1
|
Bäcklund N, Lundstedt S, Tornevi A, Wihlbäck AC, Olsson T, Dahlqvist P, Brattsand G. Salivary Cortisol and Cortisone Can Circumvent Confounding Effects of Oral Contraceptives in the Short Synacthen Test. J Clin Endocrinol Metab 2024; 109:1899-1906. [PMID: 38173358 PMCID: PMC11180507 DOI: 10.1210/clinem/dgad763] [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: 09/06/2023] [Revised: 12/06/2023] [Accepted: 12/27/2023] [Indexed: 01/05/2024]
Abstract
CONTEXT Adrenal insufficiency (AI) is usually diagnosed by low plasma cortisol levels following a short Synacthen test (SST). Most plasma cortisol is bound to corticosteroid-binding globulin, which is increased by estrogen in combined estrogen-progestin oral contraceptives (COCs). Women with AI using COCs are therefore at risk of having an apparently normal plasma cortisol level during SST, which would not adequately reflect AI. OBJECTIVE This work aimed to test whether salivary cortisol or cortisone during SST is more robust against the COC effect and to calculate the lower reference limits (LRLs) for these to be used as tentative diagnostic cutoffs to exclude AI. METHODS Forty-one healthy women on COCs and 46 healthy women without exogenous estrogens underwent an SST with collection of plasma and salivary samples at 0, 30, and 60 minutes after Synacthen injection. The groups were compared using regression analysis with age as covariate and the LRLs were calculated parametrically. RESULTS SST-stimulated plasma cortisol levels were significantly higher in the COC group vs controls, while mean salivary cortisol and cortisone levels were slightly lower in the COC group. Importantly, COC use did not significantly alter LRLs for salivary cortisol or cortisone. The smallest LRL difference between groups was seen for salivary cortisone. CONCLUSION Salivary cortisol and especially salivary cortisone are considerably less affected by COC use than plasma cortisol during SST. Due to similar LRLs, a common cutoff for salivary cortisol and cortisone during SST can be used to exclude AI in premenopausal women irrespective of COC use.
Collapse
Affiliation(s)
- Nils Bäcklund
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Staffan Lundstedt
- Department of Medical Biosciences, Division of Clinical Chemistry, Umeå University, 901 87 Umeå, Sweden
| | - Andreas Tornevi
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Anna-Carin Wihlbäck
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87 Umeå, Sweden
| | - Tommy Olsson
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Göran Brattsand
- Department of Medical Biosciences, Division of Clinical Chemistry, Umeå University, 901 87 Umeå, Sweden
| |
Collapse
|
2
|
Tucci L, Fanelli F, Improta I, Bissi V, Lena C, Galante G, Mezzullo M, Magagnoli M, Lalumera AB, Colombin G, Coscia K, Rotolo L, Vicennati V, Pagotto U, Di Dalmazi G. Monitoring adrenal insufficiency through salivary steroids: a pilot study. Eur J Endocrinol 2024; 190:327-337. [PMID: 38571387 DOI: 10.1093/ejendo/lvae037] [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: 10/24/2023] [Revised: 02/21/2024] [Accepted: 03/11/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Various glucocorticoid replacement therapies (GRTs) are available for adrenal insufficiency (AI). However, their effectiveness in restoring glucocorticoid rhythm and exposure lacks adequate biochemical markers. We described the diurnal salivary cortisol (SalF) and cortisone (SalE) rhythm among different GRTs and analysed the associations between saliva-derived parameters and life quality questionnaires. METHODS Control subjects (CSs, n = 28) and AI patients receiving hydrocortisone (HC, n = 9), cortisone acetate (CA, n = 23), and dual-release hydrocortisone once (DRHC-od, n = 10) and twice a day (DRHC-td, n = 6) collected 9 saliva samples from 07:00 to 23:00. Patients compiled Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Scale, and Addison disease-specific quality-of-life questionnaires. SalE and SalF were measured by liquid chromatography-mass spectrometry. Exposure was monitored using SalE for HC and DRHC and SalF for CA. Area under the curve (AUC) was computed. Different GRTs were compared by Z-scores calculated from saliva-derived parameters. Questionnaire results predictors were evaluated with multiple regression analysis. RESULTS Compared with controls, all GRTs resulted in glucocorticoid overexposure in the morning. Hydrocortisone, CA, and DRHC-td caused overexposure also in afternoon and evening. Compared with other treatments, CA determined increased Z-score-07:00 (P < .001), DRHC-td determined increased Z-score-AUC07:00→14:00 (P = .007), and DRHC-od induced lower Z-score-AUC14:00→23:00 (P = .015). Z-scores-AUC14:00→16:00 ≥ .619 best predicted questionnaire scores. CONCLUSIONS None of the GRTs mimics normal glucocorticoid rhythmicity and exposure. SalE, SalF, and Z-score may be useful markers for monitoring and comparing different GRTs. Excess glucocorticoid in early afternoon best associated with depressive symptoms and worse life and sleep quality.
Collapse
Affiliation(s)
- Lorenzo Tucci
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Flaminia Fanelli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Ilaria Improta
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Valentina Bissi
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Claudia Lena
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Greta Galante
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Marco Mezzullo
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Matteo Magagnoli
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Anna Bianca Lalumera
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Giacomo Colombin
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Kimberly Coscia
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Laura Rotolo
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Valentina Vicennati
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Uberto Pagotto
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Center for Applied Biomedical Research, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Guido Di Dalmazi
- Division of Endocrinology and Diabetes Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| |
Collapse
|
3
|
Voltan G, Antonelli G, Mondin A, Tizianel I, Sabbadin C, Barbot M, Basso D, Scaroni C, Ceccato F. Heat inactivation of SARS-CoV 2 enabled the measurement of salivary cortisol during COVID-19 pandemic. Endocrine 2024; 83:775-782. [PMID: 37991703 PMCID: PMC10901918 DOI: 10.1007/s12020-023-03597-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/03/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND AND AIM Salivary cortisol has become an essential tool in the management of cortisol-related disease. In 2020 the sudden outbreak of COVID-19 pandemic caused several concerns about the use of saliva, due to the risk of contamination, and a European consensus further discourage using salivary cortisol. To decrease infectious risk, we handled specimens by applying a heat treatment to inactivate viral particles, further evaluating the impact of the COVID-19 pandemic on the use of salivary cortisol in clinical practice. MATERIAL AND METHODS Saliva samples were exposed for 10 min at 70 °C, then cortisol was measured using LC-MS/MS. The number of salivary cortisol examinations from 2013 to 2022 was extracted from the local electronic database: those performed in 2019, 2020, and 2021 were analyzed and compared with the historical data. RESULTS During 2020 we observed a decrease of 408 (-20%) examinations (p = 0.05) compared to 2019; especially in salivary cortisol daily rhythm and salivary cortisol/cortisone ratio (respectively reduction of 47% and 88%, p = 0.003 and p = 0.001). Analyzing year 2021 compared with 2020 we reported an increase of 420 examinations (+20%, p = 0.01), with a complete recovery of salivary cortisol measurement (considering 2019: p = 0.71). Major differences were observed between morning salivary cortisol (-20%, p = 0.017), LNSC (-21%, p = 0.012) and salivary cortisol rhythm (-22%, p = 0.056). No Sars-Cov2 infections related to working exposure were reported among laboratory's employers. CONCLUSIONS We speculate that the adoption of an appropriate technique to inactivate viral particles in saliva specimens allowed the safety maintenance of salivary collections, also during the Sars-CoV-2 outbreak.
Collapse
Affiliation(s)
- Giacomo Voltan
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Giorgia Antonelli
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Laboratory Medicine Unit, University-Hospital of Padova, Padova, Italy
| | - Alessandro Mondin
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Irene Tizianel
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Chiara Sabbadin
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Daniela Basso
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Laboratory Medicine Unit, University-Hospital of Padova, Padova, Italy
| | - Carla Scaroni
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy.
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy.
| |
Collapse
|
4
|
Ballerini MG, Freire AV, Rodríguez ME, Suco Valle S, Castro S, Arcari A, Bergadá I, Ropelato MG. Diagnostic Accuracy of Morning Salivary Cortisol in the Assessment of the Hypothalamic-Pituitary-Adrenal Axis Recovery after Prolonged Corticosteroid Therapy in Children. Horm Res Paediatr 2023; 97:53-61. [PMID: 37231892 DOI: 10.1159/000530939] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 04/25/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Assessment of the hypothalamic-pituitary-adrenal (HPA) axis is necessary after prolonged glucocorticoid therapy withdrawal. Salivary cortisol reflects 65% of the free circulating cortisol fraction. Saliva collection is non-invasive and child friendly. OBJECTIVE We aimed to evaluate the diagnostic accuracy of morning salivary cortisol (mSAF) to determine HPA recovery after prolonged corticosteroid therapy in children. METHODS We conducted a prospective, validation study in 171 paediatric patients (mean ± SD age: 13.0 ± 4.4 years) who received glucocorticoids for >4 weeks (median and interquartile range: 11 [7-14] months) and were referred for therapy withdrawal. Serum and saliva samples were collected between 8 and 9 a.m. on the same day. Cortisol was measured by an electrochemiluminescence immunoassay (ECLIA) 48 h after cessation of glucocorticoid therapy. Serum cortisol ≥193 nmol/L was used as the reference cut-off value for HPA recovery after glucocorticoid withdrawal and mSAF as the index test. RESULTS The cut-off concentration obtained by ROC for mSAF was ≥5.0 nmol/L. True positive and true negative results were observed in 85/171 and 40/171 children, respectively. The false-positive rate was low (3/171, 1.7%); however, false-negative results were observed in 43/171 (25%) children. The main ROC results (95% CI) were area under curve: 0.98 (0.96-0.99), sensitivity: 0.66 (0.57-0.75), specificity: 0.93 (0.81-0.99), positive predictive value: 0.97 (0.90-0.99), negative predictive value: 0.48 (0.37-0.59), LR+: 9.5, and diagnostic accuracy: 73.1%. CONCLUSION The present study supports that mSAF ≥5.0 nmol/L by ECLIA is a non-invasive biomarker for the assessment of HPA recovery after prolonged glucocorticoid therapy in paediatric patients, with a positive predictive value of 97%. This proposed cut-off should be further validated using gold standard techniques for steroid quantification such as liquid chromatography-tandem mass spectrometry.
Collapse
Affiliation(s)
- María Gabriela Ballerini
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Analía Verónica Freire
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - María Eugenia Rodríguez
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Sofía Suco Valle
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Sebastián Castro
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Andrea Arcari
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ignacio Bergadá
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - María Gabriela Ropelato
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE) CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| |
Collapse
|
5
|
Raff H, Zhang CD. A New Approach - Home Waking Salivary Cortisone to Screen for Adrenal Insufficiency. NEJM EVIDENCE 2023; 2:EVIDe2200306. [PMID: 38320042 DOI: 10.1056/evide2200306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Adrenal insufficiency is a common and potentially life-threatening endocrine disorder that can be drug induced or endogenous and of adrenal (primary) or pituitary/hypothalamic (secondary/tertiary) origin.1,2 Of particular concern in drug-induced disease is the patient with glucocorticoid- or opioid-induced adrenal insufficiency. Adrenal insufficiency of any cause is typically diagnosed biochemically with a subnormal morning serum cortisol (the circadian, awakening peak) and serum dehydroepiandrosterone sulfate, followed by or simultaneously with an assessment of the acute (30 and 60 minutes) serum cortisol response to injected synthetic corticotropin (ACTH[1-24]), if clinically indicated.
Collapse
Affiliation(s)
- Hershel Raff
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee
- Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Milwaukee
| | - Catherine D Zhang
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee
| |
Collapse
|
6
|
Ben Halima H, Zine N, Bausells J, Jaffrezic-Renault N, Errachid A. A Novel Cortisol Immunosensor Based on a Hafnium Oxide/Silicon Structure for Heart Failure Diagnosis. MICROMACHINES 2022; 13:mi13122235. [PMID: 36557534 PMCID: PMC9786208 DOI: 10.3390/mi13122235] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 06/12/2023]
Abstract
Assessing cortisol levels in human bodies has become essential to diagnose heart failure (HF). In this work, we propose a salivary cortisol detection strategy as part of an easily integrable lab-on-a-chip for detection of HF biomarkers. Our developed capacitive immunosensor based on hafnium oxide (HfO2)/silicon structure showed good linearity between increasing cortisol concentration and the charge-transfer resistance/capacitance. Moreover, the developed biosensor was demonstrated to be highly selective toward cortisol compared to other HF biomarkers such as tumor necrosis factor (TNF-α) and N-terminal pro-brain natriuretic peptide (NT-proBNP). The precision of our developed biosensor was evaluated, and the difference between the determined cortisol concentration in saliva and its expected one is <18%.
Collapse
Affiliation(s)
- Hamdi Ben Halima
- Institut de Sciences Analytiques (ISA)-UMR 5280, Université Claude Bernard Lyon 1, 5 rue de la Doua, 69100 Lyon, France
| | - Nadia Zine
- Institut de Sciences Analytiques (ISA)-UMR 5280, Université Claude Bernard Lyon 1, 5 rue de la Doua, 69100 Lyon, France
| | - Joan Bausells
- Institute of Microelectronics of Barcelona (IMB-CNM, CSIC), Campus UAB, Bellaterra, 08193 Barcelona, Spain
| | - Nicole Jaffrezic-Renault
- Institut de Sciences Analytiques (ISA)-UMR 5280, Université Claude Bernard Lyon 1, 5 rue de la Doua, 69100 Lyon, France
| | - Abdelhamid Errachid
- Institut de Sciences Analytiques (ISA)-UMR 5280, Université Claude Bernard Lyon 1, 5 rue de la Doua, 69100 Lyon, France
| |
Collapse
|
7
|
Tonge JJ, Keevil BG, Craig JN, Whitaker MJ, Ross RJ, Elder CJ. Salivary Steroid Collection in Children Under Conditions Replicating Home Sampling. J Clin Endocrinol Metab 2022; 107:3128-3136. [PMID: 35961299 DOI: 10.1210/clinem/dgac419] [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: 05/17/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Measurement of salivary glucocorticoids is an accepted method for testing adrenal function but there are few data on stability during home collection. Current salivary collection techniques require active participation or present a choking hazard and are unsuitable for young children. OBJECTIVE We sought to compare different salivary collection methods; assess the stability of salivary glucocorticoids under conditions replicating home collection; and assess patient tolerability and caregiver acceptability of a salivary collection device for young children, a swab encased in an infant pacifier (SaliPac). METHODS Six healthy adults collected salivary samples using a Salivette Cortisol, passive drool, and SalivaBio at night, waking, and 3 Pm for five days. Time to collect 1-mL saliva using the SalivaBio and SaliPac and caregiver acceptability were assessed in 30 children younger than 6 years. Saliva was stored at 4 °C, room temperature (RT), and 50 °C for 24, 48, 72 hours and 1 week to replicate potential postage conditions. Salivary cortisol and cortisone concentrations were measured by mass spectrometry. RESULTS There was no difference in salivary glucocorticoid concentrations using the 3 collection methods. Salivary cortisol and cortisone were stable for 72 hours at RT and 4 °C, and repeated freeze-thaw cycles did not cause significant degradation. In children younger than 6 years the SalivaBio and SaliPac were well tolerated and collected sufficient saliva for salivary steroid analysis in less than 4 minutes. CONCLUSION Salivette, passive drool, and SalivaBio collect samples with comparable salivary cortisol and cortisone concentrations, which are stable under conditions replicating home collection. SaliPac is an acceptable device for salivary sampling in young children.
Collapse
Affiliation(s)
- Joseph J Tonge
- Academic Unit of Medical Education, Medical School, University of Sheffield, S10 2RX Sheffield, UK
| | - Brian G Keevil
- Department of Clinical Biochemistry, University Hospital of South Manchester NHS Trust, M23 9LT Manchester, UK
| | - Jessica N Craig
- Academic Unit of Medical Education, Medical School, University of Sheffield, S10 2RX Sheffield, UK
| | - Martin J Whitaker
- Department of Oncology & Metabolism, University of Sheffield, S10 2RX Sheffield, UK
| | - Richard J Ross
- Department of Oncology & Metabolism, University of Sheffield, S10 2RX Sheffield, UK
| | - Charlotte J Elder
- Department of Oncology & Metabolism, University of Sheffield, S10 2RX Sheffield, UK
- Department of Endocrinology, Sheffield Children's NHS Foundation Trust, S10 2TH Sheffield, UK
| |
Collapse
|
8
|
Mohamed RS, Abuelgasim B, Barker S, Prabhudev H, Martin NM, Meeran K, Williams EL, Darch S, Matthew W, Tan T, Wernig F. Late-night salivary cortisol and cortisone should be the initial screening test for Cushing's syndrome. Endocr Connect 2022; 11:EC-22-0050. [PMID: 35671282 PMCID: PMC9254321 DOI: 10.1530/ec-22-0050] [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: 05/18/2022] [Accepted: 06/07/2022] [Indexed: 11/08/2022]
Abstract
Endogenous Cushing's syndrome (CS) poses considerable diagnostic challenges. Although late-night salivary cortisol (LNSC) is recommended as a first-line screening investigation, it remains the least widely used test in many countries. The combined measurement of LNSC and late-night salivary cortisone (LNS cortisone) has shown to further improve diagnostic accuracy. We present a retrospective study in a tertiary referral centre comparing LNSC, LNS cortisone, overnight dexamethasone suppression test, low-dose dexamethasone suppression test and 24-h urinary free cortisol results of patients investigated for CS. Patients were categorised into those who had CS (21 patients) and those who did not (33 patients). LNSC had a sensitivity of 95% and a specificity of 91%. LNS cortisone had a specificity of 100% and a sensitivity of 86%. With an optimal cut-off for LNS cortisone of >14.5 nmol/L the sensitivity was 95.2%, and the specificity was 100% with an area under the curve of 0.997, for diagnosing CS. Saliva collection is non-invasive and can be carried out at home. We therefore advocate simultaneous measurement of LNSC and LNS cortisone as the first-line screening test to evaluate patients with suspected CS.
Collapse
Affiliation(s)
| | - Biyaser Abuelgasim
- Imperial College School of Medicine, Department of Biochemistry, Imperial College Healthcare NHS Trust, London, UK
| | - Sally Barker
- Imperial College School of Medicine, Department of Biochemistry, Imperial College Healthcare NHS Trust, London, UK
| | - Hemanth Prabhudev
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Niamh M Martin
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Karim Meeran
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Emma L Williams
- Department of Biochemistry, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah Darch
- Department of Biochemistry, Imperial College Healthcare NHS Trust, London, UK
| | - Whitlock Matthew
- Department of Biochemistry, Imperial College Healthcare NHS Trust, London, UK
| | - Tricia Tan
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Florian Wernig
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Correspondence should be addressed to F Wernig:
| |
Collapse
|
9
|
Kalaria T, Buch H, Agarwal M, Chaudhari R, Gherman-Ciolac C, Chopra R, Okeke V, Kaur S, Hughes L, Sharrod-Cole H, Ford C, Gama R. Morning serum cortisol is superior to salivary cortisone and cortisol in predicting normal adrenal function in suspected adrenal insufficiency. Clin Endocrinol (Oxf) 2022; 96:916-918. [PMID: 33290598 DOI: 10.1111/cen.14388] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/09/2020] [Accepted: 12/03/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Tejas Kalaria
- Blood Sciences, Royal Wolverhampton NHS Trust, Wolverhampton, UK
- Endocrinology and Diabetes, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Harit Buch
- Endocrinology and Diabetes, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Mayuri Agarwal
- Endocrinology and Diabetes, 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
| | - Sukhbir Kaur
- Blood Sciences, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Lauren Hughes
- Blood Sciences, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | | | - Clare Ford
- Blood Sciences, 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
| |
Collapse
|
10
|
Sabbadin C, Betterle C, Scaroni C, Ceccato F. Frequently Asked Questions in Patients With Adrenal Insufficiency in the Time of COVID-19. Front Endocrinol (Lausanne) 2021; 12:805647. [PMID: 35002978 PMCID: PMC8739913 DOI: 10.3389/fendo.2021.805647] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/10/2021] [Indexed: 12/15/2022] Open
Abstract
Adrenal insufficiency (AI) is a life-threatening disorder, with increased morbidity and mortality, especially in case of an acute illness that can increase the requirement of cortisol. A novel infectious disease, termed Coronavirus Disease 2019 (COVID-19), appeared in 2020. Therefore, AI patients are experiencing a novel challenge: the risk of infection. In our experience, a prompt contact to the Endocrine center (with a telemedicine consultation) and a full awareness of diseases (cortisol deficiency, COVID-19 and the self-management of an adrenal crisis) are important to motivate patients. Vaccine is an effective treatment to prevent hospitalization and aggressive course of COVID-19. Some patients manifest challenges due to inequitable access and vaccine hesitancy, resulting in a delay in the acceptance of vaccines despite the availability of vaccination services. Therefore, an effort of all physicians must be conducted in order to advise patients with AI. In this short review, we try to answer some frequently asked questions regarding the management of patients with AI.
Collapse
Affiliation(s)
- Chiara Sabbadin
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Corrado Betterle
- Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Filippo Ceccato
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Department of Neuroscience (DNS), University of Padova, Padova, Italy
| |
Collapse
|
11
|
Ceccato F, Selmin E, Antonelli G, Barbot M, Daniele A, Boscaro M, Plebani M, Scaroni C. Low-dose short synacthen test with salivary cortisol in patients with suspected central adrenal insufficiency. Endocr Connect 2021; 10:1189-1199. [PMID: 34424852 PMCID: PMC8494418 DOI: 10.1530/ec-21-0404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/23/2021] [Indexed: 12/26/2022]
Abstract
CONTEXT The low-dose short synacthen test (LDSST) is recommended for patients with suspected central adrenal insufficiency (AI) if their basal serum cortisol (F) levels are not indicative of an intact hypothalamic-pituitary-adrenal (HPA) axis. OBJECTIVE To evaluate diagnostic threshold for salivary F before and 30 min after administering 1 μg of synacthen, performed before 09:30 h. DESIGN A cross-sectional study from 2014 to 2020. SETTING A tertiary referral university hospital. PATIENTS In this study, 174 patients with suspected AI, 37 with central AI and 137 adrenal sufficient (AS), were included. MAIN OUTCOME MEASURE The diagnostic accuracy (sensitivity (SE), specificity (SP)) of serum and salivary F levels measured, respectively, by chemiluminescence immunoassay and liquid chromatography-tandem mass spectrometry. RESULTS Low basal serum or salivary F levels could predict AI. For the LDSST, the best ROC-calculated threshold for serum F to differentiate AI from AS was 427 nmol/L (SE 79%, SP 89%), serum F > 500 nmol/L reached SP 100%. A salivary F peak > 12.1 nmol/L after administering synacthen reached SE 95% and SP 84% for diagnosing central AI, indicating a conclusive reduction in the likelihood of AI. This ROC-calculated threshold for salivary F was similar to the 2.5th percentile of patients with a normal HPA axis, so it was considered sufficient to exclude AI. Considering AS those patients with salivary F > 12.1 nmol/L after LDSST, we could avoid unnecessary glucocorticoid treatment: 99/150 subjects (66%) had an inadequate serum F peak after synacthen, but salivary F was >12.1 nmol/L in 79 cases, who could, therefore, be considered AS. CONCLUSIONS Salivary F levels > 12.1 nmol/L after synacthen administration can indicate an intact HPA axis in patients with an incomplete serum F response, avoiding the need to start glucocorticoid replacement treatment.
Collapse
Affiliation(s)
- Filippo Ceccato
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Neuroscience DNS, University of Padova, Padova, Italy
- Correspondence should be addressed to F Ceccato:
| | - Elisa Selmin
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Giorgia Antonelli
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Laboratory Medicine, University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Neuroscience DNS, University of Padova, Padova, Italy
| | - Andrea Daniele
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Marco Boscaro
- Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Mario Plebani
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Laboratory Medicine, University-Hospital of Padova, Padova, Italy
| | - Carla Scaroni
- Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| |
Collapse
|
12
|
Olesti E, Boccard J, Visconti G, González-Ruiz V, Rudaz S. From a single steroid to the steroidome: Trends and analytical challenges. J Steroid Biochem Mol Biol 2021; 206:105797. [PMID: 33259940 DOI: 10.1016/j.jsbmb.2020.105797] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/02/2020] [Accepted: 11/24/2020] [Indexed: 12/23/2022]
Abstract
For several decades now, the analysis of steroids has been a key tool in the diagnosis and monitoring of numerous endocrine pathologies. Thus, the available methods used to analyze steroids in biological samples have dramatically evolved over time following the rapid pace of technology and scientific knowledge. This review aims to synthetize the advances in steroids' analysis, from classical approaches considering only a few steroids or a limited number of steroid ratios, up to the new steroid profiling strategies (steroidomics) monitoring large sets of steroids in biological matrices. In this context, the use of liquid chromatography coupled to mass spectrometry has emerged as the technique of choice for the simultaneous determination of a high number of steroids, including phase II metabolites, due to its sensitivity and robustness. However, the large dynamic range to be covered, the low natural abundance of some key steroids, the selectivity of the analytical methods, the extraction protocols, and the steroid ionization remain some of the current challenges in steroid analysis. This review provides an overview of the different analytical workflows available depending on the number of steroids under study. Special emphasis is given to sample treatment, acquisition strategy, data processing, steroid identification and quantification using LC-MS approaches. This work also outlines how the availability of steroid standards, the need for complementary analytical strategies and the improvement of calibration approaches are crucial for achieving complete steroidome quantification.
Collapse
Affiliation(s)
- Eulalia Olesti
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland; School of Pharmaceutical Sciences, University of Geneva, Switzerland; Swiss Centre for Applied Human Toxicology (SCAHT), Switzerland
| | - Julien Boccard
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland; School of Pharmaceutical Sciences, University of Geneva, Switzerland; Swiss Centre for Applied Human Toxicology (SCAHT), Switzerland
| | - Gioele Visconti
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland; School of Pharmaceutical Sciences, University of Geneva, Switzerland
| | - Víctor González-Ruiz
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland; School of Pharmaceutical Sciences, University of Geneva, Switzerland; Swiss Centre for Applied Human Toxicology (SCAHT), Switzerland
| | - Serge Rudaz
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland.
| |
Collapse
|
13
|
Athimulam S, Grebe S, Bancos I. Steroid profiling in the diagnosis of mild and overt Cushing's syndrome. Best Pract Res Clin Endocrinol Metab 2021; 35:101488. [PMID: 33589355 PMCID: PMC8164982 DOI: 10.1016/j.beem.2021.101488] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In this review, we provide a comprehensive overview of the utility of steroid profiling for diagnosis of management of overt Cushing syndrome and mild autonomous cortisol secretion. A diagnosis of Cushing syndrome is made through a multistep process that includes confirmation of endogenous hypercortisolism, followed by determination of its cause. Steroid metabolomic testing applied to serum or urine steroids and their metabolites can provide additional and novel insights into alterations of steroid biosynthesis and metabolism and its causes. In particular, increased availability and advances in mass spectrometry-based steroid analysis, coupled with machine learning-based algorithms, have facilitated the development of tailored diagnostic and subtyping approaches for autonomous cortisol secretion and might be useful for detecting low grade autonomous glucocorticoid secretion and in predicting and monitoring of disease severity and associated comorbidities.
Collapse
Affiliation(s)
- Shobana Athimulam
- Department of Medicine, Division of Endocrinology, Diabetes, Bone and Mineral Disorders, Henry Ford Health System, Detroit, MI, USA.
| | - Stefan Grebe
- Department of Laboratory Medicine and Pathology, Division of Clinical Biochemistry and Immunology, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.
| | - Irina Bancos
- Department of Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
14
|
Newman M, Curran DA, Mayfield BP. Dried urine and salivary profiling for complete assessment of cortisol and cortisol metabolites. J Clin Transl Endocrinol 2020; 22:100243. [PMID: 33354516 PMCID: PMC7744704 DOI: 10.1016/j.jcte.2020.100243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/06/2020] [Accepted: 11/19/2020] [Indexed: 10/29/2022] Open
|
15
|
George GS, Jabbar PK, Jayakumari C, John M, Mini M, Thekkumkara Surendran Nair A, Das DV, Gomez R, Sreenath R, Prasad N, Nair A. Long-acting porcine ACTH stimulated salivary cortisol in the diagnosis of adrenal insufficiency. Clin Endocrinol (Oxf) 2020; 93:652-660. [PMID: 32662067 DOI: 10.1111/cen.14286] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Synacthen stimulated salivary cortisol has been previously evaluated and found beneficial in the diagnosis of adrenal insufficiency (AI), especially in situations with altered cortisol-binding protein (CBG) levels. Unfortunately, Synacthen is not marketed in many parts of the world whereas porcine sequence corticotrophin (Acton Prolongatum) is readily available. This study aimed to find the diagnostic accuracy of Acton prolongatum stimulated salivary cortisol test (APSST) compared to the short synacthen test (SST). METHODS Consecutive outpatients with suspected AI underwent SST initially, followed by APSST after 3 days. For APSST, saliva was collected at 0, 60 and 120 minutes after administering 30 units Acton Prolongatum intramuscularly. Serum and salivary cortisol were estimated using electrochemiluminescence assay. (Cobas e 411, Elecsys Cortisol II kits) RESULTS: Sixty-seven patients with clinically suspected AI were enrolled for the study. Based on SST, 35 patients were classified as having AI [primary AI (n=19) and secondary AI (n=16)] whereas 32 had normal glucocorticoid reserve. The area under receiver operator curve of 0.99 and 0.98 was observed for salivary cortisol values at 60 and 120 minutes, respectively, for APSST. A cut-off value of 18.5 nmol/L (0.67 µg/dL) and 29.3 nmol/L (1.06 µg/dL) at 60 and 120 minutes, respectively, had a sensitivity as well as specificity of 93%-100% in diagnosing AI. CONCLUSION Salivary cortisol estimation following stimulation using intramuscular porcine ACTH (Adrenocorticotrophic hormone) (30 units) is an economical and accurate alternative to SST in the diagnosis of AI, m and its level of 30 nmol/L or more at 2 hours confirms adrenal sufficiency.
Collapse
Affiliation(s)
- Geena Susan George
- Department of Endocrinology & Metabolism, Govt. Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Puthiyaveettil Khadar Jabbar
- Department of Endocrinology & Metabolism, Govt. Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Chellamma Jayakumari
- Department of Endocrinology & Metabolism, Govt. Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Mathew John
- Providence Endocrine & Diabetes Specialty Centre, Trivandrum, Kerala, India
| | - Malathi Mini
- Department of Community Medicine, Govt. Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | | | - Darvin V Das
- Department of Endocrinology & Metabolism, Govt. Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Ramesh Gomez
- Department of Endocrinology & Metabolism, Govt. Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Ravindranath Sreenath
- Department of Endocrinology & Metabolism, Govt. Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Nandini Prasad
- Department of Endocrinology & Metabolism, Govt. Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Abilash Nair
- Department of Endocrinology & Metabolism, Govt. Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| |
Collapse
|
16
|
Úbeda-D’Ocasar E, Jiménez Díaz-Benito V, Gallego-Sendarrubias GM, Valera-Calero JA, Vicario-Merino Á, Hervás-Pérez JP. Pain and Cortisol in Patients with Fibromyalgia: Systematic Review and Meta-Analysis. Diagnostics (Basel) 2020; 10:diagnostics10110922. [PMID: 33182522 PMCID: PMC7698032 DOI: 10.3390/diagnostics10110922] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/03/2020] [Accepted: 11/03/2020] [Indexed: 12/11/2022] Open
Abstract
This systematic review and meta-analysis sought to gain further insight into the relationship between cortisol reactivity and chronic widespread pain in patients with fibromyalgia. The studies selected were those conducted in adults with fibromyalgia that were random controlled, non-controlled or observational. Studies were excluded if they examined diseases other than fibromyalgia or if they did not report on pain or cortisol. Twelve studies met inclusion criteria. Data were extracted into tabular format using predefined data fields by two reviewers and assessed for accuracy by a third reviewer. The methodological quality of the studies was assessed using the PEDro scale. Data Synthesis: Of 263 studies identified, 12 were selected for our review and 10 were finally included as their methodological quality was good. In the meta-analysis, we calculated effect sizes of interventions on pain indicators and cortisol levels in patients with fibromyalgia. A small overall effect of all the interventions was observed on pain tolerance and pressure pain thresholds, yet this effect lacked significance (ES = 0.150; 95%CI 0.932–1.550; p > 0.05). Conclusions: While some effects of individual nonpharmacological therapeutic interventions were observed on both cortisol levels and measures of pain, our results suggest much further work is needed to elucidate the true relationship between chronic widespread pain and cortisol levels in patients with fibromyalgia.
Collapse
Affiliation(s)
- Edurne Úbeda-D’Ocasar
- Department of Physiotherapy, Faculty of Health, Camilo José Cela University, Villanueva de la Cañada, 28692 Madrid, Spain; (E.Ú.-D.); (G.M.G.-S.); (J.A.V.-C.)
| | - Victor Jiménez Díaz-Benito
- Department of Sport Sciences, Faculty of Health, Camilo José Cela University, Villanueva de la Cañada, 28692 Madrid, Spain;
| | - Gracia María Gallego-Sendarrubias
- Department of Physiotherapy, Faculty of Health, Camilo José Cela University, Villanueva de la Cañada, 28692 Madrid, Spain; (E.Ú.-D.); (G.M.G.-S.); (J.A.V.-C.)
| | - Juan Antonio Valera-Calero
- Department of Physiotherapy, Faculty of Health, Camilo José Cela University, Villanueva de la Cañada, 28692 Madrid, Spain; (E.Ú.-D.); (G.M.G.-S.); (J.A.V.-C.)
| | - Ángel Vicario-Merino
- Department of Nursing, Faculty of Health, Camilo José Cela University, Villanueva de la Cañada, 28692 Madrid, Spain;
| | - Juan Pablo Hervás-Pérez
- Department of Physiotherapy, Faculty of Health, Camilo José Cela University, Villanueva de la Cañada, 28692 Madrid, Spain; (E.Ú.-D.); (G.M.G.-S.); (J.A.V.-C.)
- Correspondence: ; Tel.: +34-91-815-31-31
| |
Collapse
|
17
|
Purser JD, Riachy R, Blanton LS, Belalcazar LM. Rapid Development of Iatrogenic Cushing Syndrome In A Patient On Ritonavir: The Adverse Metabolic Consequence of Topical Steroid Use. AACE Clin Case Rep 2020; 6:e346-e348. [DOI: 10.4158/accr-2020-0375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/10/2020] [Indexed: 11/15/2022] Open
|
18
|
Kim JH, Kim YJ, Lee SM, Lee J. Comparison of salivary and serum cortisol levels in mechanically ventilated patients and non-critically ill patients. Acute Crit Care 2020; 35:149-155. [PMID: 32907308 PMCID: PMC7483020 DOI: 10.4266/acc.2020.00297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/09/2020] [Indexed: 02/07/2023] Open
Abstract
Background Although the measuring free cortisol is ideal for assessment of hypothalamic-pituitary-adrenal function, it is not routinely measured. Salivary cortisol correlates well with the biologically active free cortisol. Therefore, this study measured the morning basal as well as adrenocorticotropic hormone-stimulated salivary cortisol levels in mechanically ventilated patients and compared the results with non-critically ill patients. Methods We prospectively enrolled 49 mechanically ventilated patients and 120 patients from the outpatient clinic. Serum and saliva samples were collected between 8 AM and 10 AM. Salivary cortisol levels were measured using an enzyme immunoassay kit. The salivary samples were insufficient in 15 mechanically ventilated patients (30.6%), and these patients were excluded from the final analysis. Results Mechanically ventilated patients (n=34) were significantly older and had lower body mass index and serum albumin levels and higher serum creatinine levels than non-critically ill patients (n=120). After adjustment for these parameters, both basal and stimulated salivary and serum cortisol levels were higher in mechanically ventilated patients. The increase in cortisol was not significantly different between the two groups. Serum cortisol levels showed a positive correlation with salivary cortisol levels. Among mechanically ventilated patients, both basal serum and salivary cortisol levels were lower in survivors than in non-survivors. Conclusions Both basal total serum and salivary cortisol levels were elevated in mechanically ventilated patients and in non-survivors.
Collapse
Affiliation(s)
- Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon Ji Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mediplex Sejong Hospital, Incheon, Korea
| | - Sang-Min Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jinwoo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
19
|
Ceccato F, Artusi C, Barbot M, Lizzul L, Pinelli S, Costantini G, Niero S, Antonelli G, Plebani M, Scaroni C. Dexamethasone measurement during low-dose suppression test for suspected hypercortisolism: threshold development with and validation. J Endocrinol Invest 2020; 43:1105-1113. [PMID: 32060745 DOI: 10.1007/s40618-020-01197-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 02/10/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIM Dexamethasone Suppression Test (DST), recommended for Cushing's Syndrome (CS) diagnosis, explores the pituitary feedback to glucocorticoids. Its diagnostic accuracy could be affected by dexamethasone bioavailability, and therefore, we have developed and validated a dexamethasone threshold after 1-mg DST. MATERIALS AND METHODS We studied 200 subjects: 125 patients were considered retrospectively and 75 were enrolled prospectively as the validation cohort. Serum dexamethasone, Late Night Salivary Cortisol (LNSC), and Urinary Free Cortisol (UFC) were measured with LC-MS/MS. Normal LNSC and UFC levels were used to exclude CS. The lower 2.5th percentile of dexamethasone distribution in non-CS patients with cortisol ≤ 50 nmol/L after 1-mg DST was used as threshold. RESULTS 16 patients were CS and 184 non-CS (108 adrenal incidentaloma and 76 excluded CS); 4.5 nmol/L resulted the calculated threshold. Cortisol after 1-mg DST confirmed high sensitivity (100% at 50 nmol/L cut-off) and moderate-low specificity (63%, increased to 91% at 138 nmol/L) to diagnose CS in the whole cohort of patients. We could reduce the number of false-positive results (from 10 to 6 and from 7 to 4 in AI and excluded CS) considering adequate dexamethasone levels. Dexamethasone levels were not affected by hypercortisolism, age, gender, smoke, weight, and creatinine. 6% of non-CS patients did not achieve adequate dexamethasone levels (40% of tests with serum cortisol > 138 nmol/L after 1-mg DST). CONCLUSIONS We developed and validated the routine dexamethasone measurement during 1-mg DST: it is independent from patient's clinical presentation, and it should be used to increase the specificity of serum cortisol levels.
Collapse
Affiliation(s)
- F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile, 105-35128, Padua, Italy.
- Department of Neurosciences DNS, University of Padova, Padua, Italy.
| | - C Artusi
- Laboratory Medicine Unit, Department of Medicine DIMED, University-Hospital of Padova, Padua, Italy
| | - M Barbot
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile, 105-35128, Padua, Italy
| | - L Lizzul
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile, 105-35128, Padua, Italy
| | - S Pinelli
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile, 105-35128, Padua, Italy
| | - G Costantini
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile, 105-35128, Padua, Italy
| | - S Niero
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile, 105-35128, Padua, Italy
| | - G Antonelli
- Laboratory Medicine Unit, Department of Medicine DIMED, University-Hospital of Padova, Padua, Italy
| | - M Plebani
- Laboratory Medicine Unit, Department of Medicine DIMED, University-Hospital of Padova, Padua, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Via Ospedale Civile, 105-35128, Padua, Italy
| |
Collapse
|
20
|
Khurshid Z, Warsi I, Moin SF, Slowey PD, Latif M, Zohaib S, Zafar MS. Biochemical analysis of oral fluids for disease detection. Adv Clin Chem 2020; 100:205-253. [PMID: 33453866 DOI: 10.1016/bs.acc.2020.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The field of diagnostics using invasive blood testing represents the majority of diagnostic tests used as part of routine health monitoring. The relatively recent introduction of salivary diagnostics has lead to a major paradigm shift in diagnostic analyses. Additionally, in this era of big data, oral fluid testing has shown promising outcomes in a number of fields, particularly the areas of genomics, microbiomics, proteomics, metabolomics, and transcriptomics. Despite the analytical challenges involved in the interpretation of large datasets generated from biochemical studies involving bodily fluids, including saliva, many studies have identified novel oral biomarkers for diagnosing oral and systemic diseases. In this regard, oral biofluids, including saliva, gingival crevicular fluid (GCF), peri-implant crevicular fluid (PICF), dentinal tubular fluid (DTF), are now attracting increasing attention due to their important attributes, such as noninvasive sampling, easy handling, low cost, and more accurate diagnosis of oral diseases. Recently, the utilization of salivary diagnostics to evaluate systemic diseases and monitor general health has increased in popularity among clinicians. Saliva contains a wide range of protein, DNA and RNA biomarkers, which assist in the diagnosis of multiple diseases and conditions, including cancer, cardiovascular diseases (CVD), auto-immune and degenerative diseases, respiratory infections, oral diseases, and microbial (viral, bacterial and fungal) diseases. Moreover, due to its noninvasive nature and ease-of-adoption by children, it is now being used in mass screening programs, oral health-related studies and clinical trials in support of the development of therapeutic agents. The recent advent of highly sensitive technologies, such as next-generation sequencing, mass spectrometry, highly sensitives ELISAs, and homogeneous immunoassays, suggests that even small quantities of salivary biomarkers are able to be assayed accurately, providing opportunities for the development of many future diagnostic applications (including emerging technologies, such as point-of-care and rapid molecular technologies). The present article explores the omics and biochemical compositions of various oral biofluids with important value in diagnostics and monitoring.
Collapse
Affiliation(s)
- Zohaib Khurshid
- Department of Prosthodontics and Dental Implantology, College of Dentistry, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Ibrahim Warsi
- Masters in Medical Science and Clinical Investigation, Harvard Medical School, Boston, MA, United States
| | - Syed F Moin
- National Center for Proteomics, University of Karachi, Karachi, Pakistan
| | - Paul D Slowey
- Oasis Diagnostics® Corporation, Vancouver, WA, United States
| | - Muhammad Latif
- Centre for Genetics and Inherited Diseases (CGID), Taibah University, Al Madinah Al Munawwarah, Saudi Arabia
| | - Sana Zohaib
- Department of Biomedical Engineering, College of Engineering, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Muhammad S Zafar
- Department of Restorative Dentistry, College of Dentistry, Taibah University, Al Madinah Al Munawwarah, Saudi Arabia; Department of Dental Materials, Islamic International Dental College, Riphah International University, Islamabad, Pakistan.
| |
Collapse
|
21
|
Park J, Kwak J, Chung S, Hong HJ, Chon JY, Moon HS. Incidence of Adrenal Insufficiency and Cushing's Syndrome After Long-Term Epidural Steroid Injections Over Six Months or Longer: A Preliminary Study. J Pain Res 2020; 13:1505-1514. [PMID: 32606916 PMCID: PMC7321692 DOI: 10.2147/jpr.s252278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/27/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Endocrinological complications of an epidural steroid injection (ESI) are rare but dangerous. Nevertheless, despite the associated risks, repeated long-term ESIs are indispensable in some clinical situations. However, only a few reports to date have assessed the safety of this procedure. In this study, we evaluate the incidence of adrenal insufficiency (AI) and Cushing's syndrome after long-term ESIs. Methods This clinical observational study enrolled herniated nucleus pulposus or spinal stenosis patients who had received ESIs over a period of six months or longer. The adrenocorticotropic hormone (ACTH) stimulation test was performed to confirm AI and the late-night salivary cortisol (LNSC) test was performed to diagnose Cushing's syndrome. To evaluate the hypothalamus pituitary adrenal axis suppression, salivary cortisol (SC) levels were measured on days 0, 1, 7, 21, 28, 35, and 42. Results This study included 17 patients. Among these, two patients (11.8%) developed AI, but no cases of Cushing's syndrome were reported. There was no predictor for the development of AI. The SC levels tended to increase with time after an ESI (β = 0.003). The slope of the mixed effect model between the AI and non-AI groups showed a significant difference (p value = 0.015). However, the differences in mean SC levels at each time point between the two groups were not significant (adjusted p value = 0.053). Conclusion Long-term ESI use may be associated with AI development. An unexpected adrenal crisis due to AI could be life threatening. Therefore, regular monitoring of adrenal function in patients who have received long-term ESIs may be prudent.
Collapse
Affiliation(s)
- JungHyun Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jueun Kwak
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sukyung Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyo Ju Hong
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Young Chon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Sik Moon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
22
|
Dineen R, Martin-Grace J, Thompson CJ, Sherlock M. The management of glucocorticoid deficiency: Current and future perspectives. Clin Chim Acta 2020; 505:148-159. [DOI: 10.1016/j.cca.2020.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 01/10/2023]
|
23
|
|
24
|
The effect of treatment regimens on salivary cortisol levels in patients with chronic musculoskeletal disorders. J Bodyw Mov Ther 2020; 24:100-108. [PMID: 31987528 DOI: 10.1016/j.jbmt.2019.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/10/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Increased levels of circulating cortisol have been associated with pain severity in patients with chronic musculoskeletal disorders (CMD). Little is known about the potential association between pain management and salivary cortisol alterations in CPM patients treated with different regimens. OBJECTIVES This prospective feasibility study aimed to determine the effect of two treatment regimens in comparison with sham therapy on pain intensity and disability and salivary cortisol concentration (SCC) in patients with CMD. METHODS Thirty patients were randomly assigned to 3 groups of 10: two experimental groups (A and B) and a control group (C). The experimental groups followed physiotherapy treatment (A) or acupuncture (B), while the control group (C) followed a sham therapy for 10 sessions. Pain data were collected using the Chronic Pain Grade (CPG) questionnaire and SCC was measured by enzyme-linked immunosorbent assay at pre- and posttreatment. RESULTS Repeated-measures analysis of variance showed that patients treated with acupuncture experienced greater decreases in pain intensity/pain disability (P < 0.05) than the physiotherapy and sham therapy groups. No statistical differences were found between the three groups for the SCC outcome variable. Bonferroni adjustments showed that the mean values of SCC were significantly decreased at posttreatment (P < 0.05) across the three groups. CONCLUSION There was a significant decrease in both pain and cortisol outcomes at posttreatment in patients with CMD. Because of the limitations of this study, we cannot draw conclusions regarding whether the lower SCC could be an indication of pain reduction in patients with CMD.
Collapse
|
25
|
Nishioka H, Yamada S. Cushing's Disease. J Clin Med 2019; 8:jcm8111951. [PMID: 31726770 PMCID: PMC6912360 DOI: 10.3390/jcm8111951] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022] Open
Abstract
In patients with Cushing's disease (CD), prompt diagnosis and treatment are essential for favorable long-term outcomes, although this remains a challenging task. The differential diagnosis of CD is still difficult in some patients, even with an organized stepwise diagnostic approach. Moreover, despite the use of high-resolution magnetic resonance imaging (MRI) combined with advanced fine sequences, some tumors remain invisible. Surgery, using various surgical approaches for safe maximum tumor removal, still remains the first-line treatment for most patients with CD. Persistent or recurrent CD after unsuccessful surgery requires further treatment, including repeat surgery, medical therapy, radiotherapy, or sometimes, bilateral adrenalectomy. These treatments have their own advantages and disadvantages. However, the most important thing is that this complex disease should be managed by a multidisciplinary team with collaborating experts. In addition, a personalized and individual-based approach is paramount to achieve high success rates while minimizing the occurrence of adverse events and improving the patients' quality of life. Finally, the recent new insights into the pathophysiology of CD at the molecular level are highly anticipated to lead to the introduction of more accurate diagnostic tests and efficacious therapies for this devastating disease in the near future.
Collapse
Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary surgery, Toranomon Hospital, Tokyo 1058470, Japan;
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
| | - Shozo Yamada
- Hypothalamic and Pituitary Center, Moriyama Neurological Center Hospital, Tokyo 1340081, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
- Correspondence: ; Tel.: +81-336-751-211
| |
Collapse
|
26
|
Vaiani E, Lazzati JM, Ramirez P, Costanzo M, Gil S, Dratler G, Zaidman V, Chaler E, Belgorosky A. The Low-Dose ACTH Test: Usefulness of Combined Analysis of Serum and Salivary Maximum Cortisol Response in Pediatrics. J Clin Endocrinol Metab 2019; 104:4323-4330. [PMID: 31135894 DOI: 10.1210/jc.2019-00304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/22/2019] [Indexed: 02/07/2023]
Abstract
CONTEXT The low-dose (1 µg) ACTH test (LDT) is widely used to assess central adrenal insufficiency (CAI); however, the serum cortisol cutoff value is controversial. Salivary cortisol (SC) may be a more accurate measurement for CAI. OBJECTIVE To assess a new maximum cutoff value of serum cortisol after LDT in pediatric patients, taking into account serum and SC measurements. DESIGN AND SETTING Prospective study in a pediatric tertiary referral center. WORKING HYPOTHESIS The combined analysis of serum and SC response to LDT might improve LDT for CAI diagnosis. PARTICIPANT AND OUTCOME MEASUREMENT A total of 145 pediatric patients underwent LDT. Serum and SC levels were measured. A central adrenal sufficient (CAS) response was established according to the reference serum cortisol cutoff value of ≥497 nmol/L. RESULTS The LDT study showed central adrenal sufficiency in 72 patients and CAI in 73 patients. Considering the lower quartile of maximum SC value (21 nmol/L) in the CAS group, an intermediate CAI (InCAI) group and a real CAI (RCAI) group were defined. Regarding the median maximum value of serum cortisol levels in the InCAI group, a new serum cortisol cutoff value of 450 nmol/L was established. Furthermore, 91% of the patients in the RCAI group were below this cutoff value. CONCLUSION The combined evaluation of maximum serum and SC levels to LDT might be useful to define an InCAI group and to avoid unnecessary hormone replacement therapy. However, rigorous patient follow-up is required.
Collapse
Affiliation(s)
- Elisa Vaiani
- Servicio de Endocrinologia, Hospital de Pediatria Garrahan, Buenos Aires, Argentina
| | - Juan Manuel Lazzati
- Servicio de Endocrinologia, Hospital de Pediatria Garrahan, Buenos Aires, Argentina
| | - Pablo Ramirez
- Servicio de Endocrinologia, Hospital de Pediatria Garrahan, Buenos Aires, Argentina
| | - Mariana Costanzo
- Servicio de Endocrinologia, Hospital de Pediatria Garrahan, Buenos Aires, Argentina
| | - Silvia Gil
- Servicio de Endocrinologia, Hospital de Pediatria Garrahan, Buenos Aires, Argentina
| | - Gustavo Dratler
- Servicio de Endocrinologia, Hospital de Pediatria Garrahan, Buenos Aires, Argentina
| | - Veronica Zaidman
- Servicio de Endocrinologia, Hospital de Pediatria Garrahan, Buenos Aires, Argentina
| | - Eduardo Chaler
- Laboratorio Central, Hospital de Pediatria Garrahan, Buenos Aires, Argentina
| | - Alicia Belgorosky
- Servicio de Endocrinologia, Hospital de Pediatria Garrahan, Buenos Aires, Argentina
- Laboratorio Central, Hospital de Pediatria Garrahan, Buenos Aires, Argentina
- Unidad de Investigacion Garrahan - CONICET, Hospital de Pediatria Garrahan, Buenos Aires, Argentina
| |
Collapse
|
27
|
Puglisi S, Pizzuto A, Laface B, Panero F, Aprà F, Palmas E, Perotti P, Reimondo G, Boccuzzi A, Terzolo M. Determination of salivary cortisol to assess time-related changes of the adrenal response to stress in critically ill patients. Eur J Intern Med 2019; 68:66-70. [PMID: 31399330 DOI: 10.1016/j.ejim.2019.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/01/2019] [Accepted: 08/01/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The value of salivary cortisol measurement to study stress-related adrenal response is controversial. The study aim was to assess the role of salivary cortisol measurement to detect time-related changes of adrenal response in critically ill patients. PATIENTS AND METHODS Patients with organ failure, sepsis or trauma were prospectively recruited in the Emergency Department. Serum and salivary cortisol were measured at baseline (T0) and after 48 h (T48). In 33 patients ACTH test was also done. RESULTS Fifty-five patients were studied and classified as septic (22) or non-septic (33). We found a significant correlation between serum and salivary cortisol at T0 and T48. No patient had baseline serum cortisol < 276 nmol/L and salivary cortisol significantly decreased at T48 in almost all patients. A delta serum cortisol < 250 nmol/L after ACTH was found in only 4 patients who showed elevated baseline cortisol levels. CONCLUSION We found that reduced baseline and post-ACTH cortisol levels are uncommon in our samples. In patients able to provide adequate saliva samples, salivary cortisol may be used to check the degree of stress-induced response and appears as a suitable tool for multiple measurements over time.
Collapse
Affiliation(s)
- Soraya Puglisi
- Internal Medicine 1, Department of Clinical and Biological Sciences, University of Turin, Italy.
| | - Andrea Pizzuto
- Internal Medicine 2 U, A.O.U Citta della Salute e della Scienza, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Barbara Laface
- Emergency Medicine, A.O. San Giovanni Bosco Hospital, Turin, Italy
| | - Francesco Panero
- Emergency Medicine, A.O. San Giovanni Bosco Hospital, Turin, Italy
| | - Franco Aprà
- Emergency Medicine, A.O. San Giovanni Bosco Hospital, Turin, Italy
| | - Enrico Palmas
- Emergency Medicine, Azienda Sanitaria Universitaria Integrata of Udine, Italy
| | - Paola Perotti
- Internal Medicine 1, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Giuseppe Reimondo
- Internal Medicine 1, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - Adriana Boccuzzi
- Emergency Medicine, A.O.U San Luigi Hospital, Orbassano (Turin), Italy
| | - Massimo Terzolo
- Internal Medicine 1, Department of Clinical and Biological Sciences, University of Turin, Italy
| |
Collapse
|
28
|
Ceccato F, Scaroni C. Central adrenal insufficiency: open issues regarding diagnosis and glucocorticoid treatment. ACTA ACUST UNITED AC 2019; 57:1125-1135. [DOI: 10.1515/cclm-2018-0824] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/13/2018] [Indexed: 12/15/2022]
Abstract
Abstract
Background
Central adrenal insufficiency (CAI) is characterized by impaired adrenocorticotropin (ACTH) secretion because of a disease or injury to the hypothalamus or the pituitary, leading to a reduced cortisol production. CAI suspicion arises more frequently in patients with pituitary tumors, cranial irradiation/surgery/injury/infections, as well as after exogenous glucocorticoid withdrawal. Nevertheless, a late diagnosis is not uncommon because CAI may present with nonspecific signs or symptoms, as fatigue or hyponatremia.
Content
The PubMed database was searched (years 1980–2018), using “central adrenal insufficiency” and “ACTH deficiency” as keywords. Subsequently, reference sections of the retrieved articles were searched.
Summary
Dynamic tests are needed when morning basal cortisol levels are not sufficient to exclude or to confirm CAI. Short Synacthen Test (SST) is the most used, and Endocrine Society’s guidelines recommend a cortisol peak >500 nmol/L to exclude CAI. Despite thresholds, understanding the pretest probability of ACTH deficiency (the clinical background of the patient) is essential because the diagnostic accuracy of SST in case of a negative result is suboptimal. Glucocorticoid replacement therapy, able to replicate cortisol circadian rhythm, is required in patients with CAI; fludrocortisone treatment is not necessary. Short-acting glucocorticoid drugs (hydrocortisone or cortisone acetate) are the most used; lower doses than previously used are nowadays recommended to reduce cortisol-related comorbidities. Promising results have been obtained with modified-release hydrocortisone, especially regarding glucose metabolism in patients with primary adrenal insufficiency.
Outlook
An accurate clinical diagnosis and a careful individualized therapy are mandatory in patients with CAI.
Collapse
|
29
|
Raff H, Phillips JM. Bedtime Salivary Cortisol and Cortisone by LC-MS/MS in Healthy Adult Subjects: Evaluation of Sampling Time. J Endocr Soc 2019; 3:1631-1640. [PMID: 31403090 PMCID: PMC6682408 DOI: 10.1210/js.2019-00186] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 06/20/2019] [Indexed: 01/07/2023] Open
Abstract
The measurement of late-night salivary cortisol is a mainstay in the diagnosis of Cushing syndrome. Furthermore, the measurement of salivary cortisol is useful in assessing the cortisol awakening response. Because the salivary glands express 11-β-hydroxysteroid dehydrogenase, the measurement of salivary cortisone may improve the performance of salivary corticosteroid measurements. We measured salivary cortisol by enzyme immunoassay (EIA) and salivary cortisol and cortisone by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in only 50 µL of saliva sampled from 54 healthy subjects (aged 20 to 64 years). We allowed patients to sample at their normal bedtime (2025 to 2400 hours) to answer a common question as to whether sampling at the normal bedtime is equivalent to the standard required sampling at 2300 to 2400 hours. We found that the salivary cortisol and cortisone results by LC-MS/MS correlated well with salivary cortisol measured with the US Food and Drug Administration-cleared EIA. Furthermore, the upper limit of normal of salivary cortisol by EIA for bedtime samples was lower than the previously published upper limit of normal with sampling required at 2300 to 2400 hours. There were no significant effects of age or sex on any of the salivary steroid measurements. We conclude that (i) salivary cortisol and cortisone can be reliably measured by LC-MS/MS in small volumes of saliva and (ii) that patients can be evaluated using saliva sampled at their normal bedtime, rather than being required to stay awake until 2300 to 2400 hours.
Collapse
Affiliation(s)
- Hershel Raff
- Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Aurora Research Institute, Milwaukee, Wisconsin.,Departments of Medicine, Surgery, and Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jonathan M Phillips
- Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Aurora Research Institute, Milwaukee, Wisconsin
| |
Collapse
|
30
|
Chiodini I, Ramos-Rivera A, Marcus AO, Yau H. Adrenal Hypercortisolism: A Closer Look at Screening, Diagnosis, and Important Considerations of Different Testing Modalities. J Endocr Soc 2019; 3:1097-1109. [PMID: 31069279 PMCID: PMC6500795 DOI: 10.1210/js.2018-00382] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 04/05/2019] [Indexed: 11/19/2022] Open
Abstract
Although prolonged hypercortisolism is associated with increased mortality and substantial morbidity, the clinical signs and symptoms are wide ranging and often nonspecific, contributing to challenges in diagnosis, as well as treatment delays. Greater awareness is needed among clinicians to help identify which patients should undergo biochemical screening for excess cortisol. Several biochemical tests are available, each with important caveats that should be considered in the context of the individual patient. Cortisol secretion varies widely, further complicating the biochemical diagnosis of hypercortisolism, which relies on the use of definitive cutoff values. Patients with hypercortisolism resulting from adrenal adenomas, including those discovered incidentally, often do not present with overt Cushingoid features (plethora, striae, muscle weakness, moon facies, etc.). However, the consequences of prolonged exposure to even slight elevations in cortisol levels are profound, including increased risk of diabetes, hypertension, fractures, cardiovascular events, and mortality. Because most cases of hypercortisolism resulting from an adrenal adenoma can be managed, it is imperative to identify patients at risk and initiate testing early for the best outcomes. The aim of this report is to increase awareness of the indications for screening for hypercortisolism and to review the biochemical screening tests and diagnosis for hypercortisolism associated with adrenal adenomas.
Collapse
Affiliation(s)
- Iacopo Chiodini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Unit for Bone Metabolism Diseases and Diabetes and Laboratory of Endocrine and Metabolic Research, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Auxologico Italiano, Milan, Italy
| | - Arelys Ramos-Rivera
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, Florida
| | - Alan O Marcus
- South Orange County Endocrinology, Laguna Hills, California
| | - Hanford Yau
- Division of Endocrinology, University of California, San Francisco (UCSF Fresno), Fresno, California
| |
Collapse
|
31
|
A successful pregnancy in a patient with secondary hypertension caused by adrenal adenoma: a case report. BMC Pregnancy Childbirth 2019; 19:116. [PMID: 30943935 PMCID: PMC6448298 DOI: 10.1186/s12884-019-2262-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 03/25/2019] [Indexed: 02/06/2023] Open
Abstract
Background Secondary hypertension is a rare complication in pregnancy that causes poor outcomes, such as preeclampsia, premature delivery, intrauterine growth retardation, stillbirths, spontaneous abortion or intrauterine death. Cushing’s disease caused by an adrenal adenoma is rare during pregnancy and may be overlooked by obstetricians and physicians, but can lead to hypertension, diabetes mellitus and an increased risk of fetal and maternal morbidity. Approximately 200 cases have been reported in the literature. Here, we report the successful management of a pregnant patient with Cushing’s syndrome due to an adrenal adenoma. Case presentation The 35-year-old Chinese female had no individual or family medical history of hypertension, and did not exhibit chronic kidney disease, diabetes mellitus, autoimmune and common endocrine diseases. Her blood pressure was elevated from the 16th week of gestation and was not controlled by 30 mg nifedipine twice a day. Examination in our department revealed her 24 h urinary free cortisol (24 h UFC) level was 1684.3 μg/24 h (normal range: 20.26–127.55 μg/24 h) and plasma adrenocorticotropic hormone was < 1.00 ng/L in three independent measurements (normal range: 5–78 ng/L). Ultrasonography demonstrated a mass (2.9 cm × 2.8 cm) in the right side of the adrenal gland. Magnetic resonance imaging without contrast showed a 3.2 cm diameter mass in the right-side of the adrenal gland. Other medical tests were normal. Laparoscopic adrenalectomy was performed at the 26th week of gestation by a urological surgeon in the West China Hospital. Histopathology revealed an adrenocortical adenoma. After surgery, the patient accepted glucocorticoid replacement therapy. The remaining trimester continued without complication and her blood pressure was normal at the 32nd week of gestation without antihypertensive therapy. The patient gave birth to a healthy boy at the 40th week of gestation. Conclusions Cushing’s syndrome caused by adrenal adenoma is rare during pregnancy. This unique case suggested that analysis of the UFC level and circadian rhythm of plasma cortisol provides a suitable strategy to diagnose Cushing’s syndrome during pregnancy. Laparoscopic surgical resection in the second trimester provides a reasonable approach to treat pregnant patients exhibiting Cushing’s syndrome caused by an adrenal adenoma.
Collapse
|
32
|
Jones SL, Campbell B, Hart T. Laboratory tests commonly used in complementary and alternative medicine: a review of the evidence. Ann Clin Biochem 2019; 56:310-325. [PMID: 30813740 DOI: 10.1177/0004563218824622] [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] [Indexed: 01/15/2023]
Abstract
It is increasingly easy for the general public to access a wide range of laboratory tests. Tests can be ordered online with little or no input from a health professional. The complementary and alternative medicine (CAM) community promote and sell a wide range of tests, many of which are of dubious clinical significance. Many have little or no clinical utility and have been widely discredited, whilst others are established tests that are used for unvalidated purposes. They range from the highly complex, employing state of the art technology, e.g. heavy metal analysis using inductively coupled plasma-mass spectrometry, to the rudimentary, e.g. live blood cell analysis. Results of 'CAM tests' are often accompanied by extensive clinical interpretations which may recommend, or be used to justify, unnecessary or harmful treatments. There are now a small number of laboratories across the globe that specialize in CAM testing. Some CAM laboratories operate completely outside of any accreditation programme whilst others are fully accredited to the standard of established clinical laboratories. In this review, we explore CAM testing in the United States, the United Kingdom and Australia with a focus on the common tests on offer, how they are reported, the evidence base for their clinical application and the regulations governing their use. We will also review proposed changed to in-vitro diagnostic device regulations and how these might impact on CAM testing.
Collapse
Affiliation(s)
- Stuart L Jones
- 1 Department of Clinical Biochemistry, King George's Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust, London, UK
| | | | - Tanya Hart
- 3 Department of Clinical Biochemistry, Poole Hospital NHS Foundation Trust, UK
| |
Collapse
|
33
|
Dineen R, Stewart PM, Sherlock M. Factors impacting on the action of glucocorticoids in patients receiving glucocorticoid therapy. Clin Endocrinol (Oxf) 2019; 90:3-14. [PMID: 30120786 DOI: 10.1111/cen.13837] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/27/2018] [Accepted: 08/15/2018] [Indexed: 01/16/2023]
Abstract
Glucocorticoids (GCs) are steroid hormones, which are essential for life. They are secreted by the adrenal cortex under the control of the hypothalamic-pituitary-adrenal (HPA) axis. Glucocorticoids are essential for the normal function of most organ systems and, in both, excess and deficiency can lead to significant adverse consequences. Adrenal insufficiency (AI) is a rare, life-threatening disorder characterized by insufficient production of corticosteroid hormones. Primary AI is defined by the inability of the adrenal cortex to produce sufficient amounts of glucocorticoids and/or mineralocorticoids despite normal or increased adrenocorticotropin hormone (ACTH). Secondary AI is adrenal hypofunction due to insufficient amount of ACTH produced by the pituitary gland. Conventional treatment of both primary and secondary adrenal insufficiencies involves lifelong glucocorticoid replacement therapy. The role of cortisol deficiency and the impact of hydrocortisone replacement on morbidity and mortality in this patient group are under increasing scrutiny. Established glucocorticoid replacement regimens do not completely mirror endogenous hormonal production, and their monitoring to ensure optimum therapy is hampered by the lack of reliable biomarkers of hormone sufficiency. A further confounding issue is the tissue-specific regulation of glucocorticoid through the two isozymes of 11β-hydroxysteroid dehydrogenase (11β-HSD) with research focusing on the role of this prereceptor regulation in the development of adverse metabolic features in patients. This review defines the factors influencing glucocorticoid action in patients with adrenal insufficiency receiving glucocorticoid therapy.
Collapse
Affiliation(s)
- Rosemary Dineen
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul M Stewart
- Department of Endocrinology, University of Leeds, Leeds, UK
| | - Mark Sherlock
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| |
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
Hinojosa-Amaya JM, Varlamov EV, McCartney S, Fleseriu M. Hypercortisolemia Recurrence in Cushing's Disease; a Diagnostic Challenge. Front Endocrinol (Lausanne) 2019; 10:740. [PMID: 31787930 PMCID: PMC6856050 DOI: 10.3389/fendo.2019.00740] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/14/2019] [Indexed: 12/30/2022] Open
Abstract
Cushing's disease recurrence following successful pituitary surgery is common and merits prompt and careful diagnosis, as untreated hypercortisolism leads to increased morbidity and mortality. However, an established recurrence definition has not been forthcoming. This poses a diagnostic challenge especially early in the course of returning hypercortisolemia and/or in the presence of non-neoplastic hypercortisolemia. A late-night salivary cortisol (LNSC) test is the first test to reveal abnormal results, however, has limitations related to assay performance as well as individual patient variability. Dexamethasone suppression tests and 24-h urinary free cortisol (UFC) results are next to reveal abnormal results. Other tests including, corticotropin-releasing hormone (CRH) stimulation test and combined CRH-dexamethasone test, as well as desmopressin stimulation test with/without dexamethasone are also used, although, none have proven to be the preeminent diagnostic test for recurrence determination. There is a possible role for these tests in predicting recurrence in patients who have experienced remission, though, this also remains challenging due to lack of established cutoff values. This article details and summarizes evidence about different diagnostic tests currently used to diagnose and predict Cushing's disease recurrence.
Collapse
Affiliation(s)
- José Miguel Hinojosa-Amaya
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, OR, United States
- Endocrinology Division, Department of Medicine, Hospital Universitario “Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Elena V. Varlamov
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, OR, United States
- Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
| | - Shirley McCartney
- Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology), Oregon Health & Science University, Portland, OR, United States
- Neurological Surgery, Oregon Health & Science University, Portland, OR, United States
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, United States
- *Correspondence: Maria Fleseriu
| |
Collapse
|
36
|
Antonelli G, Sciacovelli L, Aita A, Padoan A, Plebani M. Validation model of a laboratory-developed method for the ISO15189 accreditation: The example of salivary cortisol determination. Clin Chim Acta 2018; 485:224-228. [DOI: 10.1016/j.cca.2018.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 07/04/2018] [Indexed: 11/25/2022]
|
37
|
Langelaan MLP, Kisters JMH, Oosterwerff MM, Boer AK. Salivary cortisol in the diagnosis of adrenal insufficiency: cost efficient and patient friendly. Endocr Connect 2018; 7. [PMID: 29531158 PMCID: PMC5890080 DOI: 10.1530/ec-18-0085] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Saliva as a diagnostic tool is patient friendly and offers analytical advantages. Hormonal analysis of saliva is not influenced by changes in concentrations of binding globulins as the free concentration of the hormones is measured. Analysis of salivary cortisol is common practice in the diagnostic work-up of hypercortisolism. We investigated the potential role of measuring salivary cortisol when adrenal insufficiency (AI) is suspected, to reduce the numbers of ACTH stimulation tests. Over a period of 6 years, patients undergoing an ACTH stimulation test (tetracosactide, 250 µg) in our hospital were included. Plasma cortisol (Elecsys, Cobas, Roche Diagnostics) and salivary cortisol and cortisone (LC-MS/MS) were determined at t = 0, 30 and 60 min after stimulation. Based on peak plasma cortisol levels, AI was ruled out in 113 patients and was established in 16 patients. Patients without AI displayed maximal salivary cortisol concentrations of 12.6-123.4 nmol/L (95th percentile) after stimulation, as opposed to 0.5-15.2 nmol/L in AI patients. At t = 0 min, a minimal salivary cortisol concentration of 1.0 nmol/L was observed in patients without AI, whereas AI patients had a maximum concentration of 5.9 nmol/L. Using these cut-off values, 34% of the initial patient group could be diagnosed without an ACTH stimulation test (28% >5.9 nmol/L, 6% <1.0 nmol/L). A novel diagnostic algorithm, including early morning salivary cortisol analysis can reduce the numbers of ACTH stimulation tests in patients suspected of AI. This patient-friendly method can thereby reduce total health care costs.
Collapse
Affiliation(s)
- Marloes L P Langelaan
- Clinical LaboratoryCatharina Hospital Eindhoven, Eindhoven, The Netherlands
- Department of Clinical Chemistry and HaematologyZuyderland Medical Centre, Heerlen, The Netherlands
| | - Jérôme M H Kisters
- Department of Internal MedicineCatharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Mirjam M Oosterwerff
- Department of Internal MedicineCatharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Arjen-Kars Boer
- Clinical LaboratoryCatharina Hospital Eindhoven, Eindhoven, The Netherlands
| |
Collapse
|
38
|
Ceccato F, Barbot M, Lizzul L, Selmin E, Saller A, Albiger N, Betterle C, Boscaro M, Scaroni C. Decrease in salivary cortisol levels after glucocorticoid dose reduction in patients with adrenal insufficiency: A prospective proof-of-concept study. Clin Endocrinol (Oxf) 2018; 88:201-208. [PMID: 28973827 DOI: 10.1111/cen.13490] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/04/2017] [Accepted: 09/20/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM Patients with adrenal insufficiency (AI) require lifelong glucocorticoid (GC) replacement therapy. Cortisol measurement in saliva is increasingly being used: we assessed salivary cortisol rhythm in outpatients with AI, to provide new insights regarding the management of GC treatment. MATERIALS AND METHODS Nineteen AI outpatients collected six saliva samples from awakening (Fa , before taking the morning GC therapy), during the day (F1.5 h , F6 h before the afternoon GC dose, F8.5 h , F12 h ) until bedtime (Fb ). We measured daily cortisol exposure by calculating the area under the curve (AUCFa→Fb ). Saliva samples were collected at baseline and one year after GG dose reduction (by at least 5 mg of hydrocortisone). RESULTS Hydrocortisone equivalents decreased from median 25 mg/d (baseline, interquartile range IQR 20-27.5) to 15 mg/d (IQR 15-20, P < .01). As expected, we observed a reduction in both daily cortisol exposure (AUCFa→Fb 23 982 nmol·h/L, IQR 12 635-45 369, to 14 689 nmol·h/L, IQR 7168-25 378, P < .001) and salivary cortisol levels at F6 h (24.8 nmol/L, IQR 20.1-35.7, to 21 nmol/L, IQR 8.7-29.2, P < .05) and Fb (8.7 nmol/L, IQR 3.4-20.2, to 3.7 nmol/L, IQR 3.0-5.8, P < .05). None of the patients developed signs or symptoms consistent with AI after GC reduction. Median diastolic blood pressure (DPB) values fell from baseline to the end of follow-up (87.5 mm Hg, IQR 80-90, to 80 mm Hg, IQR 80-85, P < .05). The AUCFa→Fb of patients at baseline was above the reference value (90th percentile of controls) in 12 patients (60%); after the dosage reduction, 30% of patients normalized their daily cortisol exposure (AUCFa→Fb ). CONCLUSIONS The reduction in GC treatment in patients with AI resulted in better control of daily cortisol rhythm, measured with salivary cortisol, and in an improvement of DPB. Further studies are needed to ascertain if salivary cortisol could be used as a biomarker to manage GC replacement therapy.
Collapse
Affiliation(s)
- Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Laura Lizzul
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Elisa Selmin
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Alois Saller
- Internal Medicine, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Nora Albiger
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Corrado Betterle
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Marco Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| |
Collapse
|
39
|
Redmer J. Adrenal Fatigue. Integr Med (Encinitas) 2018. [DOI: 10.1016/b978-0-323-35868-2.00039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
40
|
Increased Cardiovascular Risk in Patients with Adrenal Insufficiency: A Short Review. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3691913. [PMID: 29376070 PMCID: PMC5742446 DOI: 10.1155/2017/3691913] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/06/2017] [Accepted: 11/15/2017] [Indexed: 11/18/2022]
Abstract
Cardiovascular disease (CVD) is the most common cause of death in the world. Recent studies have shown an association between adrenal insufficiency (AI) and increased cardiovascular risk (CVR). Patients with AI receive glucocorticoid (GC) replacement therapy which can lead to varying levels of blood cortisol. It was shown that these imbalances in blood cortisol may lead to a higher prevalence of coronary heart disease, major adverse coronary events, and increased mortality. GC substitution is essential in the treatment of AI without which the disease has been shown to be fatal. The most frequently used GC formula for replacement therapy is hydrocortisone (HC). There is no uniform opinion on hydrocortisone replacement therapy. Alternative GC such as prednisolone is also in use. Overreplacement of GC may lead to adverse effects including obesity, high blood pressure, and hyperglycaemia. Outcome may vary between primary and secondary AI mainly due to differences in the renin-angiotensin-aldosterone system (RAAS). Furthermore, decreased blood levels of cortisol may lead to a compensatory secretion of inflammatory mediators such as Interleukin-1 (IL-1), Interleukin-6 (IL-6), and/or tumor-necrosis factor (TNF). Physicians and patients should be properly educated about the increased risk of CVD in patients with AI.
Collapse
|
41
|
Abstract
Cushing syndrome (CS) is caused by chronic exposure to excess glucocorticoids. Early recognition and treatment of hypercortisolemia can lead to decreased morbidity and mortality. The diagnosis of CS and thereafter, establishing the cause can often be difficult, especially in patients with mild and cyclic hypercortisolism. Surgical excision of the cause of excess glucocorticoids is the optimal treatment for CS. Medical therapy (steroidogenesis inhibitors, medications that decrease adrenocorticotropic hormone [ACTH] levels or glucocorticoid antagonists) and pituitary radiotherapy may be needed as adjunctive treatment modalities in patients with residual, recurrent or metastatic disease, in preparation for surgery, or when surgery is contraindicated. A multidisciplinary team approach, individualized treatment plan and long-term follow-up are important for optimal management of hypercortisolemia and the comorbidities associated with CS. ABBREVIATIONS ACTH = adrenocorticotropic hormone; BIPSS = bilateral inferior petrosal sinus sampling; CBG = corticosteroid-binding globulin; CD = Cushing disease; CRH = corticotropin-releasing hormone; CS = Cushing syndrome; Dex = dexamethasone; DST = dexamethasone suppression test; EAS = ectopic ACTH syndrome; FDA = U.S. Food & Drug Administration; HDDST = high-dose DST; IPS/P = inferior petrosal sinus to peripheral; MRI = magnetic resonance imaging; NET = neuroendocrine tumor; PET = positron emission tomography; UFC = urinary free cortisol.
Collapse
|
42
|
Vogeser M, Kratzsch J, Ju Bae Y, Bruegel M, Ceglarek U, Fiers T, Gaudl A, Kurka H, Milczynski C, Prat Knoll C, Suhr AC, Teupser D, Zahn I, Ostlund RE. Multicenter performance evaluation of a second generation cortisol assay. ACTA ACUST UNITED AC 2017; 55:826-835. [DOI: 10.1515/cclm-2016-0400] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 10/05/2016] [Indexed: 11/15/2022]
Abstract
Abstract
Background:
Untreated disorders of the adrenocortical system, such as Cushing’s or Addison’s disease, can be fatal, and accurate quantification of a patient’s cortisol levels is vital for diagnosis. The objective of this study was to assess the analytical performance of a new fully-automated Elecsys® Cortisol II assay (second generation) to measure cortisol levels in serum and saliva.
Methods:
Four European investigational sites assessed the intermediate precision and reproducibility of the Cortisol II assay (Roche Diagnostics) under routine conditions. Method comparisons of the Cortisol II assay vs. liquid chromatography-tandem mass spectrometry (LC-MS/MS), the gold standard for cortisol measurement, were performed. Cortisol reference ranges from three US sites were determined using samples from self-reported healthy individuals.
Results:
The coefficients of variation (CVs) for repeatability, intermediate precision, and reproducibility for serum samples were ≤2.6%, ≤5.8%, and ≤9.5%, respectively, and for saliva were ≤4.4% and ≤10.9%, and ≤11.4%, respectively. Agreement between the Cortisol II assay and LC-MS/MS in serum samples was close, with a slope of 1.02 and an intercept of 4.473 nmol/L. Reference range samples were collected from healthy individuals (n=300) and serum morning cortisol concentrations (5–95th percentile) were 166.1–507 nmol/L and afternoon concentrations were 73.8–291 nmol/L. Morning, afternoon, and midnight saliva concentrations (95th percentile) were 20.3, 6.94, and 7.56 nmol/L, respectively.
Conclusions:
The Cortisol II assay had good precision over the entire measuring range and had excellent agreement with LC-MS/MS. This test was found suitable for routine diagnostic application and will be valuable for the diagnosis of adrenocortical diseases.
Collapse
|
43
|
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.
Collapse
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
| |
Collapse
|
44
|
Pappachan JM, Hariman C, Edavalath M, Waldron J, Hanna FW. Cushing's syndrome: a practical approach to diagnosis and differential diagnoses. J Clin Pathol 2017; 70:350-359. [PMID: 28069628 DOI: 10.1136/jclinpath-2016-203933] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/01/2016] [Accepted: 12/08/2016] [Indexed: 02/05/2023]
Abstract
Diagnosis of Cushing's syndrome (CS) and identification of the aetiology of hypercortisolism can be challenging. The Endocrine Society clinical practice guidelines recommends one of the four tests for initial screening of CS, namely, urinary-free cortisol, late night salivary cortisol, overnight dexamethasone suppression test or a longer low-dose dexamethasone suppression test, for 48 hours. Confirmation and localisation of CS requires additional biochemical and radiological tests. Radiological evaluation involves different imaging modalities including MRI with or without different radio-nuclear imaging techniques. Invasive testing such as bilateral inferior petrosal sinus sampling may be necessary in some patients for accurate localisation of the cause for hypercortisolism. This best practice review discusses a practical approach for the diagnostic evaluation of CS with a brief discussion on differential diagnoses, and cyclical CS, to enhance the skills of clinicians and laboratory personnel.
Collapse
Affiliation(s)
- Joseph M Pappachan
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Christian Hariman
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Mahamood Edavalath
- Department of Endocrinology & Diabetes, Imperial College London Diabetes Centre, Abu Dhabi, UAE
| | - Julian Waldron
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Fahmy W Hanna
- Department of Endocrinology & Diabetes, University Hospitals of North Midlands NHS Trust & North Staffordshire University, Stoke-on-Trent, UK
| |
Collapse
|
45
|
Coelli S, Farias CB, Soares AA, Crescente GM, Hirakata VN, Souza LB, Czepielewski MA, Camargo JL, Silveiro SP. Influence of age, gender and body mass index on late-night salivary cortisol in healthy adults. ACTA ACUST UNITED AC 2017; 55:1954-1961. [DOI: 10.1515/cclm-2016-1100] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 03/28/2017] [Indexed: 11/15/2022]
Abstract
AbstractBackground:Late-night salivary cortisol (LNSC) is one of the most reliable tests to screen for endogenous Cushing syndrome. This test is simple, inexpensive and noninvasive and has high sensitivity and specificity. The aim of our study was to analyze the putative influence of age, gender and body mass index (BMI) on LNSC levels in a healthy population.Methods:Cross-sectional study conducted in healthy adults. Midnight saliva samples were collected at home. Participants refrained from teeth brushing, eating or drinking for 2 h prior to collection. Salivary cortisol measured by electrochemiluminescence immunoassay (ECLIA). The study was approved by the Ethics Committee of the hospital (number 140073).Results:We evaluated 122 nonsmoking healthy volunteers. Mean age was 35±14 years (range, 18–74 years); 63% were women. Mean BMI was 24±3 kg/mConclusions:The maximum reference value (P97.5) of LNSC was set at 8.3 nmol/L (0.3 μg/dL) using ECLIA. Advanced age was associated with higher LNSC levels, with no evident influence of gender or BMI.
Collapse
|
46
|
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.
Collapse
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
| | | |
Collapse
|
47
|
Keevil BG. LC–MS/MS analysis of steroids in the clinical laboratory. Clin Biochem 2016; 49:989-97. [DOI: 10.1016/j.clinbiochem.2016.04.009] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/14/2016] [Accepted: 04/16/2016] [Indexed: 02/06/2023]
|
48
|
Tirosh A, Lodish MB, Papadakis GZ, Lyssikatos C, Belyavskaya E, Stratakis CA. Diurnal Plasma Cortisol Measurements Utility in Differentiating Various Etiologies of Endogenous Cushing Syndrome. Horm Metab Res 2016; 48:677-681. [PMID: 27643448 PMCID: PMC6341983 DOI: 10.1055/s-0042-115644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cortisol diurnal variation may be abnormal among patients with endogenous Cushing syndrome (CS). The study objective was to compare the plasma cortisol AM/PM ratios between different etiologies of CS. This is a retrospective cohort study, conducted at a clinical research center. Adult patients with CS that underwent adrenalectomy or trans-sphenoidal surgery (n=105) were divided to those with a pathologically confirmed diagnosis of Cushing disease (n=21) and those with primary adrenal CS, including unilateral adrenal adenoma (n=28), adrenocortical hyperplasia (n=45), and primary pigmented nodular adrenocortical disease (PPNAD, n=11). Diurnal plasma cortisol measurements were obtained at 11:30 PM and midnight and at 7:30 and 8:00 AM. The ratios between the mean morning levels and mean late-night levels were calculated. Mean plasma cortisol AM/PM ratio was lower among CD patients compared to those with primary adrenal CS (1.4±0.6 vs. 2.3±1.5, p<0.001, respectively). An AM/PM cortisol ratio≥2.0 among patients with unsuppressed ACTH (>15 pg/ml) excludes CD with a 85.0% specificity and a negative predictive value (NPV) of 90.9%. Among patients with primary adrenal CS, an AM/PM cortisol≥1.2 had specificity and NPV of 100% for ruling out a diagnosis of PPNAD. Plasma cortisol AM/PM ratios are lower among patients with CD compared with primary adrenal CS, and may aid in the differential diagnosis of endogenous hypercortisolemia.
Collapse
Affiliation(s)
- A. Tirosh
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M. B. Lodish
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - G. Z. Papadakis
- Radiology and Imaging Sciences, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - C. Lyssikatos
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - E. Belyavskaya
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - C. A. Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
49
|
Machado MC, Fragoso MCBV, Moreira AC, Boguszewski CL, Vieira L, Naves LA, Vilar L, de Araújo LA, Czepielewski MA, Gadelha MR, Musolino NRC, Miranda PAC, Bronstein MD, Ribeiro-Oliveira A. Recommendations of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism for the diagnosis of Cushing's disease in Brazil. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 60:267-86. [PMID: 27355856 PMCID: PMC10522300 DOI: 10.1590/2359-3997000000174] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/10/2016] [Indexed: 11/22/2022]
Abstract
Although it is a rare condition, the accurate diagnosis and treatment of Cushing's disease is important due to its higher morbidity and mortality compared to the general population, which is attributed to cardiovascular diseases, diabetes mellitus and infections. Screening for hypercortisolism is recommended for patients who present multiple and progressive clinical signs and symptoms, especially those who are considered to be more specific to Cushing's syndrome, abnormal findings relative to age (e.g., spinal osteoporosis and high blood pressure in young patients), weight gain associated with reduced growth rate in the pediatric population and for those with adrenal incidentalomas. Routine screening is not recommended for other groups of patients, such as those with obesity or diabetes mellitus. Magnetic resonance imaging (MRI) of the pituitary, the corticotropin-releasing hormone (CRH) test and the high-dose dexamethasone suppression test are the main tests for the differential diagnosis of ACTH-dependent Cushing's syndrome. Bilateral and simultaneous petrosal sinus sampling is the gold standard method and is performed when the triad of initial tests is inconclusive, doubtful or conflicting. The aim of this article is to provide information on the early detection and establishment of a proper diagnosis of Cushing's disease, recommending follow-up of these patients at experienced referral centers. Arch Endocrinol Metab. 2016;60(3):267-86.
Collapse
Affiliation(s)
- Márcio Carlos Machado
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP); Departamento de Endocrinologia, A.C. Camargo Cancer Center, São Paulo, SP, Brasil;
| | - Maria Candida Barisson Vilares Fragoso
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP); Departamento de Endocrinologia, A.C. Camargo Cancer Center, São Paulo, SP, Brasil;
| | - Ayrton Custódio Moreira
- Faculdade de Medicina de Ribeirão PretoUniversidade de São PauloRibeirão PretoSPBrasilDivisão de Endocrinologia e Metabologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brasil;
| | - César Luiz Boguszewski
- Serviço de Endocrinologia e MetabologiaHospital de ClínicasUniversidade Federal do ParanáCuritibaPRBrasilServiço de Endocrinologia e Metabologia (SEMPR), Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brasil;
| | - Leonardo Vieira
- Serviço de EndocrinologiaHospital Universitário Clementino Fraga FilhoUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrasilServiço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF/UFRJ), Rio de Janeiro, RJ, Brasil;
| | - Luciana A. Naves
- Serviço de EndocrinologiaHospital Universitário de BrasíliaUniversidade de BrasíliaBrasíliaDFBrasilServiço de Endocrinologia, Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil;
| | - Lucio Vilar
- Serviço de EndocrinologiaHospital de ClínicasUniversidade Federal de PernambucoRecifePEBrasilServiço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil;
| | | | - Mauro A. Czepielewski
- Hospital de Clínicas de Porto AlegreFaculdade de MedicinaUniversidade Federal do Rio Grande do SulPorto AlegreRSBrasilServiço de Endocrinologia, Hospital de Clínicas de Porto Alegre (HCPA), Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil;
| | - Monica R. Gadelha
- Serviço de EndocrinologiaHospital Universitário Clementino Fraga FilhoUniversidade Federal do Rio de JaneiroRio de JaneiroRJBrasilServiço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF/UFRJ), Rio de Janeiro, RJ, Brasil;
| | - Nina Rosa Castro Musolino
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Neuroendocrinologia, Divisão de Neurocirurgia Funcional, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP;Brasil
| | - Paulo Augusto C Miranda
- Serviço de EndocrinologiaSanta Casa de Belo HorizonteBelo HorizonteMGBrasilServiço de Endocrinologia, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brasil;
| | - Marcello Delano Bronstein
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilUnidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP); Departamento de Endocrinologia, A.C. Camargo Cancer Center, São Paulo, SP, Brasil;
| | - Antônio Ribeiro-Oliveira
- Universidade Federal de Minas GeraisServiço de EndocrinologiaHospital de ClínicasBelo HorizonteMGBrasilServiço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brasil
| |
Collapse
|
50
|
Starker LF, Prieto PA, Liles JS, Tran Cao HS, Grubbs EG, Lee JE, Perrier ND, Graham PH. Endocrine incidentalomas. Curr Probl Surg 2016; 53:219-46. [DOI: 10.1067/j.cpsurg.2016.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 04/22/2016] [Indexed: 12/21/2022]
|