ACTH Stimulation Tests for the Diagnosis of Adrenal Insufficiency: Systematic Review and Meta-Analysis

Ospina, Naykky Singh; Nofal, Alaa Al; Bancos, Irina; Javed, Asma; Benkhadra, Khalid; Kapoor, Ekta; Lteif, Aida; Natt, Neena; Murad, M. Hassan

doi:10.1210/jc.2015-1700

Cited by 198 publications

(161 citation statements)

References 64 publications

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“…However, both tests had low sensitivity as suggested by the suboptimal LR of a negative test (adults: 0.39 and 0.19 for the high-and low-dose ACTH test, respectively; children: 0.65 and 0.34, respectively). A prospective cohort study of 74 adults with septic shock found that the delta cortisol using the low-and high-dose ACTH tests was equally accurate in predicting vasopressor dependency and mortality [24]. Likewise, in a prospective multicenter cohort study of critically ill children, the low-and high-dose ACTH tests showed similar accuracy in the prediction of clinical outcomes [13].…”

Section: Rationalementioning

confidence: 96%

Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017

et al. 2017

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Section: Rationalementioning

confidence: 96%

Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017

et al. 2017

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“…Synthetic corticotropin analog, tetracosactide, has 1 -24 amino acids of the endogenous ACTH and mimics its action. CST is a test of choice for diagnosis of primary adrenal insufficiency [7]. However, for secondary adrenal insufficiency, insulin tolerance test (ITT) and overnight metyrapone suppression test are gold standards.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, Kazlauskaite et al calculated that the normal HPA axis is best predicted when cortisol is above 30 μg/dL at 30 min [18]. There is a strong correlation between cortisol levels among LD and HD CST at different time points [7,14,20,21]. For this reason, when adjusted cortisol cutoffs are used, both tests provide equal sensitivity [14,15,22,23].…”

Section: Discussionmentioning

confidence: 99%

The Caveats of Corticotropin Stimulation Test in Diagnosing Secondary Adrenal Insufficiency: Case Reports and Literature Review

et al. 2016

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Corticotropin stimulation test (CST) is commonly used to diagnose secondary adrenal insufficiency. We present two patients who underwent transsphenoidal pituitary surgery for pituitary macroadenoma. Both patients had additional pituitary hormone deficiencies before and after the surgery. The patients were maintained on glucocorticoid (GC) replacement for at least 3 months after the surgery. In the remote follow-up period, they underwent conventional CST with resultant cortisol levels above 18 μg/dL. This led to discontinuation of GC treatment. Few months later, both patients developed clinically evident adrenal insufficiency. Providers should be cautious interpreting the results of CST in patients with pituitary disorders. The 250-μg CST with standard cortisol cutoff has low sensitivity and can give falsely reassuring results. Thus, it is prudent to use a higher cortisol threshold to define intact hypothalamic-pituitary-adrenal axis.

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“…In equivocal cases ACTH stimulation test is performed using standard (0.25 mg i.m or i.v.) or less often a low dose (0.001 mg -1 µg) of ACTH synthetic analogue (cosyntropin or tetracosactide) [9,10]. Standard ACTH-stimulated peak serum cortisol should exceed 18 µg/dL (500 nmol/L).…”

Section: Opis Przypadkumentioning

confidence: 99%

Addison’s disease concomitant with corticotropin deficiency and pituitary CRH resistance — a case report

Lewandowski

Malicka

Dąbrowska

et al. 2017

Endokrynologia Polska

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A 36-year-old woman was found to have a low morning ACTH concentration despite a history of Addison's disease. Past medical history: At the age of 23 years the subject developed Graves's disease, which was treated with radioiodine. At about the same time, she claimed to have two episodes of pancreatitis treated with cholecystectomy. About seven months later she was euthyroid on L-thyroxine (TSH 1.51 mIU/mL) but was admitted with hypotension, hyponatraemia (sodium 109 mmol/L), and low morning cortisol (119 nmol/L StreszczeniePrezentujemy przypadek 36-letniej pacjentki z chorobą Addisona, u której stwierdzono niskie poranne stężenie ACTH. Wywiad chorobowy: w wieku 23 lat pacjentka była poddana radiojodoterapii z powodu choroby Gravesa i Basedowa. Siedem miesięcy póź-niej została przyjęta do szpitala z powodu hipotonii z towarzyszącą hiponatremią (sód 109 mmol/l) i niskim porannym stężeniem kortyzolu (119 nmol/l). Dalsze badania potwierdziły rozpoznanie pierwotnej niewydolności kory nadnerczy. Oznaczone wówczas stężenie ACTH było wysokie i wynosiło 779 pg/ml (N: 0-60 pg/ml). Dziewięć lat później pacjentka została przyjęta do kliniki z powodu znacznego osłabienia. W badaniu przedmiotowym nie obserwowano ciemnego zabarwienia skóry, wartości ciśnienia tętniczego były prawidłowe. BMI wynosiło 22,3 kg/m 2 . Pacjentka miesiączkowała regularnie. W badaniach laboratoryjnych, pomimo bardzo niskiego stężenia kortyzolu (3,37 nmol/l), stwierdzono zaskakująco niskie stężenie ACTH (8,53 pg/ml, N: 0-46 pg/ml). W badaniu RM przysadki nie stwierdzono nieprawidłowości. W teście z hipoglikemią poinsulinową uzyskano znaczny wzrost stężenia ACTH (z 15,2 do 165 pg/ml). Natomiast w teście stymulacji z CRH wzrost stężenia ACTH był nieznamienny (z 6,05 pg/ml do 10,2 pg/ml). Wyniki te wskazywały na centralną oporność na CRH. W podsumowaniu, u pacjentki z wcześniej rozpoznaną chorobą Addisona rozwinęła się wtórna niewydolność kory nadnerczy. Brak wzrostu stężeń ACTH w teście stymulacji z CRH u tej chorej, przy zachowanej prawidłowej odpowiedzi przysadki w warunkach hipoglikemii, potwierdza, że poza CRH również inne czynniki są odpowiedzialne za pobudzenie wydzielania ACTH i kortyzolu w teście hipoglikemii poinsulinowej. (Endokrynol Pol 2017; 68 (4): 468-471) Słowa kluczowe: niewydolność kory nadnerczy, choroba Addisona, przysadka

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ACTH Stimulation Tests for the Diagnosis of Adrenal Insufficiency: Systematic Review and Meta-Analysis

Abstract: Both high- and low-dose ACTH stimulation tests had similar diagnostic accuracy. Both tests are adequate to rule in, but not rule out, secondary adrenal insufficiency. Our confidence in these estimates is low to moderate because of the likely risk of bias, heterogeneity, and imprecision.

Cited by 198 publications

References 64 publications

Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017

Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017

The Caveats of Corticotropin Stimulation Test in Diagnosing Secondary Adrenal Insufficiency: Case Reports and Literature Review

Addison’s disease concomitant with corticotropin deficiency and pituitary CRH resistance — a case report

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