International survey on high‐ and low‐dose synacthen test and assessment of accuracy in preparing low‐dose synacthen

Cross, Alexandra; Kemp, E. Helen; White, Anne; Walker, Leanne; Meredith, Suzanne; Sachdev, Pooja; Krone, Nils; Ross, R. J. M.; Wright, Neil; Elder, Charlotte

doi:10.1111/cen.13559

Cited by 28 publications

(27 citation statements)

References 26 publications

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“…Both of these tests are used in clinical practice and have similar diagnostic accuracy 5. The high-dose SST is used very widely to assess HPA function and its use has risen from 24% in 1988 to 50% in 19946 and to 98% in 2018 7. It is now considered as the ‘standard’ for the diagnosis of AI2 due to its simplicity 2.…”

Section: Introductionmentioning

confidence: 99%

Do we need 30 min cortisol measurement in the short synacthen test: a retrospective study

Kumar

Carr

Moore

et al. 2019

Postgraduate Medical Journal

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ObjectiveThe short synacthen test (SST) is widely used across the UK to assess adrenal reserve but there remains no consensus on the timing of cortisol sampling to help diagnose adrenal insufficiency. The main objective of our study was to see if both 30 and 60 min sample are required following administration of synacthen to investigate suspected adrenal insufficiency (AI).DesignThis was a single-centre retrospective study of 393 SSTs measuring 0, 30 and 60 min cortisol levels after administration of 250 µg of synacthen.Patients and methodsAll the SSTs for patients suspected of primary or secondary AI between April 2016 and October 2018 were included in this study. The tests were performed as per our hospital protocol. A post-adrenocorticotropic hormone (ACTH) cortisol response of 420 nmol/L at any time point was considered adequate to rule out AI. The data were analysed to ascertain the proportion of patients who achieved this level at 30 and/or 60 min.ResultsA total of 393 SST results were included in this study. Patients were divided into two groups depending on whether (group A) or not (group B) they were on steroids. Overall, a total of 313 (79.6%) subjects achieved cortisol level of ≥420 nmol/L at 30 and 60 min while 19 (4.8%) had late response (ie, insufficient 30 min cortisol levels, rising to ≥420 nmol/L at 60 min). Another 61 subjects (15.5%) showed insufficient response at both 30 and 60 min (ie, failed to achieved level of ≥420 nmol/L). Importantly, there was no patient in either group who had adequate response at 30 min and then failed at 60 min. Patients in group A were more likely to have inadequate response at both 30 and 60 min while patients in group B were more likely to have normal response at both time points.ConclusionsOur results suggest that about 5% of people undergoing SST may be inappropriately diagnosed as having AI (and subjected to long-term unnecessary steroid treatment) if the 60 min sample is not maintained. We suggest that 30 min sample does not add any additional diagnostic utility and can be omitted thus simplifying SST even further and saving on cost and resources. We propose that single measurement after 60 min of administration of synthetic ACTH is a sufficient screening test for AI.

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Section: Introductionmentioning

confidence: 99%

Do we need 30 min cortisol measurement in the short synacthen test: a retrospective study

Kumar

Carr

Moore

et al. 2019

Postgraduate Medical Journal

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“…The short Synacthen (corticotropin) test (SST) was introduced in the 1960s as a means to rapidly assess adrenal function4–6 and has widely been adopted as the first-line assessment of adrenal reserve 7 8. It involves the administration of Synacthen (cosyntropin, ACTH (1-24)), a truncated ACTH peptide that has full biological activity but longer half-life than native ACTH (1-39 4).…”

Section: Introductionmentioning

confidence: 99%

“…Synacthen-stimulated cortisol levels are higher at 60 min versus 30 min; however, it is the 30 min time point that has been validated against the ITT 11 13. Despite this, a recent international survey of endocrinologists reports 46% continue to sample at 0, 30 and 60 min following high-dose (250 µg) Synacthen 7…”

Section: Introductionmentioning

confidence: 99%

“…Traditionally, a peak cortisol concentration after acute stimulation with Synacthen exceeding 500 nmol/L is accepted as evidence for adrenal sufficiency,15 with a sensitivity of 0.92 (95% CI 0.81 to 0.97) 16. However, in clinical practice, there is a significant deviation from this threshold, reflecting the use of locally derived cut-offs, dependent on the assay platform used and the clinical context of the patient 7 17. Recent studies using the newest available assays report a threshold for the normal function of >450 nmol/L17–19; however, the reliability of routine immunoassays is highly variable.…”

Section: Introductionmentioning

confidence: 99%

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Outcomes of the short Synacthen test: what is the role of the 60 min sample in clinical practice?

Dineen

Mohamed

Gunness

et al. 2019

Postgraduate Medical Journal

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In recent years, the short Synacthen test (SS) has become the most widely used test to assess adrenal reserve. Despite its frequent use, there are still several areas related to the short Synacthen test (SST), which have no consensus including the optimum sampling times, that is, whether a 60 min post-Synacthen administration cortisol is necessary or not.MethodologyWe performed a retrospective data analysis of 492 SSTs performed on adult patients in a tertiary referral teaching hospital in Ireland. The SSTs were performed in the inpatient and outpatient setting and included patients across all medical disciplines and not exclusively to the endocrinology department.Results313 patients had 0, 30 and 60 min samples available for analysis. A total of 270/313 (82%) were deemed to pass the test, that is, cortisol ≥500 nmol/L at both 30 and 60 min. Of the 313 patients, 19 (6%) patients had an indeterminate response, cortisol <500 nmol/L at 30 min, but rising to ≥500 nmol/L on the 60 min sample. Of these 19 patients, only 9/19 patients had a serum cortisol level at 30 min <450 nmol/L, requiring clinical treatment with glucocorticoid replacement. All 24/313 (8%) patients who had insufficient responses at 60 min were also insufficient at 30 min sampling. No individuals passed (≥500 nmol/L) at 30 min and then failed (<500 nmol/L) at 60 min.ConclusionUsing the 30 min cortisol sample post-Synacthen administration alone identifies clinically relevant adrenal insufficiency in the majority of cases. A small subset of patients have a suboptimal response at 30 min but have a 60 min cortisol concentration above the threshold for a pass. Data regarding the long-term outcomes and management of such patients are lacking and require further study.

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“…• Worldwide, the Short Synacthen Test (SST) is the most frequently performed diagnostic test for adrenal insufficiency (AI) in children. 1 • Diagnostic cut-offs for peak plasma cortisol may be difficult to determine due to:…”

Section: Introductionmentioning

confidence: 99%

Borderline peak plasma cortisol following Synacthen stimulation - single-centre analysis of three years' data

Burn¹,

Colyer²,

Dimitri³

et al. 2018

EJEA

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International survey on high‐ and low‐dose synacthen test and assessment of accuracy in preparing low‐dose synacthen

Cited by 28 publications

References 26 publications

Do we need 30 min cortisol measurement in the short synacthen test: a retrospective study

Do we need 30 min cortisol measurement in the short synacthen test: a retrospective study

Outcomes of the short Synacthen test: what is the role of the 60 min sample in clinical practice?

Borderline peak plasma cortisol following Synacthen stimulation - single-centre analysis of three years' data

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