmark, Odense, Denmark.,Research Unit for Medical Endocrinology, Department of Clinical Research, Open Patient Data Explorative Network (OPEN), University of Southern Denmark, Odense, Denmark
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12
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Riat A, Suwandi A, Ghashang SK, Buettner M, Eljurnazi L, Grassl GA, Gutenbrunner C, Nugraha B. Ramadan Fasting in Germany (17-18 h/Day): Effect on Cortisol and Brain-Derived Neurotrophic Factor in Association With Mood and Body Composition Parameters. Front Nutr 2021; 8:697920. [PMID: 34458302 PMCID: PMC8387581 DOI: 10.3389/fnut.2021.697920] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/07/2021] [Indexed: 12/22/2022] Open
Abstract
Ramadan fasting (RF) is a type of diurnal intermittent fasting. Previous studies reported the benefits of RF in healthy subjects on mood and health related to quality of life (QoL). Cortisol and brain-derived neurotrophic factor (BDNF) have been shown to play a role in mood, body composition parameters, and health-related QoL. This study aimed at elucidating the mechanism of the benefit of RF, particularly cortisol and BNDF and their association with mood and QoL. Insulin growth factor-1 (IGF-1), interleukin (IL)-8, matrix metalloproteinase (MMP)-9, and myoglobin were determined. Thirty-four healthy men and women were recruited. Serum from peripheral venous blood samples was collected at five time points: 1 week before RF (T1); mid of RF (T2), last days of RF (T3), 1 week after RF (T4), and 1 month after RF (T5). The amounts of biological mediators in the serum samples were determined by enzyme-linked immunosorbent assay (ELISA) and Luminex assays. BDNF and cortisol significantly decreased at T3 (p < 0.05) and T4 (p < 0.001) compared to T1, respectively. It seems the benefits of RF for mood-related symptoms are mediated by different biological mediators, particularly cortisol and BDNF.
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Affiliation(s)
- Amin Riat
- Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany
| | - Abdulhadi Suwandi
- Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School and German Center for Infection Research (DZIF), Hannover, Germany.,Institute of Cell Biochemistry, Center of Biochemistry, Hannover Medical School, Hannover, Germany
| | - Samaneh Khoshandam Ghashang
- Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany.,Department of Dermatology, Johannes Wesling Medical Centre, Minden, Germany
| | - Manuela Buettner
- Institute for Laboratory Animal Science, Hannover Medical School, Hannover, Germany
| | - Luqman Eljurnazi
- Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany
| | - Guntram A Grassl
- Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School and German Center for Infection Research (DZIF), Hannover, Germany
| | | | - Boya Nugraha
- Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany
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13
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Recalibration of thinking about adrenocortical function assessment: how the 'random' cortisol relates to the short synacthen test results. Cardiovasc Endocrinol Metab 2021; 10:137-145. [PMID: 34113799 PMCID: PMC8186517 DOI: 10.1097/xce.0000000000000250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/29/2021] [Indexed: 11/26/2022]
Abstract
Background The short synacthen test (SST) is the most commonly performed investigation to assess adrenal function. Appropriate criteria for when an SST is performed are subject to debate. We investigated how random serum cortisol levels relate to SST response. Methods We examined random cortisol measurements taken between 04.40–23.55 p.m. results of SST baseline and 30-/60-min cortisol performed over 12 months (225 SSTs) at Salford Royal Hospital. Serum cortisol was measured on the Siemens Centaur Analyser. A 30–60-min cortisol concentration of ≥450 nmol/L defined a pass; 350–449 nmol/L defined borderline. Results Patients only proceeded to SST if random cortisol was <400 nmol/L. For those not on corticosteroids for at least 2 weeks, 42/43 (97.7%) cases with random cortisol concentration of ≥200 nmol/L had an SST ‘pass’. The relation was less clear with corticosteroid treatment (19/35 cases; 54%). For those not taking glucocorticoid treatment (including inhaled/topical corticosteroids) in the previous 2 weeks, 91.8% of SSTs were pass/2.7% borderline/5.5% fail. For those on steroids, 51.9% of SSTs were a pass/11.4% were borderline. In relation to the postsynacthen cortisol pass cut-off of ≥450 nmol/L, in 15/207 (7.2%) of cases, the 60-min cortisol was ≥450 nmol/L (adequate adrenocortical function), but 30-min cortisol was below this. In all cases where the 30-min cortisol did indicate a pass (i.e. was ≥450 nmol/L) the 60-min cortisol was also ≥450 nmol/L. Conclusion Our findings suggest that if the random cortisol level is ≥200 nmol/L, regardless of the time of day and the person was not taking corticosteroid treatment in the previous 2 weeks, SST may not be needed. Our data also suggests that 60-min cortisol retains utility.
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14
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Javorsky BR, Raff H, Carroll TB, Algeciras-Schimnich A, Singh RJ, Colón-Franco JM, Findling JW. New Cutoffs for the Biochemical Diagnosis of Adrenal Insufficiency after ACTH Stimulation using Specific Cortisol Assays. J Endocr Soc 2021; 5:bvab022. [PMID: 33768189 PMCID: PMC7975762 DOI: 10.1210/jendso/bvab022] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Indexed: 02/07/2023] Open
Abstract
Context The normal cortisol response 30 or 60 minutes after cosyntropin (ACTH[1-24]) is considered to be ≥18 μg/dL (500 nmol/L). This threshold is based on older serum cortisol assays. Specific monoclonal antibody immunoassays or LC-MS/MS may have lower thresholds for a normal response. Objective To calculate serum cortisol cutoff values for adrenocorticotropic hormone (ACTH) stimulation testing with newer specific cortisol assays. Methods Retrospective analysis of ACTH stimulation tests performed in ambulatory and hospitalized patients suspected of adrenal insufficiency (AI). Serum samples were assayed for cortisol in parallel using Elecsys I and Elecsys II immunoassays, and when volume was available, by Access immunoassay and LC-MS/MS. Results A total of 110 patients were evaluated. Using 18 μg/dL as the cortisol cutoff after ACTH stimulation, 14.5%, 29%, 22.4%, and 32% of patients had a biochemical diagnosis of AI using the Elecsys I, Elecsys II, Access, and LC-MS/MS assays, respectively. Deming regressions of serum cortisol were used to calculate new cortisol cutoffs based on the Elecsys I cutoff of 18 μg/dL. For 30-minute values, new cutoffs were 14.6 μg/dL for Elecsys II, 14.8 μg/dL for Access, and 14.5 μg/dL for LC-MS/MS. Baseline cortisol <2 μg/dL was predictive of subnormal stimulated cortisol values. Conclusion To reduce false positive ACTH stimulation testing, we recommend a new serum cortisol cutoff of 14 to 15 μg/dL depending on the assay used (instead of the historical value of 18 μg/dL with older polyclonal antibody assays). Clinicians should be aware of the new cutoffs for the assays available to them when evaluating patients for AI.
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Affiliation(s)
- Bradley R Javorsky
- Endocrinology Center and Clinics, Froedtert & the Medical College of Wisconsin, Milwaukee, WI 53051, USA
| | - Hershel Raff
- Division of Endocrinology and Molecular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA.,Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Advocate Aurora Research Institute, Milwaukee, WI 53215, USA
| | - Ty B Carroll
- Endocrinology Center and Clinics, Froedtert & the Medical College of Wisconsin, Milwaukee, WI 53051, USA
| | | | - Ravinder Jit Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - James W Findling
- Endocrinology Center and Clinics, Froedtert & the Medical College of Wisconsin, Milwaukee, WI 53051, USA
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15
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Ramirez Alcantara J, Halper A. Adrenal insufficiency updates in children. Curr Opin Endocrinol Diabetes Obes 2021; 28:75-81. [PMID: 33278125 DOI: 10.1097/med.0000000000000591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The current article will review the newest diagnostic tools, genetic causes, and treatment of adrenal insufficiency in children. RECENT FINDINGS It is common practice to perform an adrenocorticotropin hormone (ACTH) stimulation test when adrenal insufficiency is suspected. The indications for use of a high-dose or low-dose of synthetic ACTH in children have been refined. In addition, newer studies propose adding 15 and 30-min serum or salivary cortisol levels to the low-dose ACTH stimulation test to correctly identify adrenal insufficiency. Recent identification of genetic mutations in children with non-classic steroidogenic acute regulatory protein and other mutations associated with primary and secondary adrenal insufficiency have expanded the cause and pathophysiology of monogenic adrenal insufficiency. In addition, newer hydrocortisone formulations and delivery methods and medications to use in combination with hydrocortisone are being explored to improve treatment for children with adrenal insufficiency. SUMMARY Improved diagnostic aids, detection of newer genetic mutations, and better treatment options and delivery systems will help correctly identify and manage children with adrenal insufficiency to improve health outcomes and quality of life. VIDEO ABSTRACT http://links.lww.com/COE/A21.
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Affiliation(s)
- Jonanlis Ramirez Alcantara
- Division of Pediatric Endocrinology, Department of Pediatrics, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
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16
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Kalaria T, Agarwal M, Kaur S, Hughes L, Sharrod-Cole H, Chaudhari R, Gherman-Ciolac C, Chopra R, Okeke V, Ford C, Buch H, Gama R. Hypothalamic-pituitary-adrenal axis suppression - The value of salivary cortisol and cortisone in assessing hypothalamic-pituitary-adrenal recovery. Ann Clin Biochem 2020; 57:456-460. [PMID: 32961064 DOI: 10.1177/0004563220961745] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Tejas Kalaria
- Blood Sciences, Royal Wolverhampton NHS Trust, Wolverhampton, UK.,Endocrinology and Diabetes, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Mayuri Agarwal
- Endocrinology and Diabetes, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Sukhbir Kaur
- Blood Sciences, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Lauren Hughes
- Blood Sciences, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | | | - Rahul Chaudhari
- Endocrinology and Diabetes, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | | | - Roopa Chopra
- Endocrinology and Diabetes, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Victor Okeke
- Endocrinology and Diabetes, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Clare Ford
- Blood Sciences, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Harit Buch
- Endocrinology and Diabetes, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Rousseau Gama
- Blood Sciences, Royal Wolverhampton NHS Trust, Wolverhampton, UK.,School of Medicine and Clinical Practice, University of Wolverhampton, Wolverhampton, UK
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17
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Grassi G, Morelli V, Ceriotti F, Polledri E, Fustinoni S, D'Agostino S, Mantovani G, Chiodini I, Arosio M. Minding the gap between cortisol levels measured with second-generation assays and current diagnostic thresholds for the diagnosis of adrenal insufficiency: a single-center experience. Hormones (Athens) 2020; 19:425-431. [PMID: 32222957 PMCID: PMC7426310 DOI: 10.1007/s42000-020-00185-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/20/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE The current cut-offs for the diagnosis of adrenal insufficiency (AI) have been established using outdated immunoassays. We compared the cortisol concentrations measured with Roche Cortisol I (R1), the newly available Roche Cortisol II (R2), and liquid chromatography tandem mass spectrometry (LC-MS/MS), the gold standard procedure to measure steroids in patients undergoing the corticotropin (ACTH) test. METHODS We enrolled 30 patients (age 47 ± 21 years) referred to undergo the ACTH test (1 or 250 μg). Cortisol was measured at 0, 30, and 60 min after stimulation with R1, R2, and LC-MS/MS. AI was diagnosed for R1-stimulated peak cortisol concentrations < 500 nmol/L. RESULTS Mean cortisol concentrations measured with R2 and LC-MS/MS were comparable, while mean cortisol concentrations measured by R1 were higher than those of both R2 and LC-MS/MS (respectively, basal 411 ± 177, 287 ± 119, and 295 ± 119 nmol/L; at 30 min, 704 ± 204, 480 ± 132, and 500 ± 132 nmol/L; at 60 min, 737 ± 301, 502 ± 196, and 519 ± 201 nmol/L, p ≤ 0.01 for R1 vs. both R2 and LC-MS/MS at each point). Considering the 500 nmol/L cortisol peak cut-off, AI was diagnosed in 5/30 patients using R1 and in 12/30 using R2 (+ 140%). Based on the correlation between R1 and R2, the threshold of 500 nmol/L became 351 nmol/L (12.7 μg/dL) when cortisol was measured with R2, and 368 nmol/L (13.3 μg/dL) with LC-MS/MS. CONCLUSIONS The use of more specific cortisol assays results in lower cortisol concentrations. This could lead to misdiagnosis and overtreatment when assessing AI with the ACTH test if a different cut-off for cortisol peak is not adopted.
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Affiliation(s)
- G Grassi
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Università degli studi di Milano, Milan, Italy.
| | - V Morelli
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F Ceriotti
- Clinical Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - E Polledri
- Toxicology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - S Fustinoni
- Toxicology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - S D'Agostino
- Clinical Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - G Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - I Chiodini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Unit for Bone Metabolism Diseases and Diabetes & Lab of Endocrine and Metabolic Research IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - M Arosio
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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18
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Meinel J, Haverkamp T, Wünsche F, Richter-Unruh A. Establishment of Clinical and Lab Algorithms for the Identification of Carriers of Mutations in CYP21A2 - A Study of 365 Children and Adolescents. Exp Clin Endocrinol Diabetes 2020; 129:492-499. [PMID: 32838438 DOI: 10.1055/a-1217-7169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Mutations of CYP21A2 encoding 21-hydroxylase are the most frequent cause of congenital adrenal hyperplasia (CAH) and are associated either with elevated basal or ACTH-stimulated levels of 17-hydroxyprogesterone (17OHP) in blood. OBJECTIVE The study objective was to identify the most suitable of 12 different test algorithms and appropriate cut-off levels for that test to recognize patients with non-classical congenital adrenal hyperplasia (NCCAH) and carriers of clinically relevant mutations in CYP21A2. METHOD AND PATIENTS Between July 2006 and July 2015 ACTH-tests were conducted in 365 children and adolescents (Age 1-20 y) suspected to have NCCAH. As a reference, results from subsequent gene sequencing of CYP21A2 was used. Inclusion criteria that were used were premature pubarche with accelerated bone age, hyperandrogenism, hirsutism, or menstrual irregularities. Receiver operating characteristics (ROC) were plotted. Evaluated test algorithms were composed around 17OHP measurements by radioimmunoassays. The most suitable test was identified by the greatest area under the curve (AUC). RESULTS Among the 12 tested algorithms, the sum of 30 min and 60 min stimulated 17OHP values (sum17OHPstim) showed the highest AUC of 0.774 for identifying heterozygous and bi-allelic mutations. A cut-off of 10.1 μg/l was advisable. Bi-allelic mutations only were best identified calculating the difference between 30 min and basal 17OHP values (Δ17OHP30). A cut-off of 9.4 μg/l was most effective. CONCLUSION Alternatively to the above mentioned cut-offs the difference of 60 min after stimulation to basal 17OHP (Δ17OHP60) can be used for the benefit of a combined test to identify both heterozygotes and bi-allelic patients. There are minimal decreases in sensitivity and specificity compared to an approach that applies two tests. However, it denotes a simpler approach in the clinical routine.
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Affiliation(s)
- J Meinel
- MVZ Dr. Eberhard & Partner Dortmund (ÜBAG), Dortmund Germany
| | - T Haverkamp
- MVZ Dr. Eberhard & Partner Dortmund (ÜBAG), Dortmund Germany
| | - F Wünsche
- MVZ Dr. Eberhard & Partner Dortmund (ÜBAG), Dortmund Germany
| | - A Richter-Unruh
- MVZ Dr. Eberhard & Partner Dortmund (ÜBAG), Dortmund Germany.,Ruhr-University Bochum, University Children's Hospital Bochum, St. Josef- Hospital, Department of Pediatric Endocrinology, Bochum Germany
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19
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Borresen SW, Thorgrimsen TB, Jensen B, Hilsted L, Bartels EM, Feldt-Rasmussen U, Locht H. Adrenal insufficiency in prednisolone-treated patients with polymyalgia rheumatica or giant cell arteritis—prevalence and clinical approach. Rheumatology (Oxford) 2020; 59:2764-2773. [DOI: 10.1093/rheumatology/keaa011] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/23/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Glucocorticoid treatment is fundamental in polymyalgia rheumatica (PMR) and giant cell arteritis (GCA), but carries a risk of glucocorticoid-induced adrenal insufficiency. Adrenal insufficiency can cause reluctance to stop glucocorticoid treatment after disease remission as symptoms can resemble PMR/GCA flare. We aimed to determine the prevalence of adrenal insufficiency in prednisolone-treated patients with PMR/GCA.
Methods
We included 47 patients with PMR (n = 37), GCA (n = 1) or both (n = 9), treated with prednisolone for ≥5.4 months, current dose 2.5–10 mg/day. Adrenal function was evaluated using a corticotropin (Synacthen®) stimulation test following 48 h prednisolone pause. Two years’ clinical follow-up data are provided.
Results
Seven patients (15%) had adrenal insufficiency, 4 (11%) of the 37 patients with PMR alone, and 3 (30%) of the 10 patients with GCA. Corticotropin-stimulated P-cortisol was significantly associated with current prednisolone dose, mean daily dose the last 3 and 6 months before testing, and basal P-cortisol, but not with total dose or treatment duration. Adrenal insufficiency occurred with all current prednisolone doses (2.5–10 mg/day). Five (71%) of the glucocorticoid-insufficient patients could discontinue prednisolone treatment; two of them recovered glucocorticoid function, whereas three still needed hydrocortisone replacement 2 years later. Two patients experienced in total four acute hospital admissions with symptoms of adrenal crises.
Conclusion
Glucocorticoid-induced adrenal insufficiency occurred in 15% of patients with PMR/GCA. Mean prednisolone dose the last 3 months and basal P-cortisol were the best and simplest predictors of adrenal function. Most of the glucocorticoid-insufficient patients could discontinue prednisolone with appropriate treatment for adrenal insufficiency.
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Affiliation(s)
- Stina W Borresen
- Department of Medical Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Toke B Thorgrimsen
- Center for Rheumatology and Spine Diseases, Copenhagen University Hospital Bispebjerg and Frederiksberg, Frederiksberg, Denmark
| | - Bente Jensen
- Center for Rheumatology and Spine Diseases, Copenhagen University Hospital Bispebjerg and Frederiksberg, Frederiksberg, Denmark
| | - Linda Hilsted
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Copenhagen
| | - Else M Bartels
- Department of Neurology, The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Frederiksberg, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Henning Locht
- Center for Rheumatology and Spine Diseases, Copenhagen University Hospital Bispebjerg and Frederiksberg, Frederiksberg, Denmark
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20
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Adrenal insufficiency: Physiology, clinical presentation and diagnostic challenges. Clin Chim Acta 2020; 505:78-91. [PMID: 32035851 DOI: 10.1016/j.cca.2020.01.029] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 12/21/2022]
Abstract
Adrenal insufficiency (AI) is a serious condition, which can arise from pathology affecting the adrenal gland itself (primary adrenal insufficiency, PAI), hypothalamic or pituitary pathology (secondary adrenal insufficiency, SAI), or as a result of suppression of the hypothalamic-pituitaryadrenal (HPA) axis by exogenous glucocorticoid therapy (tertiary adrenal insufficiency, TAI). AI is associated with an increase in morbidity and mortality and a reduction in quality of life. In addition, the most common cause of PAI, autoimmune adrenalitis, may be associated with a variety of other autoimmune disorders. Untreated AI can present with chronic fatigue, weight loss and vulnerability to infection. The inability to cope with acute illness or infection can precipitate life-threatening adrenal crisis. It is therefore a critical diagnosis to make in a timely fashion, in order to institute appropriate management, aimed at reversing chronic ill health, preventing acute crises, and restoring quality of life. In this review, we will describe the normal physiology of the HPA axis and explain how knowledge of the physiology of this axis helps us understand the clinical presentation of AI, and forms the basis for the biochemical investigations which lead to the diagnosis of AI.
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Kumar R, Carr P, Moore K, Rajput Z, Ward L, Wassif WS. Do we need 30 min cortisol measurement in the short synacthen test: a retrospective study. Postgrad Med J 2019; 96:467-472. [PMID: 31810992 DOI: 10.1136/postgradmedj-2019-137125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/31/2019] [Accepted: 11/10/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The short synacthen test (SST) is widely used across the UK to assess adrenal reserve but there remains no consensus on the timing of cortisol sampling to help diagnose adrenal insufficiency. The main objective of our study was to see if both 30 and 60 min sample are required following administration of synacthen to investigate suspected adrenal insufficiency (AI). DESIGN This was a single-centre retrospective study of 393 SSTs measuring 0, 30 and 60 min cortisol levels after administration of 250 µg of synacthen. PATIENTS AND METHODS All the SSTs for patients suspected of primary or secondary AI between April 2016 and October 2018 were included in this study. The tests were performed as per our hospital protocol. A post-adrenocorticotropic hormone (ACTH) cortisol response of 420 nmol/L at any time point was considered adequate to rule out AI. The data were analysed to ascertain the proportion of patients who achieved this level at 30 and/or 60 min. RESULTS A total of 393 SST results were included in this study. Patients were divided into two groups depending on whether (group A) or not (group B) they were on steroids. Overall, a total of 313 (79.6%) subjects achieved cortisol level of ≥420 nmol/L at 30 and 60 min while 19 (4.8%) had late response (ie, insufficient 30 min cortisol levels, rising to ≥420 nmol/L at 60 min). Another 61 subjects (15.5%) showed insufficient response at both 30 and 60 min (ie, failed to achieved level of ≥420 nmol/L). Importantly, there was no patient in either group who had adequate response at 30 min and then failed at 60 min. Patients in group A were more likely to have inadequate response at both 30 and 60 min while patients in group B were more likely to have normal response at both time points. CONCLUSIONS Our results suggest that about 5% of people undergoing SST may be inappropriately diagnosed as having AI (and subjected to long-term unnecessary steroid treatment) if the 60 min sample is not maintained. We suggest that 30 min sample does not add any additional diagnostic utility and can be omitted thus simplifying SST even further and saving on cost and resources. We propose that single measurement after 60 min of administration of synthetic ACTH is a sufficient screening test for AI.
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Affiliation(s)
- Rajeev Kumar
- Diabetes and Endocrinology, Bedford Hospital NHS Trust, Bedford, UK
| | - Peter Carr
- Statistical Analyst, The Open University, Milton Keynes, UK
| | - Kimberley Moore
- Clinical Biochemistry, Bedford Hospital NHS Trust, Bedford, UK
| | - Zeeshan Rajput
- Department of Acute Medicine, Bedford Hospital NHS Trust, Bedford, UK
| | - Louise Ward
- Clinical Biochemistry, Bedford Hospital NHS Trust, Bedford, UK
| | - W S Wassif
- Clinical Biochemistry, Bedford Hospital NHS Trust, Bedford, UK
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Vieira-Correa M, Giorgi RB, Oliveira KC, Hayashi LF, Costa-Barbosa FA, Kater CE. Saliva versus serum cortisol to identify subclinical hypercortisolism in adrenal incidentalomas: simplicity versus accuracy. J Endocrinol Invest 2019; 42:1435-1442. [PMID: 31456173 DOI: 10.1007/s40618-019-01104-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 08/21/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE Subclinical hypercortisolism (SCH) leads to metabolic derangements and increased cardiovascular risk. Cortisol autonomy is defined by the overnight 1 mg dexamethasone suppression test (DST). Saliva cortisol is an easier, stress-free, and cost-effective alternative to serum cortisol. We compared 23 h and post-1 mg DST saliva with serum cortisol to identify SCH in adrenal incidentalomas (AI). METHODS We analyzed 359 DST obtained retrospectively from 226 AI subjects (173F/53 M; 19-83 years) for saliva and serum cortisol. We used three post-DST serum cortisol cutoffs to uncover SCH: 1.8, 2.5, and 5.0 μg/dL. We determined post-DST and 23 h saliva cortisol cutoffs by ROC curve analysis and calculated their sensitivities (S) and specificities (E). RESULTS The sensitive 1.8 μg/dL cutoff defined 137 SCH and 180 non-functioning adenomas (NFA): post-DST and 23 h saliva cortisol S/E were: 75.2%/74.4% and 59.5%/65.9%, respectively. Using the specific 5.0 μg/dL cortisol cutoff (22 SCH/295 NFA), post-DST and 23 h saliva cortisol S/E were 86.4%/83.4% and 66.7%/80.4%, respectively. Using the intermediate 2.5 μg/dL cutoff (89 SCH/228 NFA), post-DST and 23 h saliva cortisol S/E were 80.9%/68.9% and 65.5%/62.8%, respectively. CONCLUSION Saliva cortisol showed acceptable performance only with the 5.0 μg/dL cortisol cutoff, as in overt Cushing's syndrome. Lower cutoffs (1.8 and 2.5 μg/dL) that identify larger samples of patients with poor metabolic outcomes are less accurate for screening. These results may be attributed to pre-analytical factors and inherent patient conditions. Thus, saliva cortisol cannot replace serum cortisol to identify SCH among patients with AI for screening DST.
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Affiliation(s)
- M Vieira-Correa
- From the Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of São Paulo School of Medicine (Escola Paulista de Medicina/Universidade Federal de São Paulo), Rua Pedro de Toledo, 781-13th Floor, São Paulo, SP, 04039-032, Brazil
| | - R B Giorgi
- From the Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of São Paulo School of Medicine (Escola Paulista de Medicina/Universidade Federal de São Paulo), Rua Pedro de Toledo, 781-13th Floor, São Paulo, SP, 04039-032, Brazil
| | - K C Oliveira
- From the Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of São Paulo School of Medicine (Escola Paulista de Medicina/Universidade Federal de São Paulo), Rua Pedro de Toledo, 781-13th Floor, São Paulo, SP, 04039-032, Brazil
| | - L F Hayashi
- From the Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of São Paulo School of Medicine (Escola Paulista de Medicina/Universidade Federal de São Paulo), Rua Pedro de Toledo, 781-13th Floor, São Paulo, SP, 04039-032, Brazil
| | - F A Costa-Barbosa
- From the Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of São Paulo School of Medicine (Escola Paulista de Medicina/Universidade Federal de São Paulo), Rua Pedro de Toledo, 781-13th Floor, São Paulo, SP, 04039-032, Brazil
| | - C E Kater
- From the Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of São Paulo School of Medicine (Escola Paulista de Medicina/Universidade Federal de São Paulo), Rua Pedro de Toledo, 781-13th Floor, São Paulo, SP, 04039-032, Brazil.
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Pofi R, Gunatilake S, Macgregor V, Shine B, Joseph R, Grossman AB, Isidori AM, Cudlip S, Jafar-Mohammadi B, Tomlinson JW, Pal A. Recovery of the Hypothalamo-Pituitary-Adrenal Axis After Transsphenoidal Adenomectomy for Non-ACTH-Secreting Macroadenomas. J Clin Endocrinol Metab 2019; 104:5316-5324. [PMID: 31225871 DOI: 10.1210/jc.2019-00406] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 06/17/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Secondary adrenal insufficiency is a potential complication of transsphenoidal adenomectomy (TSA). Most centers test recovery of the hypothalamo-pituitary-adrenal (HPA) axis after TSA, but, to our knowledge, there are no data predicting likelihood of recovery or the frequency of later recovery of HPA function. OBJECTIVE To assess timing and predictors of HPA axis recovery after TSA. DESIGN Single-center, retrospective analysis of consecutive pituitary surgeries performed between February 2015 and September 2018. PATIENTS Patients (N = 109) with short Synacthen test (SST) data before and at sequential time points after TSA. MAIN OUTCOME MEASURES Recovery of HPA axis function at 6 weeks, and 3, 6, and 9 to12 months after TSA. RESULTS Preoperative SST indicated adrenal insufficiency in 21.1% Among these patients, 34.8% recovered by 6 weeks after TSA. Among the 65.2% (n = 15) remaining, 13.3% and 20% recovered at 3 months and 9 to 12 months, respectively. Of the 29% of patients with adrenal insufficiency at the 6-week SST, 16%, 12%, and 6% subsequently recovered at 3, 6, and 9 to 12 months, respectively. Preoperative SST 30-minute cortisol, postoperative day 8 cortisol, and 6-week postoperative SST baseline cortisol levels above or below 430 nmol/L [15.5 μg/dL; AUC ROC, 0.86]; 160 nmol/L (5.8 μg/dL; AUC ROC, 0.75); and 180 nmol/L (6.5 μg/dL; AUC ROC, 0.88), were identified as cutoffs for predicting 6-week HPA recovery. No patients with all three cutoffs below the threshold recovered within 12 months after TSA, whereas 92% with all cutoffs above the threshold recovered HPA function within 6 weeks (OR, 12.200; 95% CI, 5.268 to 28.255). CONCLUSION HPA axis recovery can occur as late as 9 to 12 months after TSA, demonstrating the need for periodic reassessment of patients who initially have SST-determined adrenal insufficiency after TSA. Pre- and postoperative SST values can guide which patients are likely to recover function and potentially avoid unnecessary lifelong glucocorticoid replacement.
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Affiliation(s)
- Riccardo Pofi
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
- Department of Neuroradiology, John Radcliffe Hospital, Oxford University Hospitals National Health Servce Foundation Trust, Oxford, United Kingdom
| | - Sonali Gunatilake
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Victoria Macgregor
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Brian Shine
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Robin Joseph
- Department of Neuroradiology, John Radcliffe Hospital, Oxford University Hospitals National Health Servce Foundation Trust, Oxford, United Kingdom
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Simon Cudlip
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Bahram Jafar-Mohammadi
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Jeremy W Tomlinson
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Aparna Pal
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
- National Institute for Health Research, Oxford Biomedical Research Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
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Dineen R, Mohamed A, Gunness A, Rakovac A, Cullen E, Barnwell N, Neary C, Behan LA, Boran G, Gibney J, Sherlock M. Outcomes of the short Synacthen test: what is the role of the 60 min sample in clinical practice? Postgrad Med J 2019; 96:67-72. [DOI: 10.1136/postgradmedj-2019-136669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/09/2019] [Accepted: 09/02/2019] [Indexed: 11/03/2022]
Abstract
In recent years, the short Synacthen test (SS) has become the most widely used test to assess adrenal reserve. Despite its frequent use, there are still several areas related to the short Synacthen test (SST), which have no consensus including the optimum sampling times, that is, whether a 60 min post-Synacthen administration cortisol is necessary or not.MethodologyWe performed a retrospective data analysis of 492 SSTs performed on adult patients in a tertiary referral teaching hospital in Ireland. The SSTs were performed in the inpatient and outpatient setting and included patients across all medical disciplines and not exclusively to the endocrinology department.Results313 patients had 0, 30 and 60 min samples available for analysis. A total of 270/313 (82%) were deemed to pass the test, that is, cortisol ≥500 nmol/L at both 30 and 60 min. Of the 313 patients, 19 (6%) patients had an indeterminate response, cortisol <500 nmol/L at 30 min, but rising to ≥500 nmol/L on the 60 min sample. Of these 19 patients, only 9/19 patients had a serum cortisol level at 30 min <450 nmol/L, requiring clinical treatment with glucocorticoid replacement. All 24/313 (8%) patients who had insufficient responses at 60 min were also insufficient at 30 min sampling. No individuals passed (≥500 nmol/L) at 30 min and then failed (<500 nmol/L) at 60 min.ConclusionUsing the 30 min cortisol sample post-Synacthen administration alone identifies clinically relevant adrenal insufficiency in the majority of cases. A small subset of patients have a suboptimal response at 30 min but have a 60 min cortisol concentration above the threshold for a pass. Data regarding the long-term outcomes and management of such patients are lacking and require further study.
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Valentin A, Borresen SW, Rix M, Elung-Jensen T, Sørensen SS, Feldt-Rasmussen U. Adrenal insufficiency in kidney transplant patients during low-dose prednisolone therapy: a cross-sectional case–control study. Nephrol Dial Transplant 2019; 35:2191-2197. [DOI: 10.1093/ndt/gfz180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Indexed: 12/31/2022] Open
Abstract
Abstract
Background
Maintenance immunosuppressive regimens after renal transplantation (RTx) most often include prednisolone, which may induce secondary adrenal insufficiency, a potentially life-threatening side effect to glucocorticoid (GC) treatment due to the risk of acute adrenal crisis. We investigated the prevalence of prednisolone-induced adrenal insufficiency in RTx patients receiving long-term low-dose prednisolone treatment.
Methods
We performed a case–control study of patients on renal replacement therapy differing in terms of GC exposure. The study included 30 RTx patients transplanted >11 months before enrolment in the study and treated with prednisolone (5 or 7.5 mg prednisolone/day for ≥6 months) and 30 dialysis patients not treated with prednisolone. Patients underwent testing for adrenal insufficiency by a 250-µg Synacthen test performed fasting in the morning after a 48-h prednisolone pause. Normal adrenal function was defined as P-cortisol ≥420 nmol/L 30 min after Synacthen injection. This cut-off is used routinely for the new Roche Elecsys Cortisol II assay and is validated locally based on the Synacthen test responses in 100 healthy individuals.
Results
Thirteen RTx patients {43% [95% confidence interval (CI) 27–61]} had an insufficient response to the Synacthen test compared with one patient in the control group [3% (95% CI 0.6–17)] (P = 0.0004). Insufficient responses were seen in 9/25 and 4/5 RTx patients treated with 5 and 7.5 mg prednisolone/day, respectively.
Conclusions
We found a high prevalence of adrenal insufficiency among RTx patients receiving low-dose prednisolone treatment. We therefore advocate for increased clinical alertness towards prednisolone-induced adrenal insufficiency in RTx patients and thus their potential need of rescue GC supplementation during stress.
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Affiliation(s)
- Amalie Valentin
- Department of Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Stina Willemoes Borresen
- Department of Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Elung-Jensen
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Schwartz Sørensen
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Lopez AG, Fraissinet F, Lefebvre H, Brunel V, Ziegler F. Pharmacological and analytical interference in hormone assays for diagnosis of adrenal incidentaloma. ANNALES D'ENDOCRINOLOGIE 2019; 80:250-258. [DOI: 10.1016/j.ando.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 09/27/2018] [Accepted: 11/19/2018] [Indexed: 12/19/2022]
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Lovallo WR, Cohoon AJ, Acheson A, Vincent AS, Sorocco KH. Cortisol stress reactivity in women, diurnal variations, and hormonal contraceptives: studies from the Family Health Patterns Project. Stress 2019; 22:421-427. [PMID: 30896268 PMCID: PMC6525075 DOI: 10.1080/10253890.2019.1581760] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Women have smaller cortisol responses to psychological stress than men do, and women taking hormonal contraceptives (HC+) have smaller responses than HC- women. Cortisol secretion undergoes substantial diurnal variation, with elevated levels in the morning and lower levels in the afternoon, and these variations are accompanied by differences in response to acute stress. However, the impact of HC use on these diurnal relationships has not been examined. We tested saliva cortisol values in 744 healthy young adults, 351 men and 393 women, 254 HC- and 139 HC+, who were assigned to morning (9:00 am) or afternoon (1:00 pm) test sessions that were held both on a rest day and on a stress day that included public speaking and mental arithmetic challenges. Saliva cortisol responses to stress were largest in men and progressively smaller in HC- and in HC+ women (F = 23.26, p < .0001). In the morning test sessions, HC+ women had significantly elevated rest day cortisol levels (t = 5.99, p ≪ .0001, Cohen's d = 0.95) along with a complete absence of response on the stress day. In the afternoon sessions, both HC+ and HC- women had normal rest-day cortisol levels and normal responses to the stressors. Heart rates at rest and during stress did not vary by time of day or HC status. Cortisol stress responses in HC+ women are absent in the morning and normal in size by early afternoon. Studies of stress reactivity should account for time of day in evaluating cortisol responses in women using hormonal contraceptives.
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Affiliation(s)
- William R Lovallo
- a Behavioral Sciences Laboratories , Veterans Affairs Medical Center , Oklahoma City , OK , USA
- b Department of Psychiatry and Behavioral Sciences , University of Oklahoma Health Sciences Center , Oklahoma City , OK , USA
| | - Andrew J Cohoon
- b Department of Psychiatry and Behavioral Sciences , University of Oklahoma Health Sciences Center , Oklahoma City , OK , USA
| | - Ashley Acheson
- c Department of Psychiatry , University of Arkansas for Medical Sciences , Little Rock , AK , USA
| | - Andrea S Vincent
- d Cognitive Science Research Center , University of Oklahoma , Norman , OK , USA
| | - Kristen H Sorocco
- a Behavioral Sciences Laboratories , Veterans Affairs Medical Center , Oklahoma City , OK , USA
- e Donald W. Reynolds Department of Geriatric Medicine , University of Oklahoma Health Sciences Center , Oklahoma City , OK , USA
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Mongioì LM, Condorelli RA, Barbagallo F, Cannarella R, La Vignera S, Calogero AE. Accuracy of the Low-Dose ACTH Stimulation Test for Adrenal Insufficiency Diagnosis: A Re-Assessment of the Cut-Off Value. J Clin Med 2019; 8:jcm8060806. [PMID: 31195750 PMCID: PMC6616948 DOI: 10.3390/jcm8060806] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 05/28/2019] [Accepted: 06/01/2019] [Indexed: 11/16/2022] Open
Abstract
Background: The clinical practice shows that many low-dose ACTH-stimulation tests have a false positive result. The aim of the study was to determine the diagnostic accuracy of a low-dose ACTH-stimulation test in the diagnosis of adrenal insufficiency and to define its optimal cut-off. Methods: We analyzed data from 103 patients undergoing 1 µg ACTH-stimulation test. Four patients had adrenal insufficiency (AI) upon follow up: Two primary, and two secondary AI. Cortisol serum levels were evaluated at time 0, 20’, and 30’ after the injection of 1 µg i.v. of ACTH. The sensitivity, specificity, accuracy, and positive and negative predictive values of the test were calculated for both 20’ and 30’ sampling. The receiver operating characteristic (ROC) curve was obtained to assess the sensitivity and specificity of low-dose ACTH-stimulation test in the diagnosis of adrenal insufficiency at different cut-off values. Results: Considering 500 nmol/L as the standard cut-off value, low-dose ACTH stimulation test showed a 100% sensitivity and a 67.3% specificity, with a high rate of false positive results. ROC curve analysis showed that the cut-off of 401.5 nmol/L is the best compromise between sensitivity (100%) and specificity (93.9%). Conclusions: By using a cut-off value of 401.5 nmol/L for the low-dose ACTH stimulation test, the number of false positive patients decreased significantly, but the sensitivity remained high.
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Affiliation(s)
- Laura Maria Mongioì
- Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123 Catania, Italy.
| | - Rosita Angela Condorelli
- Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123 Catania, Italy.
| | - Federica Barbagallo
- Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123 Catania, Italy.
| | - Rossella Cannarella
- Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123 Catania, Italy.
| | - Sandro La Vignera
- Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123 Catania, Italy.
| | - Aldo Eugenio Calogero
- Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123 Catania, Italy.
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Luo A, El Gierari ETM, Nally LM, Sturmer LR, Dodd D, Shi RZ. Clinical utility of an ultrasensitive urinary free cortisol assay by tandem mass spectrometry. Steroids 2019; 146:65-69. [PMID: 30951757 DOI: 10.1016/j.steroids.2019.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND 24 h urinary free cortisol measurement is a clinically important first-line screening test for Cushing's syndrome (CS). Tandem mass spectrometry (LC-MS/MS) assays have superior sensitivity and specificity compared to immunoassays. Our goal was to improve and validate a LC-MS/MS method to measure urinary free cortisol in both adult and pediatric patients and to characterize its clinical diagnostic performance of CS by chart review. METHODS We improved a LC-MS/MS method previously reported for urinary free cortisol to be able to measure urinary and salivary cortisol in the same batch for increased efficiency. The sample preparation was by liquid-liquid extraction using dichloromethane followed by stepwise washing with acidic, basic and neutral solutions. The assay's analytical performance was characterized, and a retrospective patient chart review was conducted to evaluate the assay's clinical performance in diagnosing CS. RESULTS The LC-MS/MS assay demonstrated enhanced sensitivity and was linear within an analytical measurement range of 10-10,000 ng/dL. Assay accuracy was satisfactory as determined by spike and recovery studies and highly correlated with a reference LC-MS/MS method. The assay's clinical diagnostic sensitivity and specificity in detecting CS was 96% and 91%, respectively, when compared to a urinary cortisol excretion of at least 50 µg/24 h. CONCLUSIONS The improved LC-MS/MS method is both sensitive and specific with enhanced analytical performance and clinical diagnostic utility to screen for CS. The clinical diagnostic sensitivity and specificity were superior based on retrospective patient chart review.
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Affiliation(s)
- Amy Luo
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, United States
| | | | - Laura M Nally
- Yale School of Medicine, New Heaven, CT, United States
| | - Lillian R Sturmer
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Dylan Dodd
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Run-Zhang Shi
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, United States.
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30
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Polovina TS, Kraljevic I, Solak M, Balasko A, Haxhiu A, Haxhiu A, Dusek T, Poljicanin T, Kastelan D. Early Basal Cortisol Level as a Predictor of Hypothalamic-Pituitary-Adrenal (HPA) Axis Function After Pituitary Tumor Surgery. Exp Clin Endocrinol Diabetes 2019; 128:709-714. [PMID: 31091548 DOI: 10.1055/a-0885-1568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the clinical relevance of the early postoperative basal cortisol level in assessing the postoperative hypothalamic-pituitary-adrenal (HPA) axis function after pituitary tumor surgery. METHODS We performed a prospective observational study that enrolled 83 patients operated for pituitary adenoma or other sellar lesions at the University Hospital Center Zagreb between December 2013 and April 2017 (44 nonfunctioning pituitary adenomas, 28 somatotropinomas, 5 craniopharyngiomas, 2 prolactinomas resistant to medical therapy and 4 other lesions - Rathke's cleft cyst, arachnoid cyst, chondroma and gangliocytoma). Exclusion criteria were Cushing's disease, chronic therapy with glucocorticoids prior to surgery and preoperative adrenal insufficiency. Early postoperative basal cortisol levels (measured on the second postoperative day) and the Synacthen stimulation test (performed 3 months after the surgery with the peak cortisol level of>500 nmol/L considered as a normal response) were analyzed to assess HPA axis function during follow-up. RESULTS ROC analysis showed a cut-off of the basal cortisol level of ≥300 nmol/L measured on the second postoperative day to predict normal postoperative HPA axis function with the sensitivity of 92.31%, specificity of 87.14% and positive predictive value of 57.14%. CONCLUSION The basal cortisol level on the second postoperative day is a valuable tool to predict integrity of the HPA axis after pituitary tumor surgery. Our data suggest that the cortisol level of ≥300 nmol/L accurately predicts adrenal sufficiency and that in these patients glucocorticoid therapy can be withdrawn.
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Affiliation(s)
| | - Ivana Kraljevic
- Department of Endocrinology, University Hospital Center Zagreb, Coatia
| | - Mirsala Solak
- Department of Endocrinology, University Hospital Center Zagreb, Coatia
| | - Annemarie Balasko
- Department of Endocrinology, University Hospital Center Zagreb, Coatia
| | - Arta Haxhiu
- Department of Endocrinology, University Hospital Center Zagreb, Coatia
| | - Arita Haxhiu
- Department of Endocrinology, University Hospital Center Zagreb, Coatia
| | - Tina Dusek
- Department of Endocrinology, University Hospital Center Zagreb, Coatia.,School of Medicine University of Zagreb, Coatia
| | | | - Darko Kastelan
- Department of Endocrinology, University Hospital Center Zagreb, Coatia.,School of Medicine University of Zagreb, Coatia
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Luís M, Freitas J, Costa F, Buttgereit F, Boers M, Jap DS, Santiago T. An updated review of glucocorticoid-related adverse events in patients with rheumatoid arthritis. Expert Opin Drug Saf 2019; 18:581-590. [PMID: 31056959 DOI: 10.1080/14740338.2019.1615052] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Glucocorticoids represent a cornerstone in the treatment of rheumatoid arthritis. Their effect as a disease-modifying treatment in rheumatoid arthritis is well established. Despite this, the risk of adverse events of glucocorticoids, especially in high doses and over a long time, is constantly highlighted. Data on the prevalence and impact of glucocorticoid-related adverse effects in rheumatoid arthritis is needed, therefore, to be regularly revisited. AREAS COVERED In this review, our primary aim was to provide an update of evidence from randomized controlled trials and observational cohort studies on the safety of glucocorticoid treatment in rheumatoid arthritis. Our secondary aim was to provide a critical overview of the concerns raised with both study designs - randomized clinical trials versus nonrandomized observational studies - regarding the assessment of the safety of glucocorticoids in rheumatoid arthritis. EXPERT OPINION In the meantime, adherence to recommendations and consensus on standardized methodologies for monitoring and reporting adverse events is essential to improve our knowledge and competence in the best management of glucocorticoids.
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Affiliation(s)
- Mariana Luís
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
| | - João Freitas
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
| | - Flávio Costa
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
| | - Frank Buttgereit
- b Department of Rheumatology and Clinical Immunology , Charité University Medicine , Berlin , Germany
| | - Maarten Boers
- c Department of Epidemiology and Biostatistics, Amsterdam Rheumatology and Immunology Center , Amsterdam University Medical Centers, Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
| | - Da Silva Jap
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,d Faculty of Medicine , University of Coimbra , Coimbra , Portugal.,e Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine , University of Coimbra , Coimbra , Portugal
| | - Tânia Santiago
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,d Faculty of Medicine , University of Coimbra , Coimbra , Portugal
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Albert L, Profitós J, Sánchez-Delgado J, Capel I, González-Clemente JM, Subías D, Cano A, Berlanga E, Espinal A, Hurtado M, Pareja R, Rigla M, Dalmau B, Vergara M, Miquel M, Casas M, Giménez-Palop O. Salivary Cortisol Determination in ACTH Stimulation Test to Diagnose Adrenal Insufficiency in Patients with Liver Cirrhosis. Int J Endocrinol 2019; 2019:7251010. [PMID: 31320899 PMCID: PMC6609341 DOI: 10.1155/2019/7251010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/13/2019] [Accepted: 05/19/2019] [Indexed: 11/18/2022] Open
Abstract
PURPOSE The prevalence of adrenal insufficiency (AI) in patients with decompensated liver cirrhosis is unknown. Because these patients have lower levels of cortisol-binding carrier proteins, their total serum cortisol (TSC) correlates poorly with free serum cortisol (FC). Salivary cortisol (SaC) correlates better with FC. We aimed to establish SaC thresholds for AI for the 250 μg intravenous ACTH test and to estimate the prevalence of AI in noncritically ill cirrhotic patients. METHODS We included 39 patients with decompensated cirrhosis, 39 patients with known AI, and 45 healthy volunteers. After subjects fasted ≥8 hours, serum and saliva samples were collected for determinations of TSC and SaC at baseline 0'(T0) and at 30-minute intervals after intravenous administration of 250 μg ACTH [30'(T30), 60'(T60), and 90'(T90)]. RESULTS Based on the findings in healthy subjects and patients with known AI, we defined AI in cirrhotic patients as SaC-T0< 0.08 μg/dL (2.2 nmol/L), SaC-T60 < 1.43 μg/dl (39.5 nmol/L), or ΔSaC<1 μg/dl (27.6 nmol/L). We compared AI determination in cirrhotic patients with the ACTH test using these SaC thresholds versus established TSC thresholds (TSC-T0< 9 μg/dl [248 nmol/L], TSC-T60 < 18 μg/dl [497 nmol/L], or ΔTSC<9 μg/dl [248 nmol/L]). SaC correlated well with TSC. The prevalence of AI in cirrhotic patients was higher when determined by TSC (48.7%) than by SaC (30.8%); however, this difference did not reach statistical significance. AI was associated with sex, cirrhosis etiology, and Child-Pugh classification. CONCLUSIONS Measuring SaC was more accurate than TSC in the ACTH stimulation test. Measuring TSC overestimated the prevalence of AI in noncritically ill cirrhotic patients.
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Affiliation(s)
- Lara Albert
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Joaquím Profitós
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Jordi Sánchez-Delgado
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Ismael Capel
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - José Miguel González-Clemente
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - David Subías
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Albert Cano
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Eugenio Berlanga
- Clinical Laboratory Department, Institut d'Investigació i Innovació Parc Taulí I3PT, Parc Taulí University Hospital, Autonomous University of Barcelona, Sabadell, Spain
| | - Anna Espinal
- Servei d'Estadística Aplicada, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Marta Hurtado
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Rocío Pareja
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Mercedes Rigla
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Blai Dalmau
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Mercedes Vergara
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Mireia Miquel
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Meritxell Casas
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Olga Giménez-Palop
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
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Theiler-Schwetz V, Zaufel A, Schlager H, Obermayer-Pietsch B, Fickert P, Zollner G. Bile acids and glucocorticoid metabolism in health and disease. Biochim Biophys Acta Mol Basis Dis 2019; 1865:243-251. [DOI: 10.1016/j.bbadis.2018.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/18/2018] [Accepted: 08/01/2018] [Indexed: 12/12/2022]
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Braun LT, Riester A, Oßwald-Kopp A, Fazel J, Rubinstein G, Bidlingmaier M, Beuschlein F, Reincke M. Toward a Diagnostic Score in Cushing's Syndrome. Front Endocrinol (Lausanne) 2019; 10:766. [PMID: 31787931 PMCID: PMC6856055 DOI: 10.3389/fendo.2019.00766] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/21/2019] [Indexed: 12/26/2022] Open
Abstract
Cushing's syndrome (CS) is a classical rare disease: it is often suspected in patients who do not have the disease; at the same time, it takes a mean of 3 years to diagnose CS in affected individuals. The main reason is the extreme rarity (1-3/million/year) in combination with the lack of a single lead symptom. CS has to be suspected when a combination of signs and symptoms is present, which together make up the characteristic phenotype of cortisol excess. Unusual fat distribution affecting the face, neck, and trunk; skin changes including plethora, acne, hirsutism, livid striae, and easy bruising; and signs of protein catabolism such as thinned and vulnerable skin, osteoporotic fractures, and proximal myopathy indicate the need for biochemical screening for CS. In contrast, common symptoms like hypertension, weight gain, or diabetes also occur quite frequently in the general population and per se do not justify biochemical testing. First-line screening tests include urinary free cortisol excretion, dexamethasone suppression testing, and late-night salivary cortisol measurements. All three tests have overall reasonable sensitivity and specificity, and first-line testing should be selected on the basis of the physiologic conditions of the patient, drug intake, and available laboratory quality control measures. Two normal test results usually exclude the presence of CS. Other tests and laboratory parameters like the high-dose dexamethasone suppression test, plasma ACTH, the CRH test, and the bilateral inferior petrosal sinus sampling are not part of the initial biochemical screening. As a general rule, biochemical screening should only be performed if the pre-test probability for CS is reasonably high. This article provides an overview about the current standard in the diagnosis of CS starting with clinical scores and screenings, the clinical signs, relevant differential diagnoses, the first-line biochemical screening, and ending with a few exceptional cases.
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Affiliation(s)
- Leah T. Braun
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - Anna Riester
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - Andrea Oßwald-Kopp
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - Julia Fazel
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - German Rubinstein
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - Martin Bidlingmaier
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
| | - Felix Beuschlein
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zurich, Switzerland
| | - Martin Reincke
- Department for Endocrinology, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University, Munich, Germany
- *Correspondence: Martin Reincke
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Sherlock M, Stewart PM. The Short Synacthen Test and Its Utility in Assessing Recovery of Adrenal Function in Patients With Central Adrenal Insufficiency. J Clin Endocrinol Metab 2019; 104:17-20. [PMID: 30085278 PMCID: PMC6260064 DOI: 10.1210/jc.2018-01317] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 07/30/2018] [Indexed: 01/18/2023]
Abstract
The short synacthen test is useful in assessing recovery of adrenal function in patients with central adrenal insufficiency.
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Affiliation(s)
- Mark Sherlock
- Department of Endocrinology, Beaumont Hospital, Beaumont, Dublin 9, Ireland
- Department of Endocrinology, Royal College of Surgeons in Ireland Medical School, Beaumont, Dublin 9, Ireland
| | - Paul M Stewart
- Medical School, University of Leeds, Leeds, United Kingdom
- Correspondence and Reprint Requests: Paul M. Stewart, MD, Medical School, University of Leeds, Room 7.08, Worsley Building, Clarendon Way, Leeds LS2 9NL, United Kingdom. E-mail:
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Bowden SA, Henry R. Pediatric Adrenal Insufficiency: Diagnosis, Management, and New Therapies. Int J Pediatr 2018; 2018:1739831. [PMID: 30515225 PMCID: PMC6236909 DOI: 10.1155/2018/1739831] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/27/2018] [Indexed: 12/05/2022] Open
Abstract
Adrenal insufficiency may result from a wide variety of congenital or acquired disorders of hypothalamus, pituitary, or adrenal cortex. Destruction or dysfunction of the adrenal cortex is the cause of primary adrenal insufficiency, while secondary adrenal insufficiency is a result of pituitary or hypothalamic disease. Timely diagnosis and clinical management of adrenal insufficiency are critical to prevent morbidity and mortality. This review summarizes the etiologies, presentation, and diagnosis of adrenal insufficiency utilizing different dynamic hormone testing and describes current treatment recommendations and new therapies.
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Affiliation(s)
- Sasigarn A. Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Rohan Henry
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
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Ortiz-Flores AE, Santacruz E, Jiménez-Mendiguchia L, García-Cano A, Nattero-Chávez L, Escobar-Morreale HF, Luque-Ramírez M. Role of sampling times and serum cortisol cut-off concentrations on the routine assessment of adrenal function using the standard cosyntropin test in an academic hospital from Spain: a retrospective chart review. BMJ Open 2018; 8:e019273. [PMID: 29730618 PMCID: PMC5942445 DOI: 10.1136/bmjopen-2017-019273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Aiming to validate the use of a single poststimulus sampling protocol for cosyntropin test short standard high-dose test (SST) in our institution, our primary objectives were (1) to determine the concordance between 30 and 60 min serum cortisol (SC) measurements during SST; and (2) to evaluate the diagnostic agreement between both sampling times when using classic or assay-specific and sex-specific SC cut-off values. The secondary objectives included (1) estimating the specificity and positive predictive value of 30 and 60 min sampling times while considering the suspected origin of adrenal insufficiency (AI); and (2) obtaining assay-specific cut-off values for SC after SST in a group of subjects with normal hypothalamic-pituitary-adrenal (HPA) axis. DESIGN AND SETTING This is a retrospective chart review study conducted at a Spanish academic hospital from 2011 to 2015. PARTICIPANTS AND INTERVENTIONS Two groups were evaluated: (1) a main study group including 370 patients in whom SC was measured at 30 and 60 min during SST; and (2) a confirmative group that included 150 women presenting with a normal HPA axis in whom SST was conducted to rule out late-onset congenital adrenal hyperplasia. Diagnostic agreement between both sampling times was assessed by considering both classic (500 nmol/L) and assay-specific SC cut-off concentrations. RESULTS Diagnostic agreement between both sampling times was greater when applying sex-specific and assay-specific cut-off values instead of the classic cut-off values. For suspected primary AI, 30 min SC determination was enough to establish a diagnosis in over 95% of cases, without missing any necessary treatment. When central AI is suspected, 60 min SC measurement was more specific, establishing a diagnosis in over 97% of cases. CONCLUSIONS Sex-specific and assay-specific SC cut-off values improve the diagnostic accuracy of SST. For primary disease, a subnormal SC response at 30 min is a reliable marker of adrenal dysfunction. On the contrary, when central AI is suspected, 60 min SC measurement improves the diagnostic accuracy of the test.
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Affiliation(s)
- Andrés E Ortiz-Flores
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Hospital Universitario Ramón y Cajal & Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Elisa Santacruz
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Ana García-Cano
- Department of Clinical Biochemistry, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Lia Nattero-Chávez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Héctor F Escobar-Morreale
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Hospital Universitario Ramón y Cajal & Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Manuel Luque-Ramírez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Hospital Universitario Ramón y Cajal & Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
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Ueland GÅ, Methlie P, Øksnes M, Thordarson HB, Sagen J, Kellmann R, Mellgren G, Ræder M, Dahlqvist P, Dahl SR, Thorsby PM, Løvås K, Husebye ES. The Short Cosyntropin Test Revisited: New Normal Reference Range Using LC-MS/MS. J Clin Endocrinol Metab 2018; 103:1696-1703. [PMID: 29452421 DOI: 10.1210/jc.2017-02602] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 02/09/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND The cosyntropin test is used to diagnose adrenal insufficiency (AI) and nonclassical congenital adrenal hyperplasia (NCCAH). Current cutoffs for cortisol and 17-hydroxyprogesterone (17-OHP) are derived from nonstandardized immunoassays. Liquid chromatography tandem mass spectrometry (LC-MS/MS) offers direct measurement of steroids, prompting the need to re-establish normal ranges. OBJECTIVE The goal of this study was to define cutoff values for cortisol and 17-OHP in serum by LC-MS/MS 30 and 60 minutes after intravenous administration of 250 µg tetracosactide acetate to healthy volunteers and to compare the results with LC-MS/MS with routine immunoassays. METHODS Cosyntropin testing was performed in healthy subjects (n = 138) and in patients referred for evaluation of adrenocortical function (n = 94). Steroids were assayed by LC-MS/MS and compared with two immunoassays used in routine diagnostics (Immulite and Roche platforms). The cutoff level for cortisol was defined as the 2.5% percentile in healthy subjects not using oral estrogens (n = 121) and for 17-OHP as the 97.5% percentile. RESULTS Cortisol cutoff levels for LC-MS/MS were 412 and 485 nmol/L at 30 and 60 minutes, respectively. Applying the new cutoffs, 13 of 60 (22%) subjects who had AI according to conventional criteria now had a normal test result. For 17-OHP, the cutoff levels were 8.9 and 9.0 nmol/L at 30 and 60 minutes, respectively. CONCLUSIONS LC-MS/MS provides cutoff levels for cortisol and 17-OHP after cosyntropin stimulation that are lower than those based on immunoassays, possibly because cross-reactivity between steroid intermediates and cortisol is eliminated. This reduces the number of false-positive tests for AI and false-negative tests for NCCAH.
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Affiliation(s)
- Grethe Å Ueland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- K.G. Jebsen Senter for Autoimmune Sykdommer, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Paal Methlie
- Department of Clinical Science, University of Bergen, Bergen, Norway
- K.G. Jebsen Senter for Autoimmune Sykdommer, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Marianne Øksnes
- Department of Clinical Science, University of Bergen, Bergen, Norway
- K.G. Jebsen Senter for Autoimmune Sykdommer, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | | | - Jørn Sagen
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
| | - Ralf Kellmann
- Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
| | - Gunnar Mellgren
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Hormone Laboratory, Haukeland University Hospital, Bergen, Norway
| | | | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Sandra R Dahl
- Hormone Laboratory, Department of Medical Biochemistry, Oslo University Hospital Aker, Oslo, Norway
| | - Per M Thorsby
- Hormone Laboratory, Department of Medical Biochemistry, Oslo University Hospital Aker, Oslo, Norway
| | - Kristian Løvås
- Department of Clinical Science, University of Bergen, Bergen, Norway
- K.G. Jebsen Senter for Autoimmune Sykdommer, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Eystein S Husebye
- Department of Clinical Science, University of Bergen, Bergen, Norway
- K.G. Jebsen Senter for Autoimmune Sykdommer, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Nolan BJ, Sorbello J, Brown N, Dimeski G, Inder WJ. Characterization of the serum and salivary cortisol response to the intravenous 250 µg ACTH 1-24 stimulation test. Endocrine 2018; 59:520-528. [PMID: 29299794 DOI: 10.1007/s12020-017-1505-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The ACTH1-24 stimulation test is commonly used to assess the hypothalamic-pituitary-adrenal (HPA) axis. Given variations in CBG concentration and binding affinity, serum total cortisol may misclassify some patients. Salivary cortisol correlates well with serum free cortisol but is easier to measure and widely available in commercial laboratories. The aim of this study was to investigate the utility of measuring salivary cortisol during the ACTH1-24 stimulation test. DESIGN AND METHODS Case-control study in a clinical research facility. Eighty-seven patients with suspected cortisol deficiency, twenty-four healthy controls, and ten healthy women on the oral contraceptive (OC) underwent an intravenous 250 µg ACTH1-24 stimulation test. Concordance of ACTH1-24 stimulated serum and salivary cortisol was evaluated. RESULTS There was a significant difference in serum cortisol between the healthy volunteers and the women on the OC (P < 0.001) but no difference in salivary cortisol. The lower limit of the reference interval for salivary cortisol at 60 min was 26 nmol/L. 27/89 (30%) of tests with suspected HPA axis disorder failed the 60 min serum cortisol cut-off of 500 nmol/L. Of these, 24/27 (89%) had a salivary cortisol of <26 nmol/L. In contrast, 12/19 (63%) tests and 5/43 (12%) tests where the 60 min serum cortisol was 500-599 and ≥600 nmol/L, respectively had a salivary cortisol of <26 nmol/L. CONCLUSIONS Salivary cortisol provides additional diagnostic value during the 250 µg ACTH1-24 stimulation test in patients with proven or suspected alterations in CBG and potentially those with a borderline 60 min serum cortisol 500-599 nmol/L.
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Affiliation(s)
- Brendan J Nolan
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Jane Sorbello
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Nigel Brown
- Department of Chemical Pathology, Pathology Queensland, Brisbane, QLD, Australia
| | - Goce Dimeski
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Chemical Pathology, Pathology Queensland, Brisbane, QLD, Australia
| | - Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
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The effect of time of day testing and utility of 30 and 60 minute cortisol values in the 250 mcg ACTH stimulation test. Clin Biochem 2018; 54:37-41. [PMID: 29458002 DOI: 10.1016/j.clinbiochem.2018.02.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/13/2018] [Accepted: 02/15/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Despite widespread use of the 250-mcg Cosyntropin test (ACTH test) for the diagnosis of adrenal insufficiency (AI), the effect of time of day and the utility of performing both 30- and 60-min serum cortisol values remains unclear. METHODS We conducted a retrospective cohort study of all ACTH testing at the Halifax Neuropituitary Program, Nova Scotia, Canada between January 2006 and April 2016. Data were collected on age, gender, medication history, serum cortisol levels at 0, 30 and 60 min after ACTH administration, as well as time of and indication for testing. RESULTS There were 336 tests performed, divided by time of day (0800-1000 h, 1001-1200 h, and after 1200 h). There were no differences in mean cortisol levels at 30 (574.5, 559, 534 nmol/L, respectively; p = 0.25) and 60 min (642, 623, 619 nmol/L, respectively; p = 0.63) between groups. When comparing 30- vs. 60-min values using a cut-off of ≥500 nmol/L, 45 patients (13.4%) failed to reach the cut-off at 30 min but met the cut-off at 60 min. Conversely, only 2 patients (0.6%) who met the cut-off at 30 min failed to reach it at 60 min. CONCLUSION We found that outcomes from ACTH testing are not affected by time of day. Furthermore, using a 30-min cortisol level in isolation results in more than one in seven patients having a false positive diagnosis of AI; a 60-min value of ≥500 nmol/L alone may be sufficient to diagnose AI in >99% of cases.
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Borresen SW, Klose M, Baslund B, Rasmussen ÅK, Hilsted L, Friis-Hansen L, Locht H, Hansen A, Hetland ML, Lydolph MC, Feldt-Rasmussen U. Adrenal insufficiency is seen in more than one-third of patients during ongoing low-dose prednisolone treatment for rheumatoid arthritis. Eur J Endocrinol 2017; 177:287-295. [PMID: 28877961 DOI: 10.1530/eje-17-0251] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/16/2017] [Accepted: 07/04/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Patients receiving long-term glucocorticoid treatment are at risk of developing adrenal insufficiency during treatment. We investigated the prevalence of prednisolone-induced adrenal insufficiency in the particular clinical situation where patients receive ongoing low-dose (5 mg/day) prednisolone treatment, a dose by itself too low to cover glucocorticoid needs during stress. DESIGN AND METHODS Cross-sectional study in 42 patients with rheumatoid arthritis (29 women, aged 36-86 years) treated with 5 mg prednisolone/day, who had received prednisolone for ≥6 months (median: 66, range: 6-444 months). Adrenal function was evaluated by a 250 μg Synacthen test performed after mean 48.7 h prednisolone pause. Local assay-specific cut-off for normal adrenal function was P-cortisol ≥420 nmol/L 30 min after Synacthen injection. RESULTS Overall, 20 of the 42 patients (48%, 95% CI: 33-62%) had an insufficient adrenal response to the Synacthen test. Including only patients who had not received concomitant treatment with any other glucocorticoid formulas within the last 3 months, 13 of 33 patients (39%, 95% CI: 25-56%) had an insufficient response. Adrenocorticotrophic hormone (ACTH) concentrations were generally low and anti-adrenal antibodies were negative indicating secondary adrenal insufficiency as the most likely diagnosis. There was no correlation between duration of treatment and 30 min P-cortisol (P = 0.62). Adrenal function did not depend on sex or seropositivity of rheumatoid arthritis. CONCLUSION We demonstrate a high prevalence of adrenal insufficiency during ongoing low-dose prednisolone treatment. The results urge to increase focus on the condition to ensure identification and correct management of insufficient patients during stress and withdrawal. Strategies for adrenal function evaluation during ongoing low-dose glucocorticoid treatment need to be established.
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Affiliation(s)
- Stina Willemoes Borresen
- Department of Medical Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Klose
- Department of Medical Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Bo Baslund
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Center of Rheumatology and Joint Diseases
| | - Åse Krogh Rasmussen
- Department of Medical Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Linda Hilsted
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lennart Friis-Hansen
- Department of Clinical Biochemistry, Copenhagen University Hospital, Nordsjællands Hospital, Hillerød, Denmark
| | - Henning Locht
- Center of Rheumatology and Joint Diseases, Copenhagen University Hospital, Frederiksberg Hospital, Frederiksberg, Denmark
| | - Annette Hansen
- Center of Rheumatology and Joint Diseases, Copenhagen University Hospital, Gentofte Hospital, Gentofte, Denmark
| | - Merete Lund Hetland
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Center of Rheumatology and Joint Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
| | | | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Aleknaviciute J, Tulen JHM, De Rijke YB, Bouwkamp CG, van der Kroeg M, Timmermans M, Wester VL, Bergink V, Hoogendijk WJG, Tiemeier H, van Rossum EFC, Kooiman CG, Kushner SA. The levonorgestrel-releasing intrauterine device potentiates stress reactivity. Psychoneuroendocrinology 2017; 80:39-45. [PMID: 28315609 DOI: 10.1016/j.psyneuen.2017.02.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 01/26/2017] [Accepted: 02/23/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND The levonorgestrel-releasing intrauterine device (LNG-IUD) is currently recommended as a first-line contraceptive with an exclusively local intrauterine influence. However, recent clinical trials have identified side effects of LNG-IUD that appear to be systemically mediated, including depressed mood and emotional lability. METHODS We performed two experimental studies and a cross-sectional study. For each study, women were included from three groups: LNG-IUD (0.02mg/24h), oral ethinylestradiol/levonorgestrel (0.03mg/0.15mg; EE30/LNG) and natural cycling (NC). Study 1-Salivary cortisol was measured at baseline and at defined intervals following the Trier Social Stress Test (TSST). Heart rate was monitored continuously throughout the TSST. Study 2-Salivary cortisol and serum total cortisol were evaluated relative to low-dose (1μg) adrenocorticotropic hormone (ACTH) administration. Study 3-Hair cortisol was measured as a naturalistic index of long-term cortisol exposure. RESULTS Women using LNG-IUD had an exaggerated salivary cortisol response to the TSST (24.95±13.45 nmol/L, 95% CI 17.49-32.40), compared to EE30/LNG (3.27±2.83 nmol/L, 95% CI 1.71-4.84) and NC (10.85±11.03nmol/L, 95% CI 6.30-15.40) (P<0.0001). Heart rate was significantly potentiated during the TSST in women using LNG-IUD (P=0.047). In response to ACTH challenge, women using LNG-IUD and EE30/LNG had a blunted salivary cortisol response, compared to NC (P<0.0001). Women using LNG-IUD had significantly elevated levels of hair cortisol compared to EE30/LNG or NC (P<0.0001). CONCLUSIONS Our findings suggest that LNG-IUD contraception induces a centrally-mediated sensitization of both autonomic and hypothalamic-pituitary-adrenal (HPA) axis responsivity. LNG-IUD sensitization of HPA axis responsivity was observed acutely under standardized laboratory conditions, as well as chronically under naturalistic conditions.
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Affiliation(s)
- Jurate Aleknaviciute
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Joke H M Tulen
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Yolanda B De Rijke
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Christian G Bouwkamp
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Mark van der Kroeg
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Mirjam Timmermans
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Vincent L Wester
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Veerle Bergink
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Witte J G Hoogendijk
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Henning Tiemeier
- Departments of Child and Adolescent Psychiatry and Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Elisabeth F C van Rossum
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Cornelis G Kooiman
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Steven A Kushner
- Department of Psychiatry, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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Kline GA, Buse J, Krause RD. Clinical implications for biochemical diagnostic thresholds of adrenal sufficiency using a highly specific cortisol immunoassay. Clin Biochem 2017; 50:475-480. [DOI: 10.1016/j.clinbiochem.2017.02.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 02/08/2017] [Accepted: 02/09/2017] [Indexed: 11/30/2022]
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Valassi E, Franz H, Brue T, Feelders RA, Netea-Maier R, Tsagarakis S, Webb SM, Yaneva M, Reincke M, Droste M, Komerdus I, Maiter D, Kastelan D, Chanson P, Pfeifer M, Strasburger CJ, Tóth M, Chabre O, Tabarin A, Krsek M, Fajardo C, Bolanowski M, Santos A, Wass JAH, Trainer PJ. Diagnostic tests for Cushing's syndrome differ from published guidelines: data from ERCUSYN. Eur J Endocrinol 2017; 176:613-624. [PMID: 28377460 DOI: 10.1530/eje-16-0967] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 02/13/2017] [Accepted: 02/21/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate which tests are performed to diagnose hypercortisolism in patients included in the European Registry on Cushing's syndrome (ERCUSYN), and to examine if their use differs from the current guidelines. PATIENTS AND METHODS We analyzed data on the diagnostic tests performed in 1341 patients with Cushing's syndrome (CS) who have been entered into the ERCUSYN database between January 1, 2000 and January 31, 2016 from 57 centers in 26 European countries. Sixty-seven percent had pituitary-dependent CS (PIT-CS), 24% had adrenal-dependent CS (ADR-CS), 6% had CS from an ectopic source (ECT-CS) and 3% were classified as having CS from other causes (OTH-CS). RESULTS Of the first-line tests, urinary free cortisol (UFC) test was performed in 78% of patients, overnight 1 mg dexamethasone suppression test (DST) in 60% and late-night salivary cortisol (LSaC) in 25%. Use of LSaC increased in the last five years as compared with previous years (P < 0.01). Use of HDDST was slightly more frequent in the last 5 years as compared with previous years (P < 0.05). Of the additional tests, late-night serum cortisol (LSeC) was measured in 62% and 48-h 2 mg/day low-dose dexamethasone suppression test (LDDST) in 33% of cases. ACTH was performed in 78% of patients. LSeC and overnight 1 mg DST supported the diagnosis of both PIT-CS and ADR-CS more frequently than UFC (P < 0.05). CONCLUSIONS Use of diagnostic tests for CS varies across Europe and partly differs from the currently available guidelines. It would seem pertinent that a European consensus be established to determine the best diagnostic approach to CS, taking into account specific inter-country differences with regard to the availability of diagnostic tools.
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Affiliation(s)
- Elena Valassi
- IIB-Sant Pau and Department of Endocrinology/MedicineHospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Holger Franz
- Lohmann & Birkner Health Care Consulting GmbHBerlin, Germany
| | - Thierry Brue
- Aix-Marseille UniversitéCNRS, CRN2M UMR 7286, and APHM, Hôpital Conception, Marseille, France
| | | | | | | | - Susan M Webb
- IIB-Sant Pau and Department of Endocrinology/MedicineHospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | | | - Martin Reincke
- Medizinische Klinik und Poliklinik IVCampus Innestadt, Klinikum der Universität München, München, Germany
| | | | - Irina Komerdus
- Moscow Regional Research Clinical InstituteMoscow, Russia
| | | | - Darko Kastelan
- Department of EndocrinologyUniversity Hospital Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Philippe Chanson
- Univ Paris-SudUniversité Paris-Saclay UMR-S1185, Le Kremlin Bicêtre, Paris, France
- Assistance Publique-Hôpitaux de ParisHôpital de Bicêtre, Service de Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, Paris, France
- Institut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, Paris, France
| | - Marija Pfeifer
- Department of EndocrinologyUniversity Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Christian J Strasburger
- Division of Clinical EndocrinologyDepartment of Medicine CCM, Charité-Universitätsmedizin, Berlin, Germany
| | - Miklós Tóth
- 2nd Department of MedicineSemmelweis University, Budapest, Hungary
| | - Olivier Chabre
- Service d'Endocrinologie-Diabétologie-NutritionGrenoble Cedex, France
| | - Antoine Tabarin
- Centre Hospitalier Universitaire de BordeauxBordeaux, France
| | - Michal Krsek
- 2nd Department of Internal Medicine3rd Faculty of Medicine and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Carmen Fajardo
- Department of EndocrinologyHospital Universitario de la Ribera, Alzira, Spain
| | - Marek Bolanowski
- Department of EndocrinologyDiabetology and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Alicia Santos
- IIB-Sant Pau and Department of Endocrinology/MedicineHospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | | | - Peter J Trainer
- Department of EndocrinologyChristie Hospital, Manchester, UK
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El-Farhan N, Rees DA, Evans C. Measuring cortisol in serum, urine and saliva - are our assays good enough? Ann Clin Biochem 2017; 54:308-322. [PMID: 28068807 DOI: 10.1177/0004563216687335] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Cortisol is a steroid hormone produced in response to stress. It is essential for maintaining health and wellbeing and leads to significant morbidity when deficient or present in excess. It is lipophilic and is transported bound to cortisol-binding globulin (CBG) and albumin; a small fraction (∼10%) of total serum cortisol is unbound and biologically active. Serum cortisol assays measure total cortisol and their results can be misleading in patients with altered serum protein concentrations. Automated immunoassays are used to measure cortisol but lack specificity and show significant inter-assay differences. Liquid chromatography - tandem mass spectrometry (LC-MS/MS) offers improved specificity and sensitivity; however, cortisol cut-offs used in the short Synacthen and Dexamethasone suppression tests are yet to be validated for these assays. Urine free cortisol is used to screen for Cushing's syndrome. Unbound cortisol is excreted unchanged in the urine and 24-h urine free cortisol correlates well with mean serum-free cortisol in conditions of cortisol excess. Urine free cortisol is measured predominantly by immunoassay or LC-MS/MS. Salivary cortisol also reflects changes in unbound serum cortisol and offers a reliable alternative to measuring free cortisol in serum. LC-MS/MS is the method of choice for measuring salivary cortisol; however, its use is limited by the lack of a single, validated reference range and poorly standardized assays. This review examines the methods available for measuring cortisol in serum, urine and saliva, explores cortisol in disease and considers the difficulties of measuring cortisol in acutely unwell patients and in neonates.
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Affiliation(s)
- Nadia El-Farhan
- 1 Biochemistry Department, Royal Gwent Hospital, Newport, UK
| | - D Aled Rees
- 2 Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK
| | - Carol Evans
- 3 Department of Medical Biochemistry and Immunology, University Hospital of Wales, Cardiff, UK
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Astradsson A, Munck af Rosenschöld P, Feldt-Rasmussen U, Poulsgaard L, Wiencke AK, Ohlhues L, Engelholm SA, Broholm H, Hansen Møller E, Klose M, Roed H, Juhler M. Visual outcome, endocrine function and tumor control after fractionated stereotactic radiation therapy of craniopharyngiomas in adults: findings in a prospective cohort. Acta Oncol 2017; 56:415-421. [PMID: 28084862 DOI: 10.1080/0284186x.2016.1270466] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The purpose of this study was to examine visual outcome, endocrine function and tumor control in a prospective cohort of craniopharyngioma patients, treated with fractionated stereotactic radiation therapy (FSRT). MATERIAL AND METHODS Sixteen adult patients with craniopharyngiomas were eligible for analysis. They were treated with linear accelerator-based FSRT during 1999-2015. In all cases, diagnosis was confirmed by histological analysis. The prescription dose to the tumor was 54 Gy (median, range 48-54) in 1.8 or 2.0 Gy per fraction, and the maximum radiation dose to the optic nerves and chiasm was 54.2 Gy (median, range 48.6-60.0) for the cohort. Serial ophthalmological and endocrine evaluations and magnetic resonance imaging (MRI) scans were performed at regular intervals. Median follow-up was 3.3 years (range 1.1-14.1), 3.7 years (range 0.8-15.2), and 3.6 years (range 0.7-13.1) for visual outcome, endocrine function, and tumor control, respectively. RESULTS Visual acuity impairment was present in 10 patients (62.5%) and visual field defects were present in 12 patients (75%) before FSRT. One patient developed radiation-induced optic neuropathy at seven years after FSRT. Thirteen of 16 patients (81.3%) had pituitary deficiency before FSRT, and did not develop further pituitary deficiency after FSRT. Mean tumor volume pre-FSRT was 2.72 cm3 (range 0.20-9.90) and post-FSRT 1.2 cm3 (range 0.00-13.10). Tumor control rate was 81.3% at two, five, and 10 years after FSRT. CONCLUSIONS FSRT was relatively safe in this prospective cohort of craniopharyngiomas, with only one case of radiation-induced optic neuropathy and no case of new endocrinopathy. Tumor control rate was acceptable.
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Affiliation(s)
- Arnar Astradsson
- Department of Neurorehabilitation, Traumatic Brain Injury Unit, Rigshospitalet, Hvidovre, Denmark
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Lars Poulsgaard
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | | | - Lars Ohlhues
- Department of Radiation Oncology, Finsen Center, Rigshospitalet, Copenhagen, Denmark
| | - Svend Aage Engelholm
- Department of Radiation Oncology, Finsen Center, Rigshospitalet, Copenhagen, Denmark
| | - Helle Broholm
- Department of Neuropathology, Rigshospitalet, Copenhagen, Denmark
| | - Emil Hansen Møller
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
- Department of Medical Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Klose
- Department of Medical Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Roed
- Department of Radiation Oncology, Finsen Center, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
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Mak IYF, Au Yeung BYT, Ng YW, Choi CH, Iu HYP, Shek CC, Tiu SC. Salivary Cortisol and Cortisone After Low-Dose Corticotropin Stimulation in the Diagnosis of Adrenal Insufficiency. J Endocr Soc 2017; 1:96-108. [PMID: 29264470 PMCID: PMC5686556 DOI: 10.1210/js.2016-1056] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 12/29/2016] [Indexed: 12/05/2022] Open
Abstract
Context: Basal and poststimulation salivary cortisol and cortisone levels can be useful in the diagnosis of adrenal insufficiency. However, little is known about the optimal cutoffs and performance characteristics of these tests. Objective: To derive the cutoff values and study the performance characteristics of salivary cortisol and salivary cortisone in the diagnosis of adrenal insufficiency. Design and Setting: Prospective study in a regional hospital in Hong Kong from January 2014 to September 2015. Participants: Fifty-six Chinese healthy volunteers and 171 patients suspected of having adrenal insufficiency. Main Outcome Measures: All participants underwent low-dose short Synacthen test (LDSST) with intravenous injection of 1 μg of tetracosactide (Synacthen 1–24). Serum cortisol, salivary cortisol and cortisone levels were measured at baseline and 30 and 60 minutes afterward. Results: Using the reference cutoff (mean − 2 standard deviations of post-LDSST peak serum cortisol) derived from healthy volunteers as the gold standard, receiver operating characteristic analysis of patients’ data revealed that both post-LDSST peak salivary cortisol and cortisone performed better than basal tests. The most optimal cutoff values for serum cortisol as measured by immunoassay and for salivary cortisol and salivary cortisone as measured by liquid chromatography–tandem mass spectrometry (LC-MS/MS) were 376, 8.6, and 33.5 nmol/L, respectively, for post-LDSST peak values, and 170, 1.7, and 12.5 nmol/L, respectively, for basal values. Conclusions: We established method-specific reference cutoffs for serum cortisol, salivary cortisol, and salivary cortisone during LDSST. Both post-LDSST peak salivary cortisol and cortisone performed well as diagnostic tests for adrenal insufficiency. Their measurements by LC-MS/MS can alleviate problems associated with serum cortisol immunoassays.
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Affiliation(s)
| | | | | | | | - Heidi Yan Ping Iu
- Department of Pathology, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Chi Chung Shek
- Department of Pathology, Queen Elizabeth Hospital, Kowloon, Hong Kong
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Jublanc C, Bruckert E. L’insuffisance surrénalienne chez l’adulte. Rev Med Interne 2016; 37:820-826. [DOI: 10.1016/j.revmed.2016.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 02/23/2016] [Indexed: 12/17/2022]
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Dušková M, Šimůnková K, Vítků J, Sosvorová L, Jandíková H, Pospíšilová H, Šrámková M, Kosák M, Kršek M, Hána V, Žánová M, Springer D, Stárka L. A Comparison of Salivary Steroid Levels during Diagnostic Tests for Adrenal Insufficiency. Prague Med Rep 2016; 117:18-33. [PMID: 26995200 DOI: 10.14712/23362936.2016.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Numerous diagnostic tests are used to evaluate the hypothalamic-pituitary-adrenal axis (HPA axis). The gold standard is still considered the insulin tolerance test (ITT), but this test has many limitations. Current guidelines therefore recommend the Synacthen test first when an HPA axis insufficiency is suspected. However, the dose of Synacthen that is diagnostically most accurate and sensitive is still a matter of debate. We investigated 15 healthy men with mean/median age 27.4/26 (SD±4.8) years, and mean/median BMI (body mass index) 25.38/24.82 (SD±3.2) kg/m2. All subjects underwent 4 dynamic tests of the HPA axis, specifically 1 μg, 10 μg, and 250 μg Synacthen (ACTH) tests and an ITT. Salivary cortisol, cortisone, pregnenolone, and DHEA (dehydroepiandrosterone) were analysed using liquid chromatography-tandem mass spectrometry. During the ITT maximum salivary cortisol levels over 12.5 nmol/l were found at 60 minutes. Maximum cortisol levels in all of the Synacthen tests were higher than this; however, demonstrating that sufficient stimulation of the adrenal glands was achieved. Cortisone reacted similarly as cortisol, i.e. we did not find any change in the ratio of cortisol to cortisone. Pregnenolone and DHEA were higher during the ITT, and their peaks preceded the cortisol peak. There was no increase of pregnenolone or DHEA in any of the Synacthen tests. We demonstrate that the 10 μg Synacthen dose is sufficient stimulus for testing the HPA axis and is also a safe and cost-effective alternative. This dose also largely eliminates both false negative and false positive results.
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Affiliation(s)
| | - Kateřina Šimůnková
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Jana Vítků
- Institute of Endocrinology, Prague, Czech Republic
| | | | | | | | | | - Mikuláš Kosák
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Michal Kršek
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Václav Hána
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Magdaléna Žánová
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Drahomíra Springer
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
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Rauschecker M, Abraham SB, Abel BS, Wesley R, Saverino E, Trivedi A, Heller T, Nieman LK. Cosyntropin-Stimulated Serum Free Cortisol in Healthy, Adrenally Insufficient, and Mildly Cirrhotic Populations. J Clin Endocrinol Metab 2016; 101:1075-81. [PMID: 26647150 PMCID: PMC4803155 DOI: 10.1210/jc.2015-2285] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Serum free cortisol (SFF) responses to cosyntropin simulation test (CST) may more accurately assess adrenal function than total cortisol (TF). OBJECTIVE The objective of the study was to evaluate the diagnostic utility of SFF responses during a 250-μg CST. DESIGN We recruited healthy volunteers (HV; n = 27), patients with primary and secondary adrenal insufficiency (n = 19 and n = 24, respectively), and subjects with Child-Pugh class A cirrhosis (CH; n = 15). Each received 250 μg cosyntropin with measurement of ACTH and corticosteroid binding globulin (CBG) at time 0 and TF and SFF at 0, 30, and 60 minutes. Salivary cortisol was measured at all time points in CH subjects. RESULTS Peak SFF and TF were significantly higher in HVs vs both AI groups (P < .05). Peak SFF and TF (6.8 μg/dL vs 2.2 μg/dL; [188 nmol/L vs 62 nmol/L]; P < .01) were significantly higher in the secondary adrenal insufficiency vs primary adrenal insufficiency patients. The optimal peak SFF criterion to identify adrenal insufficiency patients vs HV was 0.9 μg/dL (25 nmol/L) (sensitivity of 95%, specificity of 100%). Mean CBG and albumin levels were similar among all four groups. CH patients had a higher peak SFF than HV (2.4 vs 2.0 μg/dL; P = .02. In the CH patients, peak salivary cortisol levels correlated well with peak SFF (rs = 0.84, P = .005). CBG levels were similar among the groups. CONCLUSION We provide normative data for SFF values in HV and AI during the CST. Normal CBG levels in mild cirrhosis did not affect the interpretation of the CST.
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Affiliation(s)
- Mitra Rauschecker
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Smita Baid Abraham
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Brent S Abel
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Robert Wesley
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Elizabeth Saverino
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Apurva Trivedi
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Theo Heller
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
| | - Lynnette K Nieman
- Program in Reproductive and Adult Endocrinology (M.R., S.B.A., B.S.A., E.S., L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Biostatistics and Clinical Epidemiology Service (R.W.), Clinical Center, and Translational Hepatology Unit (A.T., T.H.), Liver Diseases Branch, The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
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