Value of Basal Plasma Cortisol Assays in the Assessment of Pituitary‐adrenal Insufficiency

Hägg, Erik; Asplund, Kjell; Lithner, Folke

doi:10.1111/j.1365-2265.1987.tb00780.x

Cited by 215 publications

(155 citation statements)

References 9 publications

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“…According to the results of the preoperative ITTs which were performed on 55 patients in this study, we found that patients with basal serum cortisol levels between 165 and 496 nmol/l (6-18 mg/dl) required dynamic testing. The majority of previous studies determined the lower cut-off for basal cortisol as 100-110 nmol/l (3.6-4 mg/dl), but the upper cut-off was found to range between 300 and 494 nmol/l (10.8-17.9 mg/dl) (15)(16)(17)(18). In a metaanalysis of 12 studies, basal cortisol levels !5 mg/dl (138 nmol/l) were found to predict HPA insufficiency best, and values O13 mg/dl (365 nmol/l) predicted normal HPA function (19).…”

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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“…Generally, a random serum cortisol of over 400 nmol/L at any time of the day makes adrenal insufficiency highly unlikely, 8 while a morning serum cortisol of less than 100 nmol/L strongly suggests adrenal failure. 13 In interpreting such results, one must consider the patient's current and prior steroid usage, as well as conditions affecting cortisol binding globulin, such as pregnancy or oral estrogen therapy, which can result in falsely reassuring cortisol concentrations.…”

Section: Investigating Adrenal Insufficiencymentioning

confidence: 99%

Adrenal insufficiency – recognition and management

Pazderska

Pearce

2017

Clinical Medicine

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Adrenal insuffi ciency is characterised by inadequate glucocorticoid production owing to destruction of the adrenal cortex or lack of adrenocorticotropic hormone stimulation. In primary adrenal insuffi ciency, lack of mineralocorticoids is also a feature. Patients can present with an insidious onset of symptoms, or acutely in adrenal crisis, which requires prompt recognition and treatment. Chronic glucocorticoid therapy is the most common cause of adrenal insuffi ciency. The diagnosis of adrenal insuffi ciency is made by demonstrating low basal and/or stimulated serum cortisol and should be followed by appropriate investigations to establish the underlying aetiology. Maintenance glucocorticoid replacement is usually given as a twice or thrice daily hydrocortisone preparation. Patients with primary adrenal insuffi ciency also require mineralocorticoid. Regular monitoring for features of underand over-replacement is essential during follow-up. Patient education is a key feature of management of this condition. IntroductionThe adrenal cortex secretes the essential steroid hormones, cortisol and aldosterone, under the control of pituitary adrenocorticotropic hormone (ACTH), angiotensin II and plasma potassium. The most frequent cause of adrenal insufficiency is exogenous steroid use. Up to 2.5% of the population are taking such steroid medications for inflammatory or immune-mediated conditions. 1 These individuals are vulnerable to steroid deficiency if the medication is stopped suddenly. ACTH deficiency (secondary adrenal insufficiency) as a result of pituitary tumours, infiltrative diseases, head injury or congenital hypopituitarism is the next most frequent cause, present in around 1 per 3,000 individuals. 2High dose opiates, which frequently induce hypogonadotropic hypogonadism, are also increasingly recognised as a cause of hypothalamic-pituitary-adrenal (HPA) suppression.3 By comparison, primary adrenal insufficiency is rare, with a prevalence of 1 in 8,000 people. 4 In developed nations, an autoimmune attack directed against the adrenal steroidogenic enzymes (predominantly 21-hydroxylase) 5 accounts for about 85% of cases. Around 60% of patients with autoimmune ABSTRACT Adrenal insuffi ciency -recognition and managementAddison's disease have an additional autoimmune condition, most frequently autoimmune thyroid disease or type 1 diabetes.

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“…The magnitude of the stress response to major surgery in 20 adult subjects was established by Plumpton & Besser (1), who equated it to a peak cortisol response to the ITT of 550 nmol/l (20 mg/dl). More recently, this value has been revised downwards to 500 nmol/l (18 mg/dl) (9) and has been validated in healthy adults (10), correcting for the 20-30% positive bias associated with the older fluorometric assay (1). Extrapolation from adult data has resulted in many paediatric centres employing a reference range for peak cortisol responses to insulin-induced hypoglycaemia between 500 and 550 nmol/l for all children and adolescents regardless of age (1,2,10).…”

Section: Introductionmentioning

confidence: 99%

Requirement for age-specific peak cortisol responses to insulin-induced hypoglycaemia in children

O’Grady

Hensey

Fallon

et al. 2013

European Journal of Endocrinology

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Objective: Based on adult data, a peak cortisol response R500 nmol/l to insulin-induced hypoglycaemia constitutes a normal. Age-specific reference ranges for basal morning cortisol have been developed for clinical use in the paediatric population. Such reference ranges are not clearly established for peak cortisol responses to insulin-induced hypoglycaemia despite limited data suggesting an effect of age on peak cortisol. The aims of this study were to assess factors affecting the cortisol response to insulin-induced hypoglycaemia in children and to determine whether the peak cortisol response was related to age. Design: The present study was a retrospective cohort study. Methods: Retrospective analysis of children and adolescents aged %18 years undergoing the insulin tolerance test with adequate hypoglycaemia was undertaken. Patients with hypopituitarism or severe hypothalamic-pituitary-adrenal axis impairment (peak cortisol value !400 nmol/l) or using systemic glucocorticoids were excluded. Results: Two hundred and twenty-three tests were analysed. Peak cortisol responses R500 nmol/l occurred in 183 (82%) tests. Age was negatively associated with peak cortisol responses (rZK0.15, PZ0.03). A peak cortisol response !500 nmol/l was significantly less common in patients aged !12 years (9/97 (9%) vs 31/126 (25%); PZ0.004). In children aged !12 years, the median (5th-95th centiles) peak cortisol values were 610 (480-806) nmol/l compared with 574 (442-789) nmol/l in children aged R12 years (P!0.004). Similarly, median cortisol increment was significantly higher in younger patients (301 nmol/l compared with 226 nmol/l (PZ0.0004)). Conclusions: Use of a single peak cortisol threshold in children of all ages is not appropriate and will result in overdiagnosis of adrenal insufficiency in adolescents.

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Value of Basal Plasma Cortisol Assays in the Assessment of Pituitary‐adrenal Insufficiency

Cited by 215 publications

References 9 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?

Adrenal insufficiency – recognition and management

Requirement for age-specific peak cortisol responses to insulin-induced hypoglycaemia in children

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