Adrenocorticotropin stimulation tests in patients with hypothalamic‐pituitary disease: low dose, standard high dose and 8‐h infusion tests

Nye, E. J.; Grice, Jeffrey E.; Hockings, G. I.; Strakosch, C. R.; Crosbie, G. V.; Walters, Margaret M.; Torpy, David J.; Jackson, Richard V.

doi:10.1046/j.1365-2265.2001.01389.x

Cited by 33 publications

(18 citation statements)

References 48 publications

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“…Theoretically, patients with primary AI may display a significant cortisol rise in response to an acute ACTH bolus but be unable to maintain sustained cortisol secretion. However, the sensitivity of this test in patients with hypothalamic-pituitary disease is not significantly greater than that of other ACTH tests [61].…”

Section: Differential Diagnosis Between Primary and Secondary Aimentioning

confidence: 71%

Isolated corticotrophin deficiency

2006

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Isolated ACTH deficiency (IAD) is a rare disorder, characterized by secondary adrenal insufficiency (AI) with low or absent cortisol production, normal secretion of pituitary hormones other than ACTH and the absence of structural pituitary defects. In adults, IAD may appear after a traumatic injury or a lymphocytic hypophysitis, the latter possibly due to autoimmune etiology. Conversely, a genetic origin may come into play in neonatal or childhood IAD. Patients with IAD usually fare relatively well during unstressed periods until intervening events spark off an acute adrenal crisis presenting with non specific symptoms, such as asthenia, anorexia, unintentional weight loss and tendency towards hypoglycemia. Blood chemistry may reveal mild hypoglycemia, hyponatremia and normal-high potassium levels, mild anemia, lymphocytosis and eosinophilia. Morning serum cortisol below 3 microg/dl are virtually diagnostic for adrenal insufficiency. whereas cortisol values comprised between 5-18 microg/dl require additional investigations: insulin tolerance test (ITT) is considered the gold standard but-when contraindicated-high or low dose-ACTH stimulation test with serum cortisol determination provides a viable alternative. Plasma ACTH concentration and prolonged ACTH infusion test are useful in differential diagnosis between primary and secondary adrenal insufficiency. For some patients with mild, near-to-asymptomatic disease, glucocorticoid replacement therapy may not be required except during stressful events; for symptomatic patients, replacement doses i.e., mean daily dose 20 mg (0.30 mg/kg) hydrocortisone or 25 mg (0.35 mg/kg) cortisone acetate, are usually sufficient. Administration of mineralocorticoids is generally not necessary as their production is maintained.

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Section: Differential Diagnosis Between Primary and Secondary Aimentioning

confidence: 71%

Isolated corticotrophin deficiency

2006

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“…Given the supraphysiological stimulation induced with the acute HDT, which allows ACTH levels at least double those measured during major physical stress (11,20), this challenge gives rise to a high rate of false negative responses, thus appearing less suitable to detect mild adrenal dysfunction (21)(22)(23). Therefore, we performed in our patients a low-dose tetracosactide test, which is considered at the moment more reliable than the standard high-dose challenge in detecting adrenal insufficiency, by inducing an ACTH increase in the same magnitude as that obtained by ITT (24,25) and major physical stress (26). In addition, to evaluate cortisol secretion in response to severe stressful conditions, we also carried out an 8-h infusion of 250 mg tetracosactide, which is considered a reliable tool to estimate the adrenal capacity to sustain a response after the exhaustion of cortisol stores (27).…”

Section: Adrenal Function In Thalassaemiamentioning

confidence: 99%

The pituitary–adrenal axis in adult thalassaemic patients

Scacchi

Danesi

Cattaneo

et al. 2010

European Journal of Endocrinology

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Objective: We previously described in young thalassaemic patients an altered cortisol and ACTH responsiveness suggesting an impaired adrenocortical reserve. Owing to iron overload, a worsening of adrenal function should be expected in adult patients. Design: In 124 adults with b-thalassaemia, urinary free cortisol (UFC) and plasma ACTH levels were determined and compared with those measured in 150 controls. In 45 patients, cortisol was measured in response to: i) tetracosactide 1 mg as an i.v. bolus (low-dose test, LDT) and ii) tetracosactide 250 mg infused i.v. over 8 h (high-dose test, HDT). Results: UFC and serum cortisol were within the reference range in all patients. Conversely, basal plasma ACTH values were above the upper limit of the normal range in 19 patients. There were no statistically significant differences in the mean values of UFC, basal serum cortisol and plasma ACTH between patients and controls. A subnormal cortisol response to the LDT was registered in 18 out of 56 patients. Three of these patients also displayed a subnormal response to the HDT, together with elevated baseline plasma ACTH levels. In the LDT, a positive correlation was found between basal and peak cortisol values (P!0.0001). The latter were negatively correlated with basal ACTH values in both LDT (P!0.0001) and HDT (P!0.0001). Conclusions: Adult thalassaemic patients often present a subtle impairment of adrenocortical function. This may become clinically relevant in case of major stressful events. Thus, we recommend an assessment of adrenocortical function in all adult thalassaemic patients.

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“…Nowadays, a lower dose of ACTH (1 µg) is being used as a sensitive test in patients with subtle adrenal dysfunction, which is considered to be the test of choice in the evaluation of adrenal function in pituitary diseases 20 . Lower doses are considered to be more physiological, avoiding a hyper-stimulus, and the results obtained are similar to hypoglycemia induced by insulin or a great physical stress 14 . There are not enough data on the use of low doses of ACTH in the evaluation of primary adrenal dysfunction.…”

Section: Discussionmentioning

confidence: 80%

Adrenal function in 23 children with paracoccidioidomycosis

Pereira

Guerra‐Júnior

Tresoldi

2006

Rev. Inst. Med. trop. S. Paulo

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SUMMARYAdrenal involvement by Paracoccidioides brasiliensis was described at necropsies and in many clinical studies, but only in adults. Therefore, the aim of this study was to evaluate adrenal function in children with paracoccidioidomycosis.Twenty-three children with the systemic form of paracoccidioidomycosis were evaluated and divided in two Groups: Group A (n = 8) included children before treatment and Group B (n = 15) children after the end of treatment. Plasma cortisol (basal and after ACTH test), ACTH, renin activity, aldosterone, sodium and potassium were measured. They were within normal range in all cases, except for renin activity and aldosterone, which were elevated in some cases. Group A patients showed basal and post-ACTH cortisol levels significantly greater than Group B patients. The results showed that adrenal function was not compromised in these children with paracoccidioidomycosis.

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Adrenocorticotropin stimulation tests in patients with hypothalamic‐pituitary disease: low dose, standard high dose and 8‐h infusion tests

Cited by 33 publications

References 48 publications

Isolated corticotrophin deficiency

Isolated corticotrophin deficiency

The pituitary–adrenal axis in adult thalassaemic patients

Adrenal function in 23 children with paracoccidioidomycosis

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