Morning cortisol as an alternative to Short Synecthan test for the diagnosis of primary adrenal insufficiency

Ulhaq, Imran; Ahmad, Tauseef; Khoja, Adeel; Islam, Najmul

doi:10.12669/pjms.35.5.1208

Cited by 7 publications

(5 citation statements)

References 11 publications

(10 reference statements)

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“…Despite being the standard of care in developed nations, injection Synacthen (tetracosactide hexa acetate) is not marketed in many developing countries including India, presumably because of its high cost 14 . A recent study has noted that majority (56.2%) of physicians did not use ACTH stimulation test for the diagnosis of AI in Africa especially the sub‐Saharan region due to its nonavailability 15 …”

Section: Introductionmentioning

confidence: 99%

Long‐acting porcine ACTH stimulated salivary cortisol in the diagnosis of adrenal insufficiency

George¹,

Jabbar²,

Chellamma³

et al. 2020

Clinical Endocrinology

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Background: Synacthen stimulated salivary cortisol has been previously evaluated and found beneficial in the diagnosis of adrenal insufficiency (AI), especially in situations with altered cortisol-binding protein (CBG) levels. Unfortunately, Synacthen is not marketed in many parts of the world whereas porcine sequence corticotrophin (Acton Prolongatum) is readily available. This study aimed to find the diagnostic accuracy of Acton prolongatum stimulated salivary cortisol test (APSST) compared to the short synacthen test (SST). Methods: Consecutive outpatients with suspected AI underwent SST initially, followed by APSST after 3 days. For APSST, saliva was collected at 0, 60 and 120 minutes after administering 30 units Acton Prolongatum intramuscularly. Serum and salivary cortisol were estimated using electrochemiluminescence assay. (Cobas e 411, Elecsys Cortisol II kits) Results: Sixty-seven patients with clinically suspected AI were enrolled for the study. Based on SST, 35 patients were classified as having AI [primary AI (n=19) and secondary AI (n=16)] whereas 32 had normal glucocorticoid reserve. The area under receiver operator curve of 0.99 and 0.98 was observed for salivary cortisol values at 60 and 120 minutes, respectively, for APSST. A cutoff value of 18.5 nmol/L (0.67 µg/dL) and 29.3 nmol/L (1.06 µg/dL) at 60 and 120 minutes, respectively, had a sensitivity as well as specificity of 93%-100% in diagnosing AI. Conclusion: Salivary cortisol estimation following stimulation using intramuscular porcine ACTH (Adrenocorticotrophic hormone) (30 units) is an economical and accurate alternative to SST in the diagnosis of AI, m and its level of 30 nmol/L or more at 2 hours confirms adrenal sufficiency.

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Section: Introductionmentioning

confidence: 99%

Long‐acting porcine ACTH stimulated salivary cortisol in the diagnosis of adrenal insufficiency

George¹,

Jabbar²,

Chellamma³

et al. 2020

Clinical Endocrinology

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“…However, those with very subtle findings such as mild hyponatremia, polyuria despite euglycemia, and frequent hypoglycemia, like our patient, may benefit from early screening with 21 hydroxylase antibodies. We hypothesize this test may catch low risk individuals and may be easier for patients to obtain compared to a morning cortisol test which should be done between 07:00 h and 09:00 h. A morning cortisol test has a 71.88% sensitivity when using values less than 5 µg/dL, while testing for 21 hydroxylase antibodies has an 87.0% sensitivity with an index value of <45 as a negative cutoff ( 10 , 11 ). However, more studies need to be done to evaluate its cost effectiveness.…”

Section: Discussionmentioning

confidence: 99%

A patient diagnosed with new-onset type 1 diabetes and Addison’s disease at initial presentation

Towslee,

Macdonald,

Shoar

2024

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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Summary A previously healthy 17-year-old female presented to the emergency department with complaints of vomiting, shortness of breath, and tachycardia. She was found to have an elevated blood glucose and was admitted for presumed new onset type 1 diabetes mellitus (T1DM). During the admission, she was noted to have frequent episodes of hypoglycemia despite conservative insulin dosing and high urine output with glucosuria, which seemed out of proportion to her glucose levels and fluid status. She also had persistent hyponatremia despite normalization of blood glucose. Further work-up was initiated to investigate alternative or additional diagnoses to explain these atypical findings. Adrenocorticotropic hormone (ACTH) level was elevated, consistent with the diagnosis of Addison’s disease, which led to the subsequent diagnosis of autoimmune polyglandular syndrome type II (APS-2). This is one of the first reports in the literature of concurrent diagnosis of T1DM and Addison’s disease at initial presentation and demonstrates the importance of not anchoring to one diagnosis. Learning points This case shows the importance of considering multiple diagnoses and investigating atypical signs and symptoms. This case highlights the importance of a thorough history including review of systems. Hyponatremia and recurrent hypoglycemia in a person with type 1 diabetes should raise suspicion for adrenal insufficiency. This case makes us consider the screening for Addison’s disease in a person with new onset type 1 diabetes in addition to autoimmune thyroid disease and celiac disease. People with an autoimmune disease should be monitored for other autoimmune diseases in the future.

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“…The use of salivary cortisol in the diagnosis of AI has been investigated in a great deal of research. In two independent studies [ 17 , 18 ], it has been shown that morning salivary cortisol is sensitive enough to be an alternative method for the ACTH stimulation test in the diagnosis of AI. The application of salivary cortisol measurement is limited by deficiently standardized assays and the lack of a single, validated reference range, as it was primarily intended for serum cortisol analysis [ 19 ].…”

Section: Discussionmentioning

confidence: 99%

Treatment with Intravenous Methylprednisolone in Patients with Graves’ Orbitopathy Significantly Affects Adrenal Function: Assessment of Serum, Salivary Cortisol and Serum Dehydroepiandrosterone Sulfate

Pelewicz

Szewczyk

Miśkiewicz

2020

JCM

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Treatment of active, moderate-to-severe Graves’ orbitopathy (GO) is the administration of intravenous methylprednisolone (IVMP). IVMP may be followed by additional therapy with oral prednisone. The aim of this study was to analyze the impact of IVMP on adrenal function by evaluation of serum, salivary cortisol and serum dehydroepiandrosterone sulfate (DHEA-S). Fourteen patients received IVMP treatment (cumulative dose of 4.5 g in 12 weekly infusions) followed by oral prednisone (for three months). All patients showed normal adrenal function before the 12th IVMP pulse and one patient was diagnosed with secondary adrenal insufficiency (AI) after prednisone treatment. DHEA-S was significantly lower before the 12th IVMP pulse and after oral prednisone (p = 0.015 and p = 0.00002, respectively) in comparison to evaluation before therapy. DHEA-S levels were below the reference range in one and three patients before the 12th IVMP pulse and after prednisone therapy, respectively. We observed decreased serum (p = 0.05) and salivary (p = 0.011) cortisol levels after oral prednisone therapy in comparison to evaluation before therapy. Treatment with IVMP in a cumulative dose of 4.5 g affects adrenal function, causing more severe impairment of DHEA-S secretion than that of cortisol but does not cause secondary AI. Additional therapy with oral glucocorticoids after IVMP can cause secondary AI.

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Morning cortisol as an alternative to Short Synecthan test for the diagnosis of primary adrenal insufficiency

Cited by 7 publications

References 11 publications

Long‐acting porcine ACTH stimulated salivary cortisol in the diagnosis of adrenal insufficiency

Long‐acting porcine ACTH stimulated salivary cortisol in the diagnosis of adrenal insufficiency

A patient diagnosed with new-onset type 1 diabetes and Addison’s disease at initial presentation

Treatment with Intravenous Methylprednisolone in Patients with Graves’ Orbitopathy Significantly Affects Adrenal Function: Assessment of Serum, Salivary Cortisol and Serum Dehydroepiandrosterone Sulfate

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