Diagnosis and Treatment of Adrenal Insufficiency in the Critically Ill Patient

Asare, Kwame Kumi

doi:10.1592/phco.27.11.1512

Cited by 41 publications

(33 citation statements)

References 102 publications

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“…2,3,[5][6][7][8][9][10][11][12][13][14] However, a consensus on the diagnostic criteria for HPA axis dysfunction in critical illness has not been fully established in human medicine. Diagnosis of HPA axis dysfunction in septic human patients currently is based on 1 or more of the following findings: (1) a basal serum cortisol concentration o10 mg/dL; 4,11,15 (2) a blunted cortisol response (delta cortisol o9 mg/dL) to administration of a high (supraphysiologic) dose of synthetic ACTH (125-250 mg) in the classical high-dose ACTH stimulation test; 4,11,16 (3) a blunted cortisol response to administration of a more ''physiologic'' low dose (1 mg) of synthetic ACTH; 3,17,18 or some combination of these findings.…”

mentioning

confidence: 99%

Hypothalamic‐Pituitary‐Adrenal Axis Dysfunction in Hospitalized Neonatal Foals

Hart

Slovis

Barton

2009

Veterinary Internal Medicne

124

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Background: Transient hypothalamic-pituitary-adrenal (HPA) axis dysfunction occurs frequently in critically ill humans and impacts survival. The prevalence and impact of HPA axis dysfunction in critically ill neonatal foals are not well characterized.Hypotheses: (1) HPA axis dysfunction occurs in hospitalized neonatal foals, and is characterized by inappropriately low basal serum cortisol concentration or inadequate cortisol response to exogenous adrenocorticotropic hormone (ACTH); (2) hospitalized foals with HPA axis dysfunction have more severe disease and are less likely to survive than hospitalized foals with normal HPA axis function.Animals: Seventy-two hospitalized foals and 23 healthy age-matched foals. Methods: Basal ACTH and cortisol concentrations were measured and a paired low-dose (10 mg)/high-dose (100 mg) cosyntropin stimulation test was performed at admission in hospitalized foals. HPA axis dysfunction was defined as (1) an inappropriately low basal cortisol concentration or (2) an inadequate increase in cortisol concentration (delta cortisol) after administration of cosyntropin, with cut-off values for appropriate basal and delta cortisol concentrations determined from results obtained in healthy age-matched foals.Results: Forty-six percent of hospitalized foals had an inappropriately low basal cortisol concentration and 52% had an inadequate delta cortisol concentration after administration of the 100 mg dose of cosyntropin. An inadequate delta cortisol response to the high (100 mg) dose of cosyntropin was significantly correlated with shock and multiple organ dysfunction syndrome in hospitalized foals, and with decreased survival in a subgroup of septic foals.Conclusions and Clinical Importance: HPA axis dysfunction occurs frequently in hospitalized neonatal foals, and negatively impacts disease severity and survival.

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mentioning

confidence: 99%

Hypothalamic‐Pituitary‐Adrenal Axis Dysfunction in Hospitalized Neonatal Foals

Hart

Slovis

Barton

2009

Veterinary Internal Medicne

124

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“…Its clinical importance is emphasized by the fact that the potency of other GCs is often compared with prednisone, being termed 'prednisone equivalent' when prescribing or advising the use of a GC. TABLE 1 gives an overview about different GCs and their distinct half-lives as well as the duration of action (data from [12] and [13]). …”

Section: Therapymentioning

confidence: 99%

The current relevance and use of prednisone in rheumatoid arthritis

Krasselt¹,

Baerwald

2014

Expert Review of Clinical Immunology

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Prednisone is an old and very valuable drug in clinical use for over 60 years by now. It is well known by physicians and widely used for different kinds of inflammatory states including rheumatoid arthritis (RA). Clinical trials during the last 20 years have changed its clinical use, particularly with regards to dosage. Today, rheumatologists are treating their patients much more likely over a long period of time using a low-dose scheme. The effectiveness and safety of this low-dose use is the objective of the current clinical research and shall be enlightened in this drug profile. It is also featuring current knowledge about the value of modified-release prednisone with regards to the just published results of the 2nd Circadian Administration of Prednisone in Rheumatoid Arthritis trial. Moreover, the mechanisms of action of prednisone and its relatives will be summed up.

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“…The low-dose ACTH stimulation test (1 μg) has been shown to be more sensitive and specific than the high-dose test (250 μg), however; the high-dose test is preferred since the low-dose test has not been validated 20,21. The test has a reported specificity of 95%, with sensitivities of 97%, 57%, and 61% for primary adrenal insufficiency (250 μg cosyntropin test), secondary adrenal insufficiency (250 μg cosyntropin test), and secondary adrenal insufficiency (1 μg cosyntropin test), respectively.…”

Section: Cosyntropin and The Diagnosis Of Adrenal Insufficiencymentioning

confidence: 99%

Cosyntropin as a diagnostic agent in the screening of patients for adrenocortical insufficiency

Hamilton¹,

Cotton²

2010

CPAA

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Adrenocortical insufficiency occurs when there is inadequate release of cortisol from the adrenal cortex. Disturbances of the hypothalamic–pituitary–adrenal axis are common following trauma, surgical stress, and critical illness. While this is often a protective mechanism, these responses may become “uncoupled” or maladaptive resulting in an exacerbation of organ failure and higher mortality rates. In these clinical settings, the patient presents with a persistent systemic inflammation state, a hyperdynamic cardiovascular response, and vasopressor dependent shock. As such, the occurrence of adrenal insufficiency in the setting of critical illness is most appropriately termed critical illness-related corticosteroid insufficiency. In these settings, recent data suggests that these patients may benefit from a short course of low-dose steroid replacement therapy. Cosyntropin, a synthetic derivative of adrenocorticotropic hormone, is being used with increased frequency in the evaluation and diagnosis of adrenocortical insufficiency in this patient population. A random cortisol level is checked before a 250-μg injection of cosyntropin and then 30–60 minutes later. The cortisol levels and response to cosyntropin may be interpreted to identify an insufficient adrenal response. Of note, the setting of critical illness can greatly affect the cosyntropin test sensitivity on identifying adrenal insufficiency. Changes in the stress response during critical illness combined with the resuscitation and management of these patients greatly disturbs serum protein levels, especially those of albumin and transcortin. Common intensive care unit (ICU) diagnoses such as sepsis and malnutrition can increase baseline levels and blunt the cortisol response to cosyntropin stimulation, respectively. As well, numerous pharmacological agents routinely used in the ICU have been shown to interfere with cortisol levels and cosyntropin responsiveness. While steroids have a place in the ICU, specific dosing and length of administration remain inconsistent

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Diagnosis and Treatment of Adrenal Insufficiency in the Critically Ill Patient

Cited by 41 publications

References 102 publications

Hypothalamic‐Pituitary‐Adrenal Axis Dysfunction in Hospitalized Neonatal Foals

Hypothalamic‐Pituitary‐Adrenal Axis Dysfunction in Hospitalized Neonatal Foals

The current relevance and use of prednisone in rheumatoid arthritis

Cosyntropin as a diagnostic agent in the screening of patients for adrenocortical insufficiency

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