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Charoensri S, Auchus RJ. A Contemporary Approach to the Diagnosis and Management of Adrenal Insufficiency. Endocrinol Metab (Seoul) 2024; 39:73-82. [PMID: 38253474 PMCID: PMC10901672 DOI: 10.3803/enm.2024.1894] [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: 11/29/2023] [Revised: 12/18/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024] Open
Abstract
Adrenal insufficiency (AI) can be classified into three distinct categories based on its underlying causes: primary adrenal disorders, secondary deficiencies in adrenocorticotropin, or hypothalamic suppression from external factors, most commonly glucocorticoid medications used for anti-inflammatory therapy. The hallmark clinical features of AI include fatigue, appetite loss, unintentional weight loss, low blood pressure, and hyponatremia. Individuals with primary AI additionally manifest skin hyperpigmentation, hyperkalemia, and salt craving. The diagnosis of AI is frequently delayed due to the non-specific symptoms and signs early in the disease course, which poses a significant challenge to its early detection prior to an adrenal crisis. Despite the widespread availability of lifesaving glucocorticoid medications for decades, notable challenges persist, particularly in the domains of timely diagnosis while simultaneously avoiding misdiagnosis, patient education for averting adrenal crises, and the determination of optimal replacement therapies. This article reviews recent advancements in the contemporary diagnostic strategy and approaches to optimal treatment for AI.
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Affiliation(s)
- Suranut Charoensri
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Richard J. Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, USA
- Endocrinology & Metabolism Section, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA
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Ciancia S, van den Berg SAA, van den Akker ELT. The Reliability of Salivary Cortisol Compared to Serum Cortisol for Diagnosing Adrenal Insufficiency with the Gold Standard ACTH Stimulation Test in Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1569. [PMID: 37761530 PMCID: PMC10527706 DOI: 10.3390/children10091569] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/03/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023]
Abstract
The ACTH (adrenocorticotropic hormone) stimulation test is the gold standard for the diagnosis of adrenal insufficiency (AI), performed with ACTH high dose (HDT) or low dose (LDT). As salivary cortisol has been proposed as an alternative to serum cortisol, our aim was to evaluate the reliability of salivary cortisol compared to serum cortisol for diagnosing AI in children. Data were collected retrospectively. Salivary and serum cortisol values derived by 80 ACTH stimulation tests were obtained (39 F, 36 M; median age 11.5 years, IQR 6.9). Sampling was performed at baseline and after 30 and 60 min from ACTH administration during the HDT, and at baseline and 10, 20, 30, 40 and 60 min after the stimulation for the LDT. A serum cortisol level > 420 nmol/L ruled out AI. The correlation coefficients between serum and salivary cortisol for the HDT (n = 24) were 0.80 at t0, 0.48 at t30 and 0.75 at t60. All patients were adrenal sufficient. In 41% of the LDT, peak serum cortisol indicated insufficient adrenal function. The correlation coefficients between serum and salivary cortisol were 0.59 at t0 and 0.33 at the peak. For a cut-off of salivary cortisol < 15 nmol/L, sensitivity was 73.9% and specificity 69.6%. Our data do not support salivary cortisol as a valid alternative to serum cortisol during LDT. Regarding the HDT, results are more encouraging, however, further studies are needed.
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Affiliation(s)
- Silvia Ciancia
- Division of Endocrinology, Department of Pediatrics, Erasmus MC-Sophia Children’s Hospital, University Medical Center, 3015 Rotterdam, The Netherlands
| | - Sjoerd A. A. van den Berg
- Department of Clinical Chemistry, Erasmus University Medical Center, 3015 Rotterdam, The Netherlands
| | - Erica L. T. van den Akker
- Division of Endocrinology, Department of Pediatrics, Erasmus MC-Sophia Children’s Hospital, University Medical Center, 3015 Rotterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW Adrenal insufficiency (AI) is the clinical manifestation of deficient production of glucocorticoids with occasionally deficiency also in mineralocorticoids and adrenal androgens and constitutes a fatal disorder if left untreated. The aim of this review is to summarize the new trends in diagnostic methods used for determining the presence of AI. RECENT FINDINGS Novel aetiologies of AI have emerged; severe acute respiratory syndrome coronavirus 2 infection was linked to increased frequency of primary AI (PAI). A new class of drugs, the immune checkpoint inhibitors (ICIs) widely used for the treatment of several malignancies, has been implicated mostly with secondary AI, but also with PAI. Salivary cortisol is considered a noninvasive and patient-friendly tool and has shown promising results in diagnosing AI, although the normal cut-off values remain an issue of debate depending on the technique used. Liquid chromatography-mass spectrometry (LC-MS/MS) is the most reliable technique although not widely available. SUMMARY Our research has shown that little progress has been made regarding our knowledge on AI. Coronavirus disease 2019 and ICIs use constitute new evidence on the pathogenesis of AI. The short synacthen test (SST) remains the 'gold-standard' method for confirmation of AI diagnosis, although salivary cortisol is a promising tool.
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Affiliation(s)
- Vasiliki Siampanopoulou
- Endocrinology Unit, First Department of Internal Medicine, Laiko General Hospital of Athens, National and Kapodistrian University of Athens, Athens
| | - Elisavet Tasouli
- First Department of Internal Medicine, Thriasio General Hospital of Elefsina, Elefsina, Greece
| | - Anna Angelousi
- Endocrinology Unit, First Department of Internal Medicine, Laiko General Hospital of Athens, National and Kapodistrian University of Athens, Athens
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Shaikh S, Nagendra L, Shaikh S, Pappachan JM. Adrenal Failure: An Evidence-Based Diagnostic Approach. Diagnostics (Basel) 2023; 13:diagnostics13101812. [PMID: 37238296 DOI: 10.3390/diagnostics13101812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/14/2023] [Accepted: 05/18/2023] [Indexed: 05/28/2023] Open
Abstract
The diagnosis of adrenal insufficiency (AI) requires a high index of suspicion, detailed clinical assessment including detailed drug history, and appropriate laboratory evaluation. The clinical characteristics of adrenal insufficiency vary according to the cause, and the presentation may be myriad, e.g. insidious onset to a catastrophic adrenal crisis presenting with circulatory shock and coma. Secondary adrenal insufficiency (SAI) often presents with only glucocorticoid deficiency because aldosterone production, which is controlled by the renin angiotensin system, is usually intact, and rarely presents with an adrenal crisis. Measurements of the basal serum cortisol at 8 am (<140 nmol/L or 5 mcg/dL) coupled with adrenocorticotrophin (ACTH) remain the initial tests of choice. The cosyntropin stimulation (short synacthen) test is used for the confirmation of the diagnosis. Newer highly specific cortisol assays have reduced the cut-off points for cortisol in the diagnosis of AI. The salivary cortisol test is increasingly being used in conditions associated with abnormal cortisol binding globulin (CBG) levels such as pregnancy. Children and infants require lower doses of cosyntropin for testing. 21-hydoxylase antibodies are routinely evaluated to rule out autoimmunity, the absence of which would require secondary causes of adrenal insufficiency to be ruled out. Testing the hypothalamic-pituitary-adrenal (HPA) axis, imaging, and ruling out systemic causes are necessary for the diagnosis of AI. Cancer treatment with immune checkpoint inhibitors (ICI) is an emerging cause of both primary AI and SAI and requires close follow up. Several antibodies are being implicated, but more clarity is required. We update the diagnostic evaluation of AI in this evidence-based review.
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Affiliation(s)
- Salomi Shaikh
- KGN Diabetes and Endocrine Centre, Mumbai 400001, India
| | - Lakshmi Nagendra
- Department of Endocrinology, JSS Medical College, JSS Academy of Higher Education and Research Center, Mysore 570015, India
| | - Shehla Shaikh
- Department of Endocrinology, Saifee Hospital, Mumbai 400004, India
| | - Joseph M Pappachan
- Department of Endocrinology & Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, UK
- Faculty of Science, Manchester Metropolitan University, Manchester M15 6BH, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, UK
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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.
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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
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Tan SYT, Tan HC, Zhu L, Loh LM, Lim DST, Swee DS, Chan YL, Lim HB, Ling SL, Ou EJ, Teo WE, Zhang XP, Goh HF, Kek PC. Expanding the use of salivary cortisol as a non-invasive outpatient test in the dynamic evaluation of suspected adrenal insufficiency. Endocr Connect 2023; 12:e230004. [PMID: 36799247 PMCID: PMC10083658 DOI: 10.1530/ec-23-0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/16/2023] [Indexed: 02/18/2023]
Abstract
Background Adrenal insufficiency (AI) is potentially life-threatening, and accurate diagnosis is crucial. The first-line diagnostic test, the adrenocorticotrophic hormone (ACTH) stimulation test, measures serum total cortisol. However, this is affected in states of altered albumin or cortisol-binding globulin levels, limiting reliability. Salivary cortisol reflects free bioactive cortisol levels and is a promising alternative. However, few studies are available, and heterogenous methodologies limit applicability. Methods This study prospectively recruited 42 outpatients undergoing evaluation for AI, excluding participants with altered cortisol-binding states. Serum (immunoassay) and salivary (liquid chromatography tandem mass spectrometry) cortisol levels were sampled at baseline, 30 min, and 60 min following 250 µg synacthen administration. AI was defined as a peak serum cortisol level <500 nmol/L in accordance with guidelines. Results The study recruited 21 (50%) participants with AI and 21 without AI. There were no significant differences in baseline characteristics, blood pressure, or sodium levels between groups. Following synacthen stimulation, serum and salivary cortisol levels showed good correlation at all timepoints (R2 = 0.74, P < 0.001), at peak levels (R2 = 0.72, P < 0.001), and at 60 min (R2 = 0.72, P < 0.001). A salivary cortisol cut-off of 16.0 nmol/L had a sensitivity of 90.5% and a specificity of 76.2% for the diagnosis of AI. Conclusion This study demonstrates a good correlation between serum and salivary cortisol levels during the 250 µg synacthen test. A peak salivary cortisol cut-off of 16.0 nmol/L can be used for the diagnosis of AI. It is a less invasive alternative to evaluate patients with suspected AI. Its potential utility in the diagnosis of AI in patients with altered cortisol-binding states should be further studied.
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Affiliation(s)
| | - Hong Chang Tan
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Ling Zhu
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Lih Ming Loh
- Department of Endocrinology, Singapore General Hospital, Singapore
| | | | - Du Soon Swee
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Yoke Ling Chan
- Department of Speciality Nursing, Singapore General Hospital, Singapore
| | - Huee Boon Lim
- Department of Speciality Nursing, Singapore General Hospital, Singapore
| | - Shiau Lee Ling
- Department of Speciality Nursing, Singapore General Hospital, Singapore
| | - En Jun Ou
- Department of Speciality Nursing, Singapore General Hospital, Singapore
| | - Wynn Ee Teo
- Department of Speciality Nursing, Singapore General Hospital, Singapore
| | - Xiao Ping Zhang
- Department of Speciality Nursing, Singapore General Hospital, Singapore
| | - Hui Fen Goh
- Department of Speciality Nursing, Singapore General Hospital, Singapore
| | - Peng Chin Kek
- Department of Endocrinology, Singapore General Hospital, Singapore
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Tabor J, La P, Kline G, Wang M, Bonfield S, Machan M, Wynne-Edwards K, Emery C, Debert C. Saliva Cortisol as a Biomarker of Injury in Youth Sport-Related Concussion. J Neurotrauma 2023; 40:296-308. [PMID: 35906800 DOI: 10.1089/neu.2022.0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Increasing rates of sport-related concussion (SRC) in youth impose a significant burden on public health systems and the lives of young athletes. Accurate prediction for those likely to develop persistent post-concussion symptomology (PPCS) using a fluid biomarker, reflecting both acute injury and recovery processes, would provide the opportunity for early intervention. Cortisol, a stress hormone released through the hypothalamic-pituitary-adrenal (HPA) axis following injury, may provide a missing physiological link to clinical recovery. This cohort study investigated the change in saliva cortisol following SRC and the association between cortisol and symptom burden in pediatric ice hockey players. Further, the association between cortisol levels and medical clearance to return to play was explored. In total, cortisol samples from 233 players were included; 165 athletes (23.6% female) provided pre-injury saliva and 68 athletes (19.1% female) provided post-SRC saliva samples for cortisol analysis. Quantile (median) regressions were used to compare cortisol between pre-injury and post-SRC groups, and the association between total symptoms (/22) and symptom severity scores (/132) reported on the Sport Concussion Assessment Tool (SCAT)3/SCAT5 and post-SRC cortisol (adjusting for age, sex, history of concussion, and time from injury to sample collection). Results demonstrated significantly lower saliva cortisol in post-SRC athletes compared with the pre-injury group (β = -0.62, 95% confidence interval [CI; -1.08, -0.16], p = 0.009). Post-SRC cortisol was not significantly associated with the SCAT3/SCAT5 symptom totals or symptom severity scores; however, females were found to report more symptoms (β = 6.95, 95% CI [0.35, 13.55], p = 0.040) and greater symptom severity (β = 23.87, 95% CI [9.58, 38.15], p = 0.002) compared with males. Exploratory time-to-event analysis revealed a point estimate suggesting a potential association between low cortisol levels and days to medical clearance to return to play. Although preliminary, these findings suggest that the HPA axis may be dysregulated post-SRC. Further, our exploratory analysis and case presentation of post-injury outliers highlight the need to further research cortisol as a prognostic biomarker to inform individualized sex-specific care after SRC.
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Affiliation(s)
- Jason Tabor
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Parker La
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregory Kline
- Division of Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meng Wang
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephan Bonfield
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Machan
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Katherine Wynne-Edwards
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carolyn Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chantel Debert
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Mahzari M, AlSohaim A, Al Mulla A, AlAssaf A, Al Amri K, Hussain SD, Sabico S, Al Daghri NM, Saleh Y. Variations in cortisol response in patients with known and suspected adrenal insufficiency. Medicine (Baltimore) 2022; 101:e32557. [PMID: 36595973 PMCID: PMC9803485 DOI: 10.1097/md.0000000000032557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Adrenal insufficiency (AI) is a relatively rare disease. While the adrenocorticotropic hormone (ACTH) stimulation test remains as one of the commonly used diagnostic test for AI, to date there is no consensus on the cortisol cutoff value post-ACTH stimulation test. This study aimed to investigate and characterize the cortisol response after the standard ACTH stimulation test in a group of Saudi Arabian patients. A single center retrospective study was conducted on Saudi Arabian adult patients who underwent ACTH stimulation test at the endocrinology clinics of King Abdulaziz Medical City in Riyadh, Saudi Arabia between 2015 and 2018. Demographic, clinical and biochemical variables were collected and analyzed. A total of 154 medical records of patients (44 males, 110 females, mean age 44.4 ± 17.0 years) were included in the study. All patients underwent ACTH stimulation test. Fatigue was the most common symptom of participants. Type 1 diabetes was the most frequent comorbidity. Cortisol levels were significantly lower in patients who received corticosteroid replacement therapy, and, within the context of ACTH stimulation tests, were useful in diagnosing AI in patients with vague symptoms and signs. For basal cortisol, the cutoff of ≤258.5 has a sensitivity and specificity of 69.2% and 58.6%, respectively. For 30-minute, the cutoff of ≤386 sensitivity and specificity are 61.5% and 69.0%. For 60-minute, the cutoff of ≤491.5 has a sensitivity and specificity of 61.5% and 65.5%, respectively. Higher cortisol cutoff values have better sensitivity. Patients with AI present with mostly nonspecific symptoms, with type 1 diabetes as the most common comorbidity. The cortisol level cutoffs obtained from Arab patients who underwent ACTH stimulation tests showed wide variability for its utility in AI diagnosis. Further studies to evaluate the optimal cortisol cutoff values for AI diagnosis in this population are needed.
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Affiliation(s)
- Moeber Mahzari
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Medicine, King Abdulaziz Medical City, Riyadh, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- * Correspondence: Moeber Mahzari, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh 22490, Saudi Arabia (e-mail: )
| | - Abdullah AlSohaim
- Department of Medicine, King Abdulaziz Medical City, Riyadh, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulrhman Al Mulla
- Department of Medicine, King Abdulaziz Medical City, Riyadh, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdullah AlAssaf
- Department of Medicine, Security Force Hospital, Riyadh, Saudi Arabia
| | - Khalid Al Amri
- Department of Medicine, King Abdulaziz Medical City, Riyadh, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Syed D. Hussain
- Chair for Biomarkers of Chronic Diseases, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Shaun Sabico
- Chair for Biomarkers of Chronic Diseases, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Naser M. Al Daghri
- Chair for Biomarkers of Chronic Diseases, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Yousef Saleh
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Medicine, King Abdulaziz Medical City, Riyadh, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Abstract
Adrenal insufficiency (AI), first described by Thomas Addison in 1855, is characterised by inadequate hormonal production by the adrenal gland, which could either be primary, due to destruction of the adrenal cortex, or secondary/tertiary, due to lack of adrenocorticotropic hormone or its stimulation by corticotropin-releasing hormone. This was an invariably fatal condition in Addison's days with most patients dying within a few years of diagnosis. However, discovery of cortisone in the 1940s not only improved the life expectancy of these patients but also had a dramatic effect on their overall quality of life. The diagnosis, easily confirmed by demonstrating inappropriately low cortisol secretion, is often delayed by months, and many patients present with acute adrenal crisis. Sudden withdrawal from chronic glucocorticoid therapy is the most common cause of AI. Currently, there remains a wide variation in the management of this condition across Europe. As primary AI is a relatively rare condition, most medical specialists will only manage a handful of these patients in their career. Despite many advances in recent years, there is currently no curative option, and modern cortisol replacement regimens fail to adequately mimic physiological cortisol rhythm. A number of new approaches including allograft of adrenocortical tissue and stem cell therapy are being tried but remain largely experimental.
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Affiliation(s)
- Rajeev Kumar
- Diabetes and Endocrinology, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - W S Wassif
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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Mifsud S, Gauci Z, Gruppetta M, Mallia Azzopardi C, Fava S. Adrenal insufficiency in HIV/AIDS: a review. Expert Rev Endocrinol Metab 2021; 16:351-362. [PMID: 34521306 DOI: 10.1080/17446651.2021.1979393] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/24/2021] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Adrenal insufficiency (AI) is one of the most common potentially life-threatening endocrine complications in people living with human immunodeficiency virus (PLHIV) infection and acquired immunodeficiency syndrome (AIDS). AREAS COVERED In this review, the authors explore the definitions of relative AI, primary AI, secondary AI and peripheral glucocorticoid resistance in PLHIV. It also focuses on the pathophysiology, etiology, diagnosis and management of this endocrinopathy in PLHIV. A literature review was conducted through Medline and Google Scholar search on the subject. EXPERT OPINION Physicians need to be aware of the endocrinological implications of HIV infection and its treatment, especially CYP3A4 enzyme inhibitors. A high index of clinical suspicion is needed in the detection of AI, especially in PLHIV, as it may present insidiously with nonspecific signs and symptoms and may be potentially life threatening if left untreated. Patients with overt primary and secondary AI require glucocorticoid replacement therapy. Overt primary AI also necessitates mineralocorticoid replacement. On the other hand, the management of relative AI remains controversial. In order to reduce the risk of adrenal crisis during periods of stress, the short-term use of glucocorticoids may be necessary in relative AI.
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Affiliation(s)
- Simon Mifsud
- Department of Diabetes, Endocrinology and General Medicine, Mater Dei Hospital, Msida, Malta
| | - Zachary Gauci
- Department of Diabetes, Endocrinology and General Medicine, Mater Dei Hospital, Msida, Malta
| | - Mark Gruppetta
- Department of Diabetes, Endocrinology and General Medicine, Mater Dei Hospital, Msida, Malta
| | | | - Stephen Fava
- Department of Diabetes, Endocrinology and General Medicine, Mater Dei Hospital, Msida, Malta
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Possible Adrenal Involvement in Long COVID Syndrome. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57101087. [PMID: 34684123 PMCID: PMC8537520 DOI: 10.3390/medicina57101087] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 12/11/2022]
Abstract
Background: A significant number of patients with COVID-19 experience prolonged symptoms, known as Long COVID. The most frequent symptoms are fatigue and cognitive dysfunction. We describe a patient suffering from Long COVID in whom adrenal involvement was highlighted. Methods: The patient described Long COVID symptoms that persist 3 months after the negativization of the molecular swab test. The main symptoms were weakness, brain fog, dizziness, and muscular and joint pain. All routine lab panels for inflammation, anemia, and thyroid and liver function were conducted. Moreover, salivary cortisol and DHEA-S determinations were used to compute the adrenal stress index (ASI). Results: All tests were negative, except the ASI that showed very low levels of free cortisol. The patient started hydrocortisone acetate supplementation. Conclusion: Long COVID symptoms could be explained by an adrenal involvement, due to a COVID-19 action on adrenal glands and by a iatrogenic side effect of high glucocorticoid therapy during the COVID-19 infection. Salivary cortisol determination is effective for establishing a correct recovery plan.
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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.
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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
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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.
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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
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Pelewicz K, Szewczyk S, Miśkiewicz P. Treatment with Intravenous Methylprednisolone in Patients with Graves' Orbitopathy Significantly Affects Adrenal Function: Assessment of Serum, Salivary Cortisol and Serum Dehydroepiandrosterone Sulfate. J Clin Med 2020; 9:jcm9103233. [PMID: 33050327 PMCID: PMC7601692 DOI: 10.3390/jcm9103233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 09/29/2020] [Accepted: 10/05/2020] [Indexed: 12/25/2022] Open
Abstract
Treatment of active, moderate-to-severe Graves’ orbitopathy (GO) is the administration of intravenous methylprednisolone (IVMP). IVMP may be followed by additional therapy with oral prednisone. The aim of this study was to analyze the impact of IVMP on adrenal function by evaluation of serum, salivary cortisol and serum dehydroepiandrosterone sulfate (DHEA-S). Fourteen patients received IVMP treatment (cumulative dose of 4.5 g in 12 weekly infusions) followed by oral prednisone (for three months). All patients showed normal adrenal function before the 12th IVMP pulse and one patient was diagnosed with secondary adrenal insufficiency (AI) after prednisone treatment. DHEA-S was significantly lower before the 12th IVMP pulse and after oral prednisone (p = 0.015 and p = 0.00002, respectively) in comparison to evaluation before therapy. DHEA-S levels were below the reference range in one and three patients before the 12th IVMP pulse and after prednisone therapy, respectively. We observed decreased serum (p = 0.05) and salivary (p = 0.011) cortisol levels after oral prednisone therapy in comparison to evaluation before therapy. Treatment with IVMP in a cumulative dose of 4.5 g affects adrenal function, causing more severe impairment of DHEA-S secretion than that of cortisol but does not cause secondary AI. Additional therapy with oral glucocorticoids after IVMP can cause secondary AI.
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Affiliation(s)
- Katarzyna Pelewicz
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, 02–091 Warsaw, Poland;
| | - Sebastian Szewczyk
- Student’s Scientific Circle “Endocrinus”, Department of Internal Medicine and Endocrinology, Medical University of Warsaw, 02–091 Warsaw, Poland;
| | - Piotr Miśkiewicz
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, 02–091 Warsaw, Poland;
- Correspondence:
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Kim YJ, Kim JH, Hong AR, Park KS, Kim SW, Shin CS, Kim SY. Stimulated Salivary Cortisol as a Noninvasive Diagnostic Tool for Adrenal Insufficiency. Endocrinol Metab (Seoul) 2020; 35:628-635. [PMID: 32981305 PMCID: PMC7520577 DOI: 10.3803/enm.2020.707] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/20/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Salivary cortisol is routinely used as a diagnostic test for Cushing syndrome. The diagnostic use of salivary cortisol for adrenal insufficiency (AI), however, is less established. We aimed to investigate the utility of morning basal and adrenocorticotropic hormone-stimulated salivary cortisol in diagnosing AI in Korean adults. METHODS We prospectively included 120 subjects (female, n=70) from Seoul National University Hospital. AI was defined as a stimulated serum cortisol level of <496.8 nmol/L during the short Synacthen test (SST). Serum and saliva samples were drawn between 8:00 AM and 10:00 AM. Salivary cortisol levels were measured using an enzyme immunoassay kit. RESULTS Thirty-four patients were diagnosed with AI according to the SST results. Age, sex, body mass index, serum albumin levels, and serum creatinine levels did not significantly differ between the normal and AI groups. Basal and stimulated salivary cortisol levels were positively correlated with basal (r=0.538) and stimulated serum cortisol levels (r=0.750), respectively (all P<0.001). Receiver operating characteristic curve analysis yielded a cutoff level of morning basal salivary cortisol of 3.2 nmol/L (sensitivity, 84.9%; specificity, 73.5%; area under the curve [AUC]=0.822). The optimal cutoff value of stimulated salivary cortisol was 13.2 nmol/L (sensitivity, 90.7%; specificity, 94.1%; AUC=0.959). Subjects with a stimulated salivary cortisol level above 13.2 nmol/L but a stimulated serum cortisol level below 496.8 nmol/L (n=2) had lower serum albumin levels than those showing a concordant response. CONCLUSION The diagnostic performance of stimulated salivary cortisol measurements after the SST was comparable to serum cortisol measurements for diagnosing AI.
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Affiliation(s)
- Yoon Ji Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Mediplex Sejong Hospital, Incheon, Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - A Ram Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyeong Seon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Chan Soo Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seong Yeon Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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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.
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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
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Mahajan M, Belgaumi UI, Baad R, Vibhute N, Kadashetti V, Bommanavar S, Kamate W. Salivary Human Chorionic Gonadotropin as a Novel Biomarker for Early Detection of Pregnancy: A Pilot Study. Gynecol Minim Invasive Ther 2019; 8:59-61. [PMID: 31143624 PMCID: PMC6515747 DOI: 10.4103/gmit.gmit_47_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 11/06/2018] [Accepted: 11/15/2018] [Indexed: 11/19/2022] Open
Abstract
Context: The role of saliva in detection of pregnancy has not received the due importance it deserves. Aims: The present paper aims at determining the role of saliva in detection of pregnancy using home-based pregnancy detection kits to provide an alternative biofluid that is more user friendly, acceptable, noninvasive, rapid, and easy for home use. Settings and Design: The study was conducted among 35 women visiting a gynecology clinic for confirmation of pregnancy, who gave a history of a missed menstrual cycle not more than 4 weeks. Subjects and Methods: A home-based pregnancy detection kit meant for urinary human chorionic gonadotropin (hCG) detection with 20 mIU specification was used in the study for estimation of salivary hCG. Routine test that was prescribed to the patient such as laboratory-based urine hCG and/or ultrasound examination was used for confirmation of pregnancy status and correlation with the saliva-based result. Results: A positive test was obtained in 74% participants, with a dark band in 43% participants and a light band in 31% participants. A negative result was noted in 26% participants. We observed that salivary hCG estimation showed a 77% accuracy and 23% false-negative results. Conclusions: An astounding 74% of participants showed a positive result with an existing pregnancy kit which indicates a strong plausibility of using salivary hCG as a biomarker for detection of pregnancy. With the findings obtained from our study, we could positively affirm that salivary hCG can be used as a potential, user friendly, and more acceptable biomarker for early detection of pregnancy.
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Affiliation(s)
- Madhura Mahajan
- Intern, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India
| | - Uzma Iqbal Belgaumi
- Department of Oral Pathology and Microbiology, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India
| | - Rajendra Baad
- Department of Oral Pathology and Microbiology, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India
| | - Nupura Vibhute
- Department of Oral Pathology and Microbiology, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India
| | - Vidya Kadashetti
- Department of Oral Pathology and Microbiology, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India
| | - Sushma Bommanavar
- Department of Oral Pathology and Microbiology, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India
| | - Wasim Kamate
- Department of Oral Pathology and Microbiology, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India
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Albert L, Profitós J, Sánchez-Delgado J, Capel I, González-Clemente JM, Subías D, Cano A, Berlanga E, Espinal A, Hurtado M, Pareja R, Rigla M, Dalmau B, Vergara M, Miquel M, Casas M, Giménez-Palop O. Salivary Cortisol Determination in ACTH Stimulation Test to Diagnose Adrenal Insufficiency in Patients with Liver Cirrhosis. Int J Endocrinol 2019; 2019:7251010. [PMID: 31320899 PMCID: PMC6609341 DOI: 10.1155/2019/7251010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/13/2019] [Accepted: 05/19/2019] [Indexed: 11/18/2022] Open
Abstract
PURPOSE The prevalence of adrenal insufficiency (AI) in patients with decompensated liver cirrhosis is unknown. Because these patients have lower levels of cortisol-binding carrier proteins, their total serum cortisol (TSC) correlates poorly with free serum cortisol (FC). Salivary cortisol (SaC) correlates better with FC. We aimed to establish SaC thresholds for AI for the 250 μg intravenous ACTH test and to estimate the prevalence of AI in noncritically ill cirrhotic patients. METHODS We included 39 patients with decompensated cirrhosis, 39 patients with known AI, and 45 healthy volunteers. After subjects fasted ≥8 hours, serum and saliva samples were collected for determinations of TSC and SaC at baseline 0'(T0) and at 30-minute intervals after intravenous administration of 250 μg ACTH [30'(T30), 60'(T60), and 90'(T90)]. RESULTS Based on the findings in healthy subjects and patients with known AI, we defined AI in cirrhotic patients as SaC-T0< 0.08 μg/dL (2.2 nmol/L), SaC-T60 < 1.43 μg/dl (39.5 nmol/L), or ΔSaC<1 μg/dl (27.6 nmol/L). We compared AI determination in cirrhotic patients with the ACTH test using these SaC thresholds versus established TSC thresholds (TSC-T0< 9 μg/dl [248 nmol/L], TSC-T60 < 18 μg/dl [497 nmol/L], or ΔTSC<9 μg/dl [248 nmol/L]). SaC correlated well with TSC. The prevalence of AI in cirrhotic patients was higher when determined by TSC (48.7%) than by SaC (30.8%); however, this difference did not reach statistical significance. AI was associated with sex, cirrhosis etiology, and Child-Pugh classification. CONCLUSIONS Measuring SaC was more accurate than TSC in the ACTH stimulation test. Measuring TSC overestimated the prevalence of AI in noncritically ill cirrhotic patients.
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Affiliation(s)
- Lara Albert
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Joaquím Profitós
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Jordi Sánchez-Delgado
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Ismael Capel
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - José Miguel González-Clemente
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - David Subías
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Albert Cano
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Eugenio Berlanga
- Clinical Laboratory Department, Institut d'Investigació i Innovació Parc Taulí I3PT, Parc Taulí University Hospital, Autonomous University of Barcelona, Sabadell, Spain
| | - Anna Espinal
- Servei d'Estadística Aplicada, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Marta Hurtado
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Rocío Pareja
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Mercedes Rigla
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Blai Dalmau
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Mercedes Vergara
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Mireia Miquel
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain
| | - Meritxell Casas
- Liver and Gastrointestinal Diseases Department, Parc Tauli University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
| | - Olga Giménez-Palop
- Endocrinology Department, Parc Taulí University Hospital, Institut d'Investigacio i Innovació Parc Taulí I3PT, Autonomous University of Barcelona, Sabadell, Spain
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Lee JH, Bae YJ, Lee SH, Kim SC, Lee HY, Ban GY, Shin YS, Park HS, Kratzsch J, Ye YM. Adaptation and Validation of the Korean Version of the Urticaria Control Test and Its Correlation With Salivary Cortisone. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2019; 11:55-67. [PMID: 30479077 PMCID: PMC6267182 DOI: 10.4168/aair.2019.11.1.55] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/25/2018] [Accepted: 08/07/2018] [Indexed: 12/15/2022]
Abstract
Purpose Frequent changes in chronic urticaria (CU) activity over time can cause psychological stress, which also serves as a trigger of CU. To measure the control status of CU, the Urticaria Control Test (UCT) was developed in Germany. This study aimed to investigate the validity, reliability and responsiveness to changes in CU for the Korean version of the UCT (K-UCT) and its relation with salivary cortisol and cortisone levels. Methods Linguistic adaptation of the UCT into Korean was conducted. A total of 96 CU patients were enrolled, and 80 of them completed the study. The K-UCT and other outcome scores for CU were measured and repeated after 4 weeks of treatment. Control status was classified by physicians into well-controlled, partly-controlled, and uncontrolled CU. Salivary cortisol and cortisone were measured by liquid chromatography-tandem mass spectrometry. Results Excellent internal consistency and intra-class reliability were obtained. Strong correlations between the K-UCT and disease severity, reflected in the Urticaria Activity Score (UAS)/global assessment of urticaria control by physicians/patient assessment of symptom severity/CU-specific quality of life were noted. K-UCT scores ≥12 were found to be optimal for determining well-controlled CU (sensitivity, 75.0%; specificity, 758%; area under the curve, 0.824). Perceived stress scale scores were significantly correlated with the UAS and the K-UCT. Salivary cortisone levels were significantly correlated with K-UCT (r = 0.308, P = 0.009) and differed significantly according to control status determined by a K-UCT ≥12. Conclusions This study demonstrated that the K-UCT can be a valid instrument with which to gauge CU control status in Korean patients. Further studies are needed to validate salivary cortisone as a biomarker for CU control.
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Affiliation(s)
- Ji Ho Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yoon Ju Bae
- Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig, Leipzig, Germany
| | - So Hee Lee
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Su Chin Kim
- Clinical Trial Center, Ajou University Medical Center, Suwon, Korea
| | - Hyun Young Lee
- Clinical Trial Center, Ajou University Medical Center, Suwon, Korea
| | - Ga Young Ban
- Department of Pulmonary, Allergy and Critical Care Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Yoo Seob Shin
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Hae Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Juergen Kratzsch
- Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig, Leipzig, Germany
| | - Young Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.
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Joseph RM, Ray DW, Keevil B, van Staa TP, Dixon WG. Low salivary cortisol levels in patients with rheumatoid arthritis exposed to oral glucocorticoids: a cross-sectional study set within UK electronic health records. RMD Open 2018; 4:e000700. [PMID: 30305930 PMCID: PMC6173262 DOI: 10.1136/rmdopen-2018-000700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/09/2018] [Accepted: 07/18/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Glucocorticoids (GCs) suppress endogenous cortisol levels which can lead to adrenal insufficiency (AI). The frequency of GC-induced AI remains unclear. In this cross-sectional study, low morning salivary cortisol (MSC) levels were used as a measure of adrenal function. The study aim was to investigate the prevalence of low MSC in patients with rheumatoid arthritis (RA) currently and formerly exposed to oral GCs, and the association with potential risk factors. METHODS Sample collection was nested within UK primary care electronic health records (from the Clinical Practice Research Datalink). Participants were patients with RA with at least one prescription for oral GCs in the past 2 years. Self-reported oral GC use was used to define current use and current dose; prescription data were used to define exposure duration. MSC was determined from saliva samples; 5 nmol/L was the cut-off for low MSC. The prevalence of low MSC was estimated, and logistic regression was used to assess the association with potential risk factors. RESULTS 66% of 38 current and 11 % of 38 former GC users had low MSC. Among former users with low MSC, the longest time since GC withdrawal was 6 months. Current GC dose, age and RA duration were significantly associated with increased risk of low MSC. CONCLUSION The prevalence of low MSC among current GC users is high, and MSC levels may remain suppressed for several months after GC withdrawal. Clinicians should therefore consider the risk of suppressed cortisol and remain vigilant for symptoms of AI following GC withdrawal.
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Affiliation(s)
- Rebecca M Joseph
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, School of Biological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - David W Ray
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Brian Keevil
- Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Tjeerd P van Staa
- Health eResearch Centre, Centre for Health Informatics, School of Health Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Faculty of Science, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - William G Dixon
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, School of Biological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Health eResearch Centre, Centre for Health Informatics, School of Health Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Rheumatology Department, Salford Royal NHS Foundation Trust, Salford, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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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]
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