Expanding the use of salivary cortisol as a non-invasive outpatient test in the dynamic evaluation of suspected adrenal insufficiency

Tan, Sarah Ying Tse; Tan, Hong Chang; Zhu, Ling; Loh, L.; Lim, Dawn Shao Ting; Soon, Swee Du; Chan, Yoke Ling; Lim, Huee Boon; Ling, Shiau Lee; Ou, En Jun; Teo, Wynn Ee; Zhang, Xiaoping; Goh, Hui Fen Jacqueline; Kek, Peng Chin

doi:10.1530/ec-23-0004

Cited by 5 publications

(1 citation statement)

References 45 publications

(117 reference statements)

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“…In such situations, a salivary cortisol assay can be used as a reliable alternative test. A very recent study demonstrated a sensitivity of 90.5% and specificity of 76.2% after SST for diagnosing AI using a stimulated salivary cortisol cut-off value of ≥16 nmol/L [32].…”

Section: Stress Testing For Proving Paimentioning

confidence: 99%

Adrenal Failure: An Evidence-Based Diagnostic Approach

Shaikh¹,

Nagendra

Shaikh

et al. 2023

Diagnostics

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The diagnosis of adrenal insufficiency (AI) requires a high index of suspicion, detailed clinical assessment including detailed drug history, and appropriate laboratory evaluation. The clinical characteristics of adrenal insufficiency vary according to the cause, and the presentation may be myriad, e.g. insidious onset to a catastrophic adrenal crisis presenting with circulatory shock and coma. Secondary adrenal insufficiency (SAI) often presents with only glucocorticoid deficiency because aldosterone production, which is controlled by the renin angiotensin system, is usually intact, and rarely presents with an adrenal crisis. Measurements of the basal serum cortisol at 8 am (<140 nmol/L or 5 mcg/dL) coupled with adrenocorticotrophin (ACTH) remain the initial tests of choice. The cosyntropin stimulation (short synacthen) test is used for the confirmation of the diagnosis. Newer highly specific cortisol assays have reduced the cut-off points for cortisol in the diagnosis of AI. The salivary cortisol test is increasingly being used in conditions associated with abnormal cortisol binding globulin (CBG) levels such as pregnancy. Children and infants require lower doses of cosyntropin for testing. 21-hydoxylase antibodies are routinely evaluated to rule out autoimmunity, the absence of which would require secondary causes of adrenal insufficiency to be ruled out. Testing the hypothalamic–pituitary–adrenal (HPA) axis, imaging, and ruling out systemic causes are necessary for the diagnosis of AI. Cancer treatment with immune checkpoint inhibitors (ICI) is an emerging cause of both primary AI and SAI and requires close follow up. Several antibodies are being implicated, but more clarity is required. We update the diagnostic evaluation of AI in this evidence-based review.

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Section: Stress Testing For Proving Paimentioning

confidence: 99%

Adrenal Failure: An Evidence-Based Diagnostic Approach

Shaikh¹,

Nagendra

Shaikh

et al. 2023

Diagnostics

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Post-Traumatic Hypopituitarism

Blocher

2024

Curr Phys Med Rehabil Rep

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Purpose of Review Traumatic brain injury (TBI) frequently effects the integrity and function of the anterior and/or posterior pituitary gland. This review will cover the current understanding of post-trauma hypopituitarism (PTHP) including frequency, risk factors, screening, and treatment. Recent Findings There is continuingly increased data on frequency of hormone deficiencies over time. This has created a push for algorithms to guide screening. Oxytocin is emerging as a potential target for treatment, but data is mixed and no treatment has been tested. There is significantly increased data regarding the long-term effect of growth hormone (GH) deficiency on metabolism and on the liver, which is driving renewed recommendations for consideration of GH replacement. Summary Pituitary dysfunction after TBI is frequent and has significant impact on morbidity, mortality, and recovery. If recognized, basic treatment is straightforward, though many gaps remain in our knowledge. Future work should focus on ideal screening strategies and treatment optimization.

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Extensive expertise in endocrinology: adrenal crisis in assisted reproduction and pregnancy

Feldt-Rasmussen

2024

European Journal of Endocrinology

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Appropriate management of adrenal insufficiency in pregnancy is challenging due to the rarity of both primary, secondary and tertiary forms of the disease as well as the lack of evidence-based recommendations to guide clinicians to glucocorticoid and sometimes also mineralocorticoid dosage adjustments. Debut of adrenal insufficiency during pregnancy requires immediate diagnosis as it can lead to adrenal crisis, intrauterine growth restriction and foetal demise. Diagnosis is difficult due to overlap of symptoms of adrenal insufficiency and its crisis with those of pregnancy. Adrenal insufficiency in stable replacement treatment needs careful monitoring during pregnancy to adapt to the physiological changes in the requirement of the adrenal hormones. This is hampered because the diagnostic threshold of most adrenocortical hormones is not applicable during pregnancy. The frequent use of assisted reproduction technology with controlled ovarian hyperstimulation in these patient groups with disease induced low fertility has created an unrecognised risk of adrenal crises due to accelerated oestrogen stimulation with increased risk of even be life-threatening complications for both the woman and foetus. The area needs consensus recommendations between gynaecologists and endocrinologists in tertiary referral centres to alleviate such increased gestational risk. Patient and partner education, use of the EU emergency card for management of adrenal crises can also contribute to better pregnancy outcomes. There is a strong need of more research on e.g. improvement of glucocorticoid replacement as well as crisis management treatment, and biomarkers for treatment optimisation in this field, which suffers from the rare nature of the diseases and poor funding.

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Expanding the use of salivary cortisol as a non-invasive outpatient test in the dynamic evaluation of suspected adrenal insufficiency

Cited by 5 publications

References 45 publications

Adrenal Failure: An Evidence-Based Diagnostic Approach

Adrenal Failure: An Evidence-Based Diagnostic Approach

Post-Traumatic Hypopituitarism

Extensive expertise in endocrinology: adrenal crisis in assisted reproduction and pregnancy

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