The insulin hypoglycaemia and overnight metyrapone tests in the assessment of the hypothalamic–pituitary–adrenal axis following pituitary surgery

Courtney,; McAllister,; McCance,; Hadden,; Leslie,; Sheridan,; Atkinson, Joanna

doi:10.1046/j.1365-2265.2000.01093.x

Cited by 45 publications

(42 citation statements)

References 14 publications

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“…Although controversy exists regarding the optimal test and optimal time for conducting tests in the postoperative period, the ITT is considered to be the gold standard test and is used as reference in clinical trials (6,7,9,12,13).…”

Section: Discussionmentioning

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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Section: Discussionmentioning

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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“…14,16,21,50,62,63 However, there have been reports of postoperative relapse despite complete disappearance of the preoperative positive desmopressin response. 4,17,28,39 In a series of more than 100 patients with CD, Losa et al demonstrated that 50 of 87 patients had a complete disappearance of positive preoperative response to desmopressin following surgery, yet 4 of these patients experienced a relapse shortly after surgery. Furthermore, 18 of 37 patients with continued positive response to desmopressin postoperatively were ultimately deemed to be in remission via dexamethasone suppression testing.…”

Section: Desmopressin Stimulationmentioning

confidence: 99%

“…63 However, the specificity of this test has been questioned in the setting of several follow-up reports of patients with recurrent CD with a wide range of 11-deoxycortisol values. 4,17,28 Consequently, the use of the metyrapone stimulation test for predicting CD recurrence has been limited. 28 …”

Section: Metyrapone Stimulationmentioning

confidence: 99%

Cushing's disease: predicting long-term remission after surgical treatment

Pendharkar¹,

Sussman²,

Ho³

et al. 2015

FOC

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Cushing's disease (CD) is a state of excess glucocorticoid production resulting from an adrenocorticotropic hormone (ACTH)–secreting pituitary adenoma. The gold-standard treatment for CD is transsphenoidal adenomectomy. In the hands of an experienced neurosurgeon, gross-total resection is possible in the majority of ACTH-secreting pituitary adenomas, with early postoperative remission rates ranging from 67% to 95%. In contrast to the strong data in support of resection, the clinical course of postsurgical persistent or recurrent disease remains unclear. There is significant variability in recurrence rates, with reports as high as 36% with a mean time to recurrence of 15–50 months. It is therefore important to develop biochemical criteria that define postsurgical remission and that may provide prognosis for long-term recurrence. Despite the use of a number of biochemical assessments, there is debate regarding the accuracy of these tests in predicting recurrence. Here, the authors review the various biochemical criteria and assess their utility in predicting CD recurrence after resection.

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“…In all cases, GHD was documented before start of rhGh replacement according to the international guidelines and when stimulation tests were performed. Severe GHD was defined as a GH peak response to the insulin tolerance test (ITT) <3 μg/L (glucose nadir <2.2 mmol/L) or, in case of contraindications for ITT, by the peak response to combined growth hormone-releasing hormone/arginine stimulation (GHRH/Arg) with BMIadjusted GH cutoffs (21,22,23,24,25,26). Of all the patients, 41 were diagnosed as GHD by insulin tolerance test and 20 by GHRH+arginine.…”

Section: The Diagnosis and Treatment Protocol Of Adult Patients With Ghdmentioning

confidence: 99%

Effects of discontinuation of growth hormone replacement in adult GH-deficient patients: a cohort study and a systematic review of the literature

Appelman‐Dijkstra

Rijndorp

Biermasz

et al. 2016

European Journal of Endocrinology

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Background: Recombinant human growth hormone (rhGH) replacement is advocated in adult growth hormonedeficient (GHD) patients to increase bone mass and improve lipid profile, body composition, and quality of life. The long-term effects of discontinuation of rhGh replacement are unknown. Methods: This cohort study and systematic review aim to evaluate the long-term metabolic effects of discontinuation of rhGh replacement in adult GHD patients, with a subgroup analyses according to age (< or > 60 years). Data on anthropometry, lipids, glucose, and bone mass density (BMD) were assessed for 3 years after discontinuation. Results: Cohort study included 64 patients who had discontinued rhGh replacement for >12 months. Fat percentage increased from 31.5 ± 9.5% to 33.8 ± 9.0% (mean difference 2.3, P = 0.003). BMI decreased only in subjects <60 years (P = 0.014). Glucose, total cholesterol, and LDL-cholesterol levels did not change; however, the percentage of patients on statins increased slightly from 39% to 44%. HDL-C concentration increased only in patients <60 years (mean difference 0.2, P = 0.043). Lumbar spine BMD did not change; however, femoral neck BMD and bone turnover markers decreased in subjects <60 years (P = 0.001). Systematic review included eight studies (n = 166 patients) with a follow-up duration of 6-18 months. Of the eight studies, three qualified as low risk of bias and five as having an intermediate risk of bias. None of the studies reported handling of statins, bisphosphonates, and glucose-lowering medication or excluded patients using these medications. Conclusions: In this study, discontinuation of rhGh replacement resulted in metabolic changes only in patients <60 years after 3 years. Further research warrants to determine the optimal strategies for (dis)continuation of rhGh replacement in adult patients with GHD.

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The insulin hypoglycaemia and overnight metyrapone tests in the assessment of the hypothalamic–pituitary–adrenal axis following pituitary surgery

Cited by 45 publications

References 14 publications

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?

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?

Cushing's disease: predicting long-term remission after surgical treatment

Effects of discontinuation of growth hormone replacement in adult GH-deficient patients: a cohort study and a systematic review of the literature

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