Pitfalls in the interpretation of the cosyntropin stimulation test for the diagnosis of adrenal insufficiency

Abstract

Purpose of reviewAdrenal insufficiency is a rare disease characterized by cortisol deficiency. The evaluation of patients suspected of having adrenal insufficiency can be challenging because of the rarity of the disease and limitations in the biochemical assessment of the cortisol status by either basal or dynamic testing [adrenocorticotropic hormone (ACTH) stimulation test]. Prompt and adequate diagnosis is of paramount importance to avoid adverse outcomes. We aimed to summarize the recent developments in the conduction and interpretation of the ACTH stimulation test for the diagnosis of adrenal insufficiency. Recent findingsThe ACTH stimulation test is commonly performed in patients suspected of having adrenal insufficiency when the basal serum cortisol levels are inconclusive. Recent literature has evaluated the impact of technical aspects such as time of the day the test is performed, type of assay and sample source used for cortisol measurement on the clinical value of this test, as well as the feasibility of reliable low dose ACTH testing. SummaryClinicians evaluating patients with suspected adrenal insufficiency should take into consideration the clinical presentation (likelihood of adrenal insufficiency before testing) when interpreting the results of the ACTH stimulation test and be aware of clinical and technical factors that can affect cortisol values and diagnostic accuracy of this test.

Secondary adrenal insufficiency induced by long-term use of opioid analgesics

“…3 Moreover, even low-dose cosyntropin testing may not predict response to glucocorticoids 4 and thus initial cosyntropin testing may miss secondary cortisol deficiency. 5 We agree with Burgos et al 6 that the patient's clinical presentation should be considered when interpreting cosyntropin tests. We believe that glucocorticoid treatment should not be withheld on the basis of a cortisol level if the clinical presentation is consistent with hypoadrenalism.…”

Common Pitfalls in the Interpretation of Endocrine Tests

“…a) ACTH Stimulation test: Stimulation test with a 250 ug IV or IM tetracosactide (Synacthen ®) with cortisol sampling at zero, 30, 60 minutes is a simple and secure way to evaluate adrenal function. Both post-stimulation cortisol values must be > 18 ug/dL to rule out a primary AI ( 15 ). The common mistake is that this test with high ACTH analog doses does not rule out primary AI or central AI.…”

A Multicenter Cohort Study in Patients With Primary Empty Sella: Hormonal and Neuroradiological Features Over a Long Follow-Up

“…On the opposite, some patients (14/166, 8.4%) displayed an improvement in pituitary function, especially in adrenal axes on retesting. We are aware that pitfalls in stimulation tests can explain why hormonal responses sometimes differ in the same patient ( 17 , 27 , 28 ). On the other hand, we can’t exclude a real recovery in the pituitary function.…”