Morning serum cortisol is superior to salivary cortisone and cortisol in predicting normal adrenal function in suspected adrenal insufficiency

2020 ◽  
Author(s):  
Tejas Kalaria ◽  
Harit Buch ◽  
Mayuri Agarwal ◽  
Rahul Chaudhari ◽  
Carolina Gherman‐Ciolac ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Serum Cortisol ◽  
Adrenal Function ◽  
Morning Serum Cortisol

scholarly journals Steroid-Induced Iatrogenic Adrenal Insufficiency in Children: A Literature Review

Endocrines ◽  
2020 ◽  
Vol 1 (2) ◽  
pp. 125-137
Author(s):  
Shogo Akahoshi ◽  
Yukihiro Hasegawa
Keyword(s):  
Adrenal Insufficiency ◽  
Serum Cortisol ◽  
Early Morning ◽  
Serum Cortisol Level ◽  
Adrenal Crisis ◽  
Acth Stimulation ◽  
Morning Serum Cortisol ◽  
High Doses ◽  
Loss Of Appetite ◽  
Cortisol Suppression

The present review focuses on steroid-induced adrenal insufficiency (SIAI) in children and discusses the latest findings by surveying recent studies. SIAI is a condition involving adrenocorticotropic hormone (ACTH) and cortisol suppression due to high doses or prolonged administration of glucocorticoids. While its chronic symptoms, such as fatigue and loss of appetite, are nonspecific, exposure to physical stressors, such as infection and surgery, increases the risk of adrenal crisis development accompanied by hypoglycemia, hypotension, or shock. The low-dose ACTH stimulation test is generally used for diagnosis, and the early morning serum cortisol level has also been shown to be useful in screening for the condition. Medical management includes gradually reducing the amount of steroid treatment, continuing administration of hydrocortisone corresponding to the physiological range, and increasing the dosage when physical stressors are present.

scholarly journals Neuroendocrine dysfunctions and their consequences following traumatic brain injury

2012 ◽  
Vol 153 (24) ◽  
pp. 927-933 ◽  
Author(s):  
Sándor Czirják ◽  
Károly Rácz ◽  
Miklós Góth
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Adrenal Insufficiency ◽  
Serum Cortisol ◽  
Ice Hockey ◽  
Hormone Deficiency ◽  
Public Health Importance ◽  
Morning Serum Cortisol ◽  
Life Threatening ◽  
One Year

Posttraumatic hypopituitarism is of major public health importance because it is more prevalent than previously thought. The prevalence of hypopituitarism in children with traumatic brain injury is unknown. Most cases of posttraumatic hypopituitarism remain undiagnosed and untreated in the clinical practice, and it may contribute to the severe morbidity seen in patients with traumatic brain injury. In the acute phase of brain injury, the diagnosis of adrenal insufficiency should not be missed. Determination of morning serum cortisol concentration is mandatory, because adrenal insufficiency can be life threatening. Morning serum cortisol lower than 200 nmol/L strongly suggests adrenal insufficiency. A complete hormonal investigation should be performed after one year of the trauma. Isolated growth hormone deficiency is the most common deficiency after traumatic brain injury. Sports-related chronic repetitive head trauma (because of boxing, kickboxing, football and ice hockey) may also result in hypopituitarism. Close co-operation between neurosurgeons, endocrinologists, rehabilitation physicians and representatives of other disciplines is important to provide better care for these patients. Orv. Hetil., 2012, 153, 927–933.

MORNING SERUM CORTISOL LEVEL PREDICTS CENTRAL ADRENAL INSUFFICIENCY DIAGNOSED BY INSULIN TOLERANCE TEST

2021 ◽  
Author(s):  
Valentina Gasco ◽  
Chiara Bima ◽  
Alice Geranzani ◽  
Jacopo Giannelli ◽  
Lorenzo Marinelli ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Serum Cortisol ◽  
Tolerance Test ◽  
Insulin Tolerance Test ◽  
Cortisol Concentration ◽  
Serum Cortisol Level ◽  
Cortisol Response ◽  
Insulin Tolerance ◽  
Morning Serum Cortisol ◽  
Serum Cortisol Concentration

Introduction According to guidelines, a morning serum cortisol level <83 nmol/L is diagnostic for central adrenal insufficiency (CAI), a value >414 nmol/L excludes CAI, while values between 83 and 414 nmol/L require stimulation tests. However, there are no currently reliable data on morning serum cortisol for prediction of cortisol response to insulin tolerance test (ITT). Objective Using the receiver operating characteristic curve analysis, the purpose of this study was to detect the morning serum cortisol cut-off with a specificity (SP) or a sensitivity (SE) above 95% that identify those patients who should not be tested with ITT. Methods We included 141 adult patients (83 males) aged 42.7+/-12.3 (mean +/- SD) years old. Based on serum cortisol response to ITT, patients have been divided in two groups: subjects with CAI (peak serum cortisol <500 nmol/L; 65 patients) and subjects with preserved adrenocortical function (peak cortisol >500 nmol/L; 76 patients). Results The best morning cortisol cut-off, in terms of SE (87.7%) and SP (46.1%), was ≤323.3 nmol/L. The cut-off of morning serum cortisol concentration that best predicted a deficient response to ITT was ≤126.4 nmol/L (SE 13.8%, SP 98.7%). The cut-off of morning serum cortisol concentration that best predicted a normal response to ITT was >444.7 nmol/L (SE 96.9%, SP 14.5%). Conclusions This is the first study that identifies a morning serum cortisol cut-off that best predict the response to ITT in order to simplify the diagnostic process in patients with suspected CAI. A new diagnostic flow chart for CAI is proposed.

scholarly journals Morning Serum Cortisol May Be Less Accurate for Diagnosing Adrenal Insufficiency in Hospitalized Patients, Particularly Those on Opioids

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A89-A90
Author(s):  
Caitlin Ann Colling ◽  
Lisa B Nachtigall ◽  
Beverly M K Biller ◽  
Karen Klahr Miller
Keyword(s):  
Positive Predictive Value ◽  
Adrenal Insufficiency ◽  
Predictive Value ◽  
Serum Cortisol ◽  
Hospitalized Patients ◽  
Opioid Use ◽  
Morning Cortisol ◽  
Morning Serum Cortisol ◽  
Cortisol Levels ◽  
The Impact

Abstract Introduction: The positive predictive value of a low morning serum cortisol to diagnose adrenal insufficiency (AI) is reported to be &gt;90%, which is the basis for guidelines recommending morning cortisol as the first-line test for central AI. A level &lt;3 µg/dL is considered diagnostic. However, studies that established this cut-off were conducted primarily in outpatients, not hospitalized patients in whom diurnal variation may be disrupted. Studies suggest that opioids suppress cortisol levels acutely, may disrupt diurnal cortisol rhythm, and cause adrenal insufficiency in 8–50% of chronically-exposed patients. The impact of hospitalization, particularly in the setting of opioid use, on the accuracy of diagnostics for AI is unknown. We hypothesized that low morning cortisol values in hospitalized patients, especially those prescribed opioids, do not accurately diagnose adrenal insufficiency, as determined by corticotropin stimulation test (CST) peak cortisol &lt;18 µg/dL. Methods: We performed a retrospective analysis of CSTs in hospitalized patients in the Mass General Brigham health system from 5/2015 to 9/2020. Opioid-exposed adults who underwent CST were included if they had a morning cortisol (5–9 AM) result. Control patients were matched by age, gender and race and had no opioid prescriptions within 30 days of testing. Patients were excluded if tested in the outpatient or ICU setting, had a history of cirrhosis or pituitary disease, had an elevated ACTH, were prescribed oral estrogen, or received oral, IV or intraarticular glucocorticoids within 30 days. Results: The analysis included 124 opioid-exposed and 322 control patients, mean (±SD) age 60.8±14.4 and 63.8±15.3y, and 55.6% and 45.0% female, respectively. Twenty-two (17.7%) opioid-exposed and 33 (10.2%) control patients were diagnosed with AI by CST (p=0.031). Nineteen opioid-exposed (15.3%) and 22 control (6.8%) patients had morning cortisol of &lt;3 µg/dL (p=0.005). A morning cortisol &lt;3 µg/dL had a positive predictive value of 36.8% (CI 19.1–59.0%) for AI in opioid-exposed and 50.0% (CI 30.7–69.3%) in control patients. In opioid-exposed patients with low morning cortisol levels, mean daily morphine milligram equivalent and duration of opioid exposure did not differ between those with AI confirmed by CST and those with normal CST (p=0.13 and 0.38, respectively). Conclusion: Among hospitalized patients with suspected AI, those prescribed opioids have a higher prevalence of central AI than controls. Serum morning cortisol &lt;3 µg/dL is not an accurate test for AI in hospitalized patients, including those prescribed opioids in whom low morning cortisol is more prevalent than in controls. Given the risks associated with misdiagnosis of AI, caution should be exercised in relying on morning cortisol values for the diagnosis of AI in hospitalized patients.

scholarly journals IATROGENIC CUSHING SYNDROME IN AN HIV-INFECTED PATIENT SECONDARY TO CONCOMITANT THERAPY WITH GENVOYA AND EPIDURAL TRIAMCINOLONE

2020 ◽  
Vol 6 (5) ◽  
pp. e217-e220
Author(s):  
Priyanka M. Mathias ◽  
Eric J. Epstein
Keyword(s):  
Drug Interaction ◽  
Adrenal Insufficiency ◽  
Chronic Back Pain ◽  
Cushing Syndrome ◽  
Serum Cortisol ◽  
Adverse Outcomes ◽  
Adrenal Crisis ◽  
Secondary Adrenal Insufficiency ◽  
Long Term Outcome ◽  
Morning Serum Cortisol

Objective: We report the first known case of Cushing syndrome and secondary adrenal insufficiency in a patient with concomitant use of epidural triamcinolone and Genvoya® (elvitegravir 150 mg/cobicistat 150 mg/emtricitabine 200 mg/tenofovir alafenamide 10 mg) for the human immunodeficiency viruses (HIV). The prompt recognition of this drug-drug interaction is critical to avoid adverse outcomes when glucocorticoids are used with anti-retroviral treatment containing cobicistat, a potent cytochrome P450 3A (CYP3A4) inhibitor. Methods: The patient was evaluated by determining morning serum cortisol concentrations, the serum cortisol response to cosyntropin, and a urine synthetic glucocorticoid panel that is capable of measuring triamcinolone. We also employed the Naranjo Nomogram for Causality as well as a Drug Interaction Probability scale to assess medication-related adverse effects. Long term outcome was assessed by measuring morning serum cortisol and adrenocorticotropic hormone levels. Results: A 76-year-old female with HIV on Genvoya® presented with fatigue, weight loss, and hyperglycemia. She had received multiple epidural triamcinolone injections for chronic back pain before her presentation. We hypothesized that the patient’s presentation of Cushing syndrome and adrenal insufficiency was caused by the inhibition of triamcinolone metabolism by cobicistat. The patient’s antiretroviral therapy was changed to a regimen without cobicistat. She was started on maintenance hydrocortisone to prevent an adrenal crisis. A repeat urine glucocorticoid panel, within 3 days of the patient’s HIV regimen being changed, showed a significant decrease in triamcinolone levels. Conclusion: It is essential to avoid drugs that include cobicistat when administering glucocorticoids that are metabolized via the CYP3A4 pathway due to the risk of developing Cushing syndrome and secondary adrenal insufficiency.

scholarly journals Functional Adrenal Insufficiency among Tuberculosis-Human Immunodeficiency Virus co-infected patients: A Cross-section study in Uganda

2019 ◽  
Author(s):  
Agnes Bwanika Bwanika Naggirinya ◽  
Irene Andia Biraro ◽  
David B. Meya ◽  
Ezekiel Mupere ◽  
Andrew Mujugira ◽  
...  
Keyword(s):  
Human Immunodeficiency Virus ◽  
Adrenal Insufficiency ◽  
Serum Cortisol ◽  
Early Morning ◽  
Drug Resistant ◽  
Drug Resistant Tuberculosis ◽  
Resistant Tuberculosis ◽  
Multi Drug Resistant Tuberculosis ◽  
Immunodeficiency Virus ◽  
Morning Serum Cortisol

Abstract Objective:Tuberculosis is the leading cause of adrenal insufficiency in resource-limited settings. The adrenal gland is the most commonly affected endocrine organ in tuberculosis infection. We assessed prevalence and factors associated with functional adrenal insufficiency among human immunodeficiency virus infected patients with multidrug-resistant and drug-susceptible tuberculosis in Uganda. Patients with drug-sensitive and resistant tuberculosis were enrolled, examined for clinical signs and symptoms of adrenal insufficiency, an early morning serum cortisol level obtained. Functional adrenal insufficiency was defined as early morning serum cortisol below 414/nmol//L. Associations with functional adrenal insufficiency were estimated using multivariable logistic regression.ResultsA total of 311 tuberculosis patients were screened, and 272 enrolled. Of these, 117 (43%) had multi-drug resistant tuberculosis. Median age was 32 years (IQR 18-66) and 66% were men. Prevalence of functional adrenal insufficiency was 59.8%. Mean cortisol levels were lower in participants with multi-drug resistant than drug-susceptible tuberculosis (317.4 versus 488.5 nmol/L; p<0.001). In multivariable analysis, multi-drug resistant tuberculosis (aOR 36.60; 95% CI 8.30-161.42; p<0.001) and skin hyperpigmentation (aOR 9.63; 95% CI: 2.83-32.8; p<0.001) were significantly associated with functional adrenal insufficiency. Early morning serum cortisol levels should be quantified in TB-HIV co-infected patients.

scholarly journals Functional Adrenal Insufficiency among Tuberculosis-Human Immunodeficiency Virus co-infected patients: A Cross-section study in Uganda

2020 ◽  
Author(s):  
Agnes Bwanika Bwanika Naggirinya ◽  
Andrew Mujugira ◽  
David B. Meya ◽  
Irene Andia Biraro ◽  
Ezekiel Mupere ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Serum Cortisol ◽  
Early Morning ◽  
Serum Cortisol Level ◽  
Drug Resistant ◽  
Morning Serum Cortisol ◽  
Cortisol Levels ◽  
Clinical Signs And Symptoms

Abstract Objective: Tuberculosis (TB) is the leading cause of adrenal insufficiency in resource-limited settings. The adrenal gland is the most commonly affected endocrine organ in TB infection. We assessed factors associated with functional adrenal insufficiency (FAI) among TB-HIV patients with and without drug-resistance in Uganda. Patients with drug-sensitive and drug-resistant TB were enrolled and examined for clinical signs and symptoms of FAI with an early morning serum cortisol level obtained. FAI was defined as early morning serum cortisol <414 nmol//L. Associations with FAI were modeled using multivariable logistic regression.Results: We screened 311 TB patients and enrolled 272. Of these, 117 (43%) had drug-resistant TB. Median age was 32 years (IQR 18-66) and 66% were men. The proportion with FAI was 59.8%. Mean cortisol levels were lower in participants with drug-resistant than susceptible TB (317.4 versus 488.5 nmol/L; p<0.001). In multivariable analyses, drug-resistant TB (aOR 4.61; 95% CI: 2.3-9.1; p<0.001), treatment duration > 1 month (aOR 2.86; 95% CI: 1.4-5.5; p=0.002) and abdominal pain (aOR 2.06; 95% CI: 1.04-4.09; p=0.038) were significantly associated with FAI. Early morning serum cortisol levels should be quantified in TB-HIV co-infected patients with drug-resistant TB.

SERUM MORNING CORTISOL AS A SCREENING TEST FOR ADRENAL INSUFFICIENCY

2020 ◽  
Vol 26 (1) ◽  
pp. 30-35 ◽  
Author(s):  
Juan Montes-Villarreal ◽  
Luis Alberto Perez-Arredondo ◽  
Rene Rodriguez-Gutierrez ◽  
Alejandro Diaz Gonzalez-Colmenero ◽  
Ricardo Cesar Solis ◽  
...  
Keyword(s):  
Confidence Interval ◽  
Adrenal Insufficiency ◽  
Area Under The Curve ◽  
Test Group ◽  
Serum Cortisol ◽  
Stimulation Test ◽  
Cortisol Response ◽  
Acth Stimulation ◽  
Morning Serum Cortisol ◽  
Stimulation Tests

Objective: To evaluate the performance of morning serum cortisol (MSC) compared to a 10 mg adrenocortico-tropic hormone (ACTH) stimulation test in the diagnosis of adrenal insufficiency (AI). Methods: A retrospective, cross-sectional analysis of ACTH stimulation tests were conducted. From a total of 312 potentially eligible ACTH stimulation tests, 306 met the inclusion criteria. The population was randomized into 2 groups: test (n = 159) and validation (n = 147). In the test group, the receiver operating characteristics curve test evaluated the diagnostic performance of MSC. Results: A subnormal cortisol response to ACTH was found in 25.8% of the test group. The area under the curve values of MSC to predict AI at +30 minutes, +60 minutes, or at maximal cortisol response were 0.874, 0.897, and 0.925 (95% confidence interval [CI] 0.81 to 0.92, 0.83 to 0.93, and 0.87 to 0.96). The Youden index was 234.2 mmol/L with a sensitivity of 83.3% (95% CI 65.2 to 94.3%), and a specificity of 89.1% (95% CI 82.4 to 93.9%). Positive and negative predictive values were 64.1% (95% CI 47.1 to 78.8%) and 95.8% (95% CI 90.5 to 98.6%). There was no difference in age, gender, AI prevalence, or mean serum cortisol at +30 or +60 minutes in the validation group; however, a lower mean MSC value was found. Lower sensitivity and specificity values (88.3% and 60%, respectively) were found for the 234.2 mmol/L cutoff value. Conclusion: This study supports the role of MSC as a first-step diagnostic test in patients with clinically suspected AI. The short stimulation test could be omitted in almost half of the cases. Prospective and longitudinal studies to reproduce and confirm the cutoff values proposed are warranted. Abbreviations: ACTH = adrenocorticotropic hormone; AI = adrenal insufficiency; AUC = area under the curve; CI = confidence interval; HPA = hypothalamic pituitary adrenal; ITT = insulin tolerance test; MSC = morning serum cortisol

scholarly journals Functional Adrenal Insufficiency among Tuberculosis-Human Immunodeficiency Virus co-infected patients: A Cross-section study in Uganda

2020 ◽  
Author(s):  
Agnes Bwanika Bwanika Naggirinya ◽  
Andrew Mujugira ◽  
David B. Meya ◽  
Irene Andia Biraro ◽  
Ezekiel Mupere ◽  
...  
Keyword(s):  
Human Immunodeficiency Virus ◽  
Adrenal Insufficiency ◽  
Multivariable Analysis ◽  
Serum Cortisol ◽  
Early Morning ◽  
Serum Cortisol Level ◽  
Drug Resistant ◽  
Immunodeficiency Virus ◽  
Morning Serum Cortisol ◽  
Cortisol Levels

Abstract Objective Tuberculosis (TB) is the leading cause of adrenal insufficiency in resource-limited settings. The adrenal gland is the most commonly affected endocrine organ in TB infection. We assessed prevalence and factors associated with functional adrenal insufficiency (FAI) among human immunodeficiency virus (HIV)-infected patients with drug-resistant and drug-susceptible TB in Uganda. Patients with drug-sensitive and -resistant TB were enrolled, examined for clinical signs and symptoms of FAI with an early morning serum cortisol level obtained. FAI was defined as early morning serum cortisol <414 nmol//L. Associations with FAI were modeled using multivariable logistic regression. Results : A total of 311 TB patients were screened, and 272 enrolled. Of these, 117 (43%) had drug-resistant TB. Median age was 32 years (IQR 18-66) and 66% were men. Prevalence of FAI was 59.8%. Mean cortisol levels were lower in participants with drug-resistant than susceptible TB (317.4 versus 488.5 nmol/L; p<0.001 ) . In multivariable analysis, drug-resistant TB (aOR 4.61; 95% CI: 2.3-9.1; p < 0.001), treatment duration > 1month (aOR 2.86 95% CI: 1.4- 5.5; p=0.002) and abdominal pain (aOR 2.06; 95% CI: 1.04-4.09; p=0.038) were significantly associated with FAI. Early morning serum cortisol levels should be quantified in TB-HIV co-infected patients.

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