The adrenocortical response to surgery and insulin-induced hypoglycaemia in corticosteroid-treated and normal subjects

Plumpton, F. S.; Besser, G. M.

doi:10.1002/bjs.1800560315

Cited by 159 publications

(123 citation statements)

References 7 publications

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“…Thereafter the integrity of the hypothalamic-pituitary-adrenal axis was assessed by an insulin-hypoglycaemia test. 37 The thyrotrophic, gonadotrophic and somatotrophic axis were checked regularly.…”

Section: Postoperative Evaluation After First and Second Tsmentioning

confidence: 99%

Repeated transsphenoidal pituitary surgery (TS) via the endoscopic technique: a good therapeutic option for recurrent or persistent Cushing's disease (CD)

Wagenmakers¹,

Netea‐Maier²,

Lindert

et al. 2009

Clinical Endocrinology

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SummaryBackground No data on results of repeated transsphenoidal surgery via the endoscopic technique for patients with persistent or recurrent Cushing's disease are available. Design and patients We retrospectively evaluated the remission rates and complications of repeated transsphenoidal surgery via the endoscopic technique in 14 patients with persistent ( N = 6) or recurrent ( N = 8) Cushing's disease treated in our centre between 1999 and 2007. Main outcomes Remission was defined as the disappearance of symptoms of hypercortisolism with basal plasma cortisol level ≤ 50 nmol/l 24-48 h after glucocorticoid withdrawal and/or suppression of plasma cortisol level ≤ 50 nmol/l after 1 mg dexamethasone overnight within the first 3 months after transsphenoidal surgery. Results With repeated endoscopic transsphenoidal surgery a remission rate of 10/14 (71%) was achieved. No patient had a relapse during a median follow-up of 24 months. Cerebrospinal fluid leakage was the most frequent complication (6 patients) and 11 patients required hormonal substitution after surgery. The success of repeated transsphenoidal surgery could not be predicted by visualization of an adenoma on MRI before first or second surgery, histopathological confirmation of an ACTH secreting adenoma after first or second surgery, treatment with cortisol lowering agents before first or second surgery, the operation technique used during the first surgery, persistent vs. recurrent disease after the first surgery, age, gender and interval between the two surgeries. Conclusion Repeated transsphenoidal surgery via the endoscopic technique is a good treatment option for selected patients with recurrent or persistent Cushing's disease following primary pituitary surgery.

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Section: Postoperative Evaluation After First and Second Tsmentioning

confidence: 99%

Repeated transsphenoidal pituitary surgery (TS) via the endoscopic technique: a good therapeutic option for recurrent or persistent Cushing's disease (CD)

Wagenmakers¹,

Netea‐Maier²,

Lindert

et al. 2009

Clinical Endocrinology

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“…The insulin tolerance test (ITT) is the gold standard for the evaluation of the hypothalamic-pituitary-adrenal (HPA) axis (1,2) and is regarded as the optimum test for the pharmacological assessment of GH secretion in children (3). In contrast to the extensive published literature pertaining to the GH response following insulin-induced hypoglycaemia in children, comparatively few reports have considered the magnitude of the cortisol response.…”

Section: Introductionmentioning

confidence: 99%

“…The magnitude of the stress response to major surgery in 20 adult subjects was established by Plumpton & Besser (1), who equated it to a peak cortisol response to the ITT of 550 nmol/l (20 mg/dl). More recently, this value has been revised downwards to 500 nmol/l (18 mg/dl) (9) and has been validated in healthy adults (10), correcting for the 20-30% positive bias associated with the older fluorometric assay (1). Extrapolation from adult data has resulted in many paediatric centres employing a reference range for peak cortisol responses to insulin-induced hypoglycaemia between 500 and 550 nmol/l for all children and adolescents regardless of age (1,2,10).…”

Section: Introductionmentioning

confidence: 99%

Requirement for age-specific peak cortisol responses to insulin-induced hypoglycaemia in children

O’Grady

Hensey

Fallon

et al. 2013

European Journal of Endocrinology

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Objective: Based on adult data, a peak cortisol response R500 nmol/l to insulin-induced hypoglycaemia constitutes a normal. Age-specific reference ranges for basal morning cortisol have been developed for clinical use in the paediatric population. Such reference ranges are not clearly established for peak cortisol responses to insulin-induced hypoglycaemia despite limited data suggesting an effect of age on peak cortisol. The aims of this study were to assess factors affecting the cortisol response to insulin-induced hypoglycaemia in children and to determine whether the peak cortisol response was related to age. Design: The present study was a retrospective cohort study. Methods: Retrospective analysis of children and adolescents aged %18 years undergoing the insulin tolerance test with adequate hypoglycaemia was undertaken. Patients with hypopituitarism or severe hypothalamic-pituitary-adrenal axis impairment (peak cortisol value !400 nmol/l) or using systemic glucocorticoids were excluded. Results: Two hundred and twenty-three tests were analysed. Peak cortisol responses R500 nmol/l occurred in 183 (82%) tests. Age was negatively associated with peak cortisol responses (rZK0.15, PZ0.03). A peak cortisol response !500 nmol/l was significantly less common in patients aged !12 years (9/97 (9%) vs 31/126 (25%); PZ0.004). In children aged !12 years, the median (5th-95th centiles) peak cortisol values were 610 (480-806) nmol/l compared with 574 (442-789) nmol/l in children aged R12 years (P!0.004). Similarly, median cortisol increment was significantly higher in younger patients (301 nmol/l compared with 226 nmol/l (PZ0.0004)). Conclusions: Use of a single peak cortisol threshold in children of all ages is not appropriate and will result in overdiagnosis of adrenal insufficiency in adolescents.

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“…The insulin tolerance test (ITT) is the gold standard test for examining HPA axis function (1)(2)(3). It is used in the preoperative and postoperative assessment of patients with pituitary adenoma.…”

Section: Introductionmentioning

confidence: 99%

Can basal cortisol measurement be an alternative to the insulin tolerance test in the assessment of the hypothalamic–pituitary–adrenal axis before and after pituitary surgery?

Karaca

Tanrıverdi²,

Atmaca³

et al. 2010

European Journal of Endocrinology

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Background: The aims of this study were to evaluate the validity of preoperative basal serum cortisol levels measured in predicting preoperative adrenal insufficiency and also the validity of basal serum cortisol levels and early postoperative insulin tolerance test (ITT) in predicting postoperative adrenal insufficiency. Methods: The study was prospectively designed and included 64 patients who underwent pituitary surgery for conditions other than Cushing's disease. An ITT was performed preoperatively, on the 6th postoperative day and at the 1st postoperative month. Basal serum cortisol levels were measured on the 2nd, 3rd, 4th, 5th, and 6th postoperative days. Results: Patients with a preoperative basal cortisol level of !165 nmol/l (6 mg/dl) showed insufficient cortisol response and those with levels higher than 500 nmol/l (18 mg/dl) had sufficient cortisol response to the preoperative ITT. The positive predictive value of the ITT performed on the 6th postoperative day was 69.7%, and the negative predictive value in predicting adrenal insufficiency at the 1st postoperative month was 58%. Patients were considered to have an insufficient cortisol response to ITT at the 1st postoperative month if their basal cortisol levels were !193 nmol/l (7 mg/dl) or 220 nmol/l (8 mg/dl) or 193 nmol/l (7 mg/dl) or 165 nmol/l (6 mg/dl) or 83 nmol/l (3 mg/dl) on the 2nd-6th postoperative days respectively. Conclusion: Serum basal cortisol levels may be used as the first-line test in the assessment of the hypothalamic-pituitary-adrenal axis both preoperatively and postoperatively. Dynamic testing should be limited to the patients with indeterminate basal cortisol levels.

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The adrenocortical response to surgery and insulin-induced hypoglycaemia in corticosteroid-treated and normal subjects

Cited by 159 publications

References 7 publications

Repeated transsphenoidal pituitary surgery (TS) via the endoscopic technique: a good therapeutic option for recurrent or persistent Cushing's disease (CD)

Repeated transsphenoidal pituitary surgery (TS) via the endoscopic technique: a good therapeutic option for recurrent or persistent Cushing's disease (CD)

Requirement for age-specific peak cortisol responses to insulin-induced hypoglycaemia in children

Can basal cortisol measurement be an alternative to the insulin tolerance test in the assessment of the hypothalamic–pituitary–adrenal axis before and after pituitary surgery?

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