scholarly journals Mifepristone Accelerates HPA Axis Recovery in Secondary Adrenal Insufficiency

2016 ◽  
Vol 2016 ◽  
pp. 1-4 ◽  
Author(s):  
Pejman Cohan
Keyword(s):  
Adrenal Insufficiency ◽  
Hpa Axis ◽  
Adrenal Adenoma ◽  
Serum Cortisol ◽  
Pharmacological Therapy ◽  
Secondary Adrenal Insufficiency ◽  
Unilateral Adrenalectomy ◽  
Undetectable Serum ◽  
Biochemical Testing ◽  
Acth Secreting

Context. Transient secondary adrenal insufficiency (SAI) is an expected complication following successful adenomectomy of ACTH-secreting pituitary adenomas or unilateral adrenalectomy for cortisol-secreting adrenal adenomas. To date, no pharmacological therapy has been shown to hasten recovery of the hypothalamic-pituitary-adrenal (HPA) axis in this clinical scenario.Case Description. A 33-year-old woman underwent uncomplicated unilateral adrenalectomy for a 3.7 cm cortisol-secreting adrenal adenoma. Postoperatively, she developed SAI and was placed on hydrocortisone 15 mg/day, given in divided doses. In the ensuing six years, the patient’s HPA axis failed to recover and she remained corticosteroid-dependent. Quarterly biochemical testing (after withholding hydrocortisone for 18 hours) consistently yielded undetectable serum cortisol and subnormal plasma ACTH levels. While she was on hydrocortisone 15 mg/day, mifepristone was initiated and gradually titrated to a maintenance dose of 600 mg/day after 5 months. Rapid recovery of the HPA axis was subsequently noted with ACTH rising into the supranormal range at 4 months followed by a subsequent rise in cortisol levels into the normal range. After 6 months, the dose of hydrocortisone and mifepristone was lowered and both were ultimately stopped after 8 months. The HPA axis remains normal after an additional 16 months of follow-up.Conclusion. Mifepristone successfully restored the HPA axis in a woman with prolonged secondary adrenal insufficiency (SAI) after adrenalectomy for Cushing’s syndrome (CS).

scholarly journals Recovery of the Hypothalamo-Pituitary-Adrenal Axis After Transsphenoidal Adenomectomy for Non–ACTH-Secreting Macroadenomas

2019 ◽  
Vol 104 (11) ◽  
pp. 5316-5324 ◽  
Author(s):  
Riccardo Pofi ◽  
Sonali Gunatilake ◽  
Victoria Macgregor ◽  
Brian Shine ◽  
Robin Joseph ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Hpa Axis ◽  
Secondary Adrenal Insufficiency ◽  
Baseline Cortisol ◽  
Transsphenoidal Adenomectomy ◽  
Synacthen Test ◽  
Acth Secreting ◽  
Short Synacthen Test ◽  
Pituitary Adrenal Axis ◽  
Hpa Function

Abstract Context Secondary adrenal insufficiency is a potential complication of transsphenoidal adenomectomy (TSA). Most centers test recovery of the hypothalamo-pituitary-adrenal (HPA) axis after TSA, but, to our knowledge, there are no data predicting likelihood of recovery or the frequency of later recovery of HPA function. Objective To assess timing and predictors of HPA axis recovery after TSA. Design Single-center, retrospective analysis of consecutive pituitary surgeries performed between February 2015 and September 2018. Patients Patients (N = 109) with short Synacthen test (SST) data before and at sequential time points after TSA. Main outcome measures Recovery of HPA axis function at 6 weeks, and 3, 6, and 9 to12 months after TSA. Results Preoperative SST indicated adrenal insufficiency in 21.1% Among these patients, 34.8% recovered by 6 weeks after TSA. Among the 65.2% (n = 15) remaining, 13.3% and 20% recovered at 3 months and 9 to 12 months, respectively. Of the 29% of patients with adrenal insufficiency at the 6-week SST, 16%, 12%, and 6% subsequently recovered at 3, 6, and 9 to 12 months, respectively. Preoperative SST 30-minute cortisol, postoperative day 8 cortisol, and 6-week postoperative SST baseline cortisol levels above or below 430 nmol/L [15.5 μg/dL; AUC ROC, 0.86]; 160 nmol/L (5.8 μg/dL; AUC ROC, 0.75); and 180 nmol/L (6.5 μg/dL; AUC ROC, 0.88), were identified as cutoffs for predicting 6-week HPA recovery. No patients with all three cutoffs below the threshold recovered within 12 months after TSA, whereas 92% with all cutoffs above the threshold recovered HPA function within 6 weeks (OR, 12.200; 95% CI, 5.268 to 28.255). Conclusion HPA axis recovery can occur as late as 9 to 12 months after TSA, demonstrating the need for periodic reassessment of patients who initially have SST-determined adrenal insufficiency after TSA. Pre- and postoperative SST values can guide which patients are likely to recover function and potentially avoid unnecessary lifelong glucocorticoid replacement.

National German Audit of Diagnosis, Treatment, and Teaching in Secondary Adrenal Insufficiency

2017 ◽  
Vol 49 (08) ◽  
pp. 580-588 ◽  
Author(s):  
Stephan Petersenn ◽  
Jürgen Honegger ◽  
Marcus Quinkler
Keyword(s):  
Clinical Practice ◽  
Adrenal Insufficiency ◽  
Replacement Therapy ◽  
Diagnostic Testing ◽  
Treatment Strategies ◽  
Serum Cortisol ◽  
National Audit ◽  
Secondary Adrenal Insufficiency ◽  
Endocrine Society ◽  
Great Heterogeneity

AbstractGreat heterogeneity seems to exist regarding diagnosis, therapy, and teaching of patients with secondary adrenal insufficiency (SAI) across Germany resulting in different diagnosis and treatment strategies. The aim of the work was to present the first national audit on diagnosis, treatment, and patient teaching of SAI reflecting common clinical practice in Germany. A self-designed questionnaire was sent via e-mail to all members of the German Endocrine Society (approx. 120 centers). Returned questionnaires (response rate 38.3%) were checked for duplicity of institutions and analyzed. Diagnostic testing focuses on those patients with relevant risk for adrenal insufficiency. Basal serum cortisol is mostly used as screening test. Short synacthen and CRH tests are the preferred confirmatory tests, however, cut-off values vary due to different assays used. Patients with radiation, second surgery, progressive disease or new symptoms are followed by serial re-testing. Perioperative management and frequency of postoperative re-evaluations differ among centers. Hydrocortisone is the preferred glucocorticoid for replacement therapy, but daily doses vary considerably (10–30 mg/day). Some centers perform hormone measurements for dose adjustment of glucocorticoid replacement therapy whereas others rely on clinical judgement. Patients’ teaching is done in 84% of centers, but only half of the centers include patients’ relatives. Homogeneity exists in patients’ teaching regarding intercurrent illnesses (fever, diarrhoea). Recommendations regarding dose adaptations in situations such as sport-activities, dental-procedures, or coughing are highly variable. This first national audit reveals great heterogeneity among German centers and could improve patients’ care in SAI, for example, by initiating new trials and developing clinical practice guidelines.

scholarly journals Post-surgical hypocortisolism after removal of an adrenal incidentaloma: is it predictable by an accurate endocrinological work-up before surgery?

2010 ◽  
Vol 162 (1) ◽  
pp. 91-99 ◽  
Author(s):  
Cristina Eller-Vainicher ◽  
Valentina Morelli ◽  
Antonio Stefano Salcuni ◽  
Massimo Torlontano ◽  
Francesca Coletti ◽  
...  
Keyword(s):  
Hpa Axis ◽  
Adrenal Incidentaloma ◽  
Serum Cortisol ◽  
Urinary Free Cortisol ◽  
Tolerance Test ◽  
Surgical Removal ◽  
Acth Stimulation ◽  
Unilateral Adrenalectomy ◽  
Free Cortisol ◽  
Few Data

ObjectiveFew data are available regarding the need of steroid substitutive therapy after unilateral adrenalectomy for adrenal incidentaloma (AI). It is unknown whether, before surgery, the hypothalamic–pituitary–adrenal (HPA) axis secretion parameters can predict post-surgical hypocortisolism.AimThis study aimed to evaluate whether, in AI patients undergoing unilateral adrenalectomy, post-surgical hypocortisolism could be predicted by the parameters of HPA axis function.DesignProspective, multicenter.MethodsA total of 60 patients underwent surgical removal of AI (surgical indication: 29 subclinical hypercortisolism (SH); 31 AI dimension). Before surgery, SH was diagnosed in patients presenting at least three criteria out of urinary free cortisol (UFC) levels>60 μg/24 h, cortisol after 1-mg dexamethasone suppression test (1 mg-DST)>3.0 μg/dl, ACTH levels<10 pg/ml, midnight serum cortisol (MSC)>5.4 μg/dl.Two months after surgery, HPA axis function was assessed by low dose ACTH stimulation test or insulin tolerance test when needed: 39 patients were affected (Group B) and 21 were not affected (Group A) with hypocortisolism. The accuracy in predicting hypocortisolism of pre-surgical HPA axis parameters or their combinations was evaluated.ResultsThe presence of >2 alterations among 1 mg-DST>5.0 μg/dl, ACTH<10 pg/ml, elevated UFC and MSC has the highest odds ratio (OR) for predicting post-surgical hypocortisolism (OR 10.45, 95% confidence interval, CI 2.54–42.95, P=0.001). Post-surgical hypocortisolism was predicted with 100% probability by elevated UFC plus MSC levels, but not ruled out even in the presence of the normality of all HPA axis parameters.ConclusionPost-surgical hypocortisolism cannot be pre-surgically ruled out. A steroid substitutive therapy is indicated after unilateral adrenalectomy for SH or size of the adenoma.

scholarly journals P.089 Recovery from chronic secondary adrenal insufficiency in patients with pituitary disorders

2016 ◽  
Vol 43 (S2) ◽  
pp. S41-S41
Author(s):  
V Munro ◽  
B Tugwell ◽  
S Doucette ◽  
DB Clarke ◽  
A Lacroix ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Tumour Size ◽  
Pituitary Surgery ◽  
Complete Recovery ◽  
Glucocorticoid Therapy ◽  
Hormone Deficiency ◽  
Secondary Adrenal Insufficiency ◽  
Glucocorticoid Treatment ◽  
Acth Secreting

Background: Patients with pituitary disorders may be placed on steroid replacement for secondary adrenal insufficiency (SAI), generally after pituitary surgery; however, data regarding recovery of long-term SAI are lacking. We conducted a study to assess the longer term recovery rate of SAI in patients with pituitary disorders. Methods: We identified all SAI patients from prospectively entered data in the Halifax Neuropituitary Database from November 1, 2005 to September 30, 2014, who had required glucocorticoid therapy for >3 months, and a minimum follow-up of 6 months. Exclusion: ACTH-secreting adenomas; peri-operative glucocorticoid treatment only; glucocorticoids for non-pituitary conditions. Results: 55 patients fulfilled the criteria, 41 (75%) of which had transsphenoidal surgery. Nine (16.4%) patients had complete recovery of SAI over a median of 20 months (range: 8–51). Smaller tumour size and initial cortisol >175 nmol/L had increased likelihood of recovery; those with secondary hypogonadism or growth hormone deficiency were less likely to recover. Conclusions: This is the first study to examine long-term recover of SAI in patients with pituitary disorders: approximately 1 in 6 patients recover adrenal function, up to 5 years after diagnosis. Consequently, patients with SAI should undergo regular testing to prevent unnecessary chronic glucocorticoid therapy.

scholarly journals Reduced epinephrine reserve in response to insulin-induced hypoglycemia in patients with pituitary adenoma

2007 ◽  
Vol 157 (3) ◽  
pp. 265-270 ◽  
Author(s):  
Shinya Morita ◽  
Michio Otsuki ◽  
Maki Izumi ◽  
Nobuyuki Asanuma ◽  
Shuichi Izumoto ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Adrenal Insufficiency ◽  
Serum Cortisol ◽  
Tolerance Test ◽  
Secondary Adrenal Insufficiency ◽  
Counterregulatory Hormones ◽  
Insulin Tolerance ◽  
Secondary Hypothyroidism ◽  
Severe Impairment ◽  
Plasma Gh

Objective: Hypoglycemia induces rapid secretion of counterregulatory hormones such as catecholamine, glucagon, cortisol, and GH. Insulin-induced hypoglycemia is used for evaluating GH–IGF-I and ACTH–adrenal axes in patients with pituitary disorders. The aim of this study was to determine whether the response of catecholamine secretion to hypoglycemia is disrupted in patients with pituitary adenoma. Methods: The study population comprised 23 patients with pituitary adenoma (non-functioning adenoma or prolactinoma). An insulin tolerance test was performed and serum catecholamines as well as plasma GH and serum cortisol were measured. Results: The study patients showed diminished response of plasma epinephrine to insulin-induced hypoglycemia. With the cutoff level of peak epinephrine for defining severe impairment set at 400 pg/ml, more patients with secondary adrenal insufficiency showed severe impairment of the epinephrine response than did those without it. Peak epinephrine levels to insulin-induced hypoglycemia were significantly correlated with peak cortisol levels. In patients with secondary hypothyroidism, secondary hypogonadism, GH deficiency, or diabetes insipidus, the prevalence of severe impairment of the epinephrine response was similar to that in patients without these deficiencies. Conclusions: Impaired epinephrine secretion in response to insulin-induced hypoglycemia was frequently observed in patients with pituitary adenoma. This disorder was especially severe in patients with secondary adrenal insufficiency.

scholarly journals Perioperative anaesthetic management of a child with cushing’s syndrome for bilateral adrenalectomy

2014 ◽  
Vol 22 (2) ◽  
pp. 84-87
Author(s):  
Sabina Yeasmeen ◽  
Debasish Banik ◽  
Quamrul Huda ◽  
Sayeed Mahmud Ali Reza ◽  
Abdul Hye ◽  
...  
Keyword(s):  
Adrenal Adenoma ◽  
Serum Cortisol ◽  
Anaesthetic Management ◽  
Control Mode ◽  
Electrolyte Imbalance ◽  
Paediatric Surgery ◽  
Benign Adenoma ◽  
Acth Secreting ◽  
Medical University ◽  
Adrenocortical Tumour

Nearly twenty five percent of the cases of cushing’s syndrome are due to adrenal hyperplasia without an ACTH secreting tumour. Twenty percent of patients with endogenous cushing have adrenocortical tumour about half of which are benign adenoma. Surgical intervention done due to failed medi cal therapy and in case of adrenal adenoma. A child aged 4½ years, weighting 29kg with features suggestive of cushing’s syndrome was admitted under paediatric surgery unit in Bangabandhu Sheikh Mujib Medical University. On investigation serum cortisol levels were raised. blood pressure was controlled by ACE inhibitor, calcium channel blocker and beta-blocker. He was scheduled for resection of adrenal cortical tumour. Electrolyte imbalance was corrected, steroid replacement was done. Patient was haemodynamically stable preoperatively.Surgery was completed unevenetfuly. Postoperatively patient was kept in ICU, ventilation maintained by control mode (CMV). After 24 hours the patient was extubated. When the patient found haemodynamically stable he was sent to the recovery room. DOI: http://dx.doi.org/10.3329/jbsa.v22i2.18148 Journal of BSA, 2009; 22(2): 84-87

scholarly journals Day 5 Morning Serum Cortisol Predicts Hypothalamic-Pituitary-Adrenal Function after Transsphenoidal Surgery for Pituitary Tumors

2009 ◽  
Vol 55 (5) ◽  
pp. 972-977 ◽  
Author(s):  
Channa N Jayasena ◽  
Kunal A Gadhvi ◽  
Bhavini Gohel ◽  
Niamh M Martin ◽  
Nigel Mendoza ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Transsphenoidal Surgery ◽  
Pituitary Tumors ◽  
Serum Cortisol ◽  
Tolerance Test ◽  
Cortisol Concentration ◽  
Correct Identification ◽  
Secondary Adrenal Insufficiency ◽  
Hypothalamic Pituitary Adrenal ◽  
Hpa Function

Abstract Background: Adrenal insufficiency is a complication of transsphenoidal surgery (TSS) for pituitary adenoma, and correct identification of patients requiring glucocorticoid replacement is important. Controversy exists over which early postoperative 9 AM cortisol concentration reliably predicts hypothalamic-pituitary-adrenal (HPA) axis reserve, as defined by the insulin tolerance test (ITT). Methods: Data were reviewed for 36 patients undergoing TSS followed by day 5 postoperative 9 AM cortisol measurement and ITT 6 weeks postsurgery. All patients received postoperative glucocorticoid replacement, which was discontinued if the 9 AM serum cortisol was &gt;300 nmol/L. Results: Of 23 patients who failed the ITT (peak cortisol &lt;500 nmol/L), 20 also had a day 5, 9 AM serum cortisol &lt;300 nmol/L. Nine of 13 patients who passed the ITT had a day 5, 9 AM cortisol &gt;300 nmol/L. The cutoff cortisol concentration of 300 nmol/L had 86.9% (66.4%–97.2%) diagnostic sensitivity, 69.2% (38.6%–90.9%) diagnostic specificity, and 83.3% (61.8%–94.5%) positive predictive value (PPV) for detecting secondary adrenal insufficiency. Increasing the cutoff to 392 nmol/L resulted in 100% (85.2%–100%) sensitivity, 46.1% (19.2%–74.9%) specificity, and 76.6% (57.3%–89.4%) PPV. Decreasing the cutoff to 111 nmol/L resulted in 100% (75.3%–100%) specificity and 100% (67.9%–100%) PPV, although sensitivity was 47.8% (26.8%–69.4%). Conclusions: A day 5 post-TSS 9 AM serum cortisol &lt;111 nmol/L reliably detects secondary adrenal insufficiency, and concentrations &gt;392 nmol/L support intact HPA function. Because concentrations of 111–392 nmol/L are poorly predictive of HPA function, glucocorticoid replacement should continue in such cases until definitive testing is performed using an ITT.

scholarly journals Chemotherapy-Induced Regression of an Adrenocorticotropin-Secreting Pituitary Carcinoma Accompanied by Secondary Adrenal Insufficiency

2013 ◽  
Vol 2013 ◽  
pp. 1-10 ◽  
Author(s):  
Robert Frank Cornell ◽  
Daniel F. Kelly ◽  
Gal Bordo ◽  
Ty B. Carroll ◽  
Huy T. Duong ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Substantial Reduction ◽  
Multimodality Treatment ◽  
Cytotoxic Chemotherapy ◽  
Pituitary Carcinoma ◽  
Proliferation Index ◽  
Complete Regression ◽  
Secondary Adrenal Insufficiency ◽  
Ki 67 ◽  
Acth Secreting

Purpose. Adrenocorticotropin- (ACTH-) secreting pituitary carcinomas are rare and require multimodality treatment. The aim of this study was to report the response to various therapies and discuss the potential development of secondary adrenal insufficiency with cytotoxic chemotherapy.Methods. This report describes a man with a large silent corticotroph adenoma progressing to endogenous hypercortisolism and metastatic ACTH-secreting pituitary carcinoma over a period of 14 years.Results. Seven years after initial presentation, progressive tumor enlargement associated with the development of hypercortisolism mandated multiple pituitary tumor debulking procedures and radiotherapy. Testing of the Ki-67 proliferation index was markedly high and he developed a hepatic metastasis. Combination therapy with cisplatin and etoposide resulted in a substantial reduction in tumor size, near-complete regression of his liver metastasis, and dramatic decrease in ACTH secretion. This unexpectedly resulted in symptomatic secondary adrenal insufficiency.Conclusions. This is the first reported case of secondary adrenal insufficiency after use of cytotoxic chemotherapy for metastatic ACTH-secreting pituitary carcinoma. High proliferative indices may be predictive of dramatic responses to chemotherapy. Given the potential for such responses, the development of secondary adrenal insufficiency may occur and patients should be monitored accordingly.

scholarly journals Severe Symptomatic SIADH as a Sign of Unknow Hypopituitarism: A Case Report

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A609-A610
Author(s):  
Juliana Marques-Sá ◽  
Catarina Silva Araújo ◽  
Maria Joana Santos
Keyword(s):  
Adrenal Insufficiency ◽  
Rare Condition ◽  
Urine Osmolality ◽  
Serum Cortisol ◽  
Empty Sella ◽  
Secondary Adrenal Insufficiency ◽  
Severe Hyponatremia ◽  
Long Time ◽  
Remarkable Recovery ◽  
High Level

Abstract Background: SIADH due to secondary adrenal insufficiency is a rare condition that can be life-threatening. Treatment with glucocorticoids is highly effective, but, as symptomatology of hypopituitarism can be mild and unspecific, a high level of clinical suspicion is necessary. Clinical Case: A 64-year-old postmenopausal woman, with a previously diagnosed and treated hypothyroidism and depressive syndrome, presented at the emergency room with nausea, vomits, asthenia and recurrent syncopes over the past three weeks and weight loss in the last months. One week before, she had been admitted at other hospital due to the same complaints and a serum Na+ of 112mmol/L (N 135-145 mmol/L) was detected. One year earlier, she had reported the same symptomology and hyponatremia had also been found, but no etiologic study was performed. At admission, she was conscient, hydrated, pale, hemodynamically stable, with unremarkable cardiopulmonary auscultation. A severe hyponatremia was found (Na+ 111mmol/L), with low serum osmolarity (241mOsm/Kg, N 280-301mOsm/Kg), low urine osmolality (125mOsm/kg N 300-900 mOsm/Kg) and low urinary sodium (33mmol/24h, N 40-220mmol/24h). Treatment with saline fluids was initiated and the patient was admitted for etiological investigation, which showed a low morning serum cortisol (3.7 µg/dl)) with inappropriately low-normal ACTH level (12.2 pg/mL), low FSH (15.07 mUI/mL, N 23.0-116.3 mUI/mL) and LH (4.28 mUI/mL, N 15.9-54 mUI/mL), estradiol of 78.81 pmol/L (N &lt;118.2 pmol/L), undetectable IGF-1 (&lt;25 ng/mL, N 36-244 ng/mL) and PRL of 21.98 ng/mL (N 1.8-20.3 ng/mL). Under 50µg of levothyroxine, TSH was 2.5 µUI/mL (N 0.358-3.74 µUI/ml), and FT4 was 1.1 ng/dL (N 0.76-1.46 ng/dL). Anti-thyroglobulin and anti-TPO antibodies were negative. A pituitary MRI revealed an empty sella with arachnoidocele. Other differential diagnosis of SIADH were excluded. The patient was started on oral hydrocortisone 30 mg/day, with a remarkable recovery, with better mood, more energy and appetite, resolution of all symptoms and normalization of the natremia. Conclusion: Hypopituitarism due to an empty sella is a relative rare disorder, whose etiology may be difficult to prove. It usually develops insidiously, with unspecific symptoms, which often delays the diagnosis. In our patient, this severe hyponatremia likely developed over a long time, allowing adaptation to such low levels of Na+. Moreover, the presence of a previously diagnosed hypothyroidism raises the suspicion if this wasn’t the first manifestation of the pituitary disease and if treatment of levothyroxine did not worsen an undetected secondary adrenal insufficiency.

scholarly journals Salivary cortisol as a diagnostic tool for Cushing's syndrome and adrenal insufficiency: improved screening by an automatic immunoassay

2012 ◽  
Vol 166 (4) ◽  
pp. 613-618 ◽  
Author(s):  
Timo Deutschbein ◽  
Martina Broecker-Preuss ◽  
Jörg Flitsch ◽  
Andrea Jaeger ◽  
Ricarda Althoff ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Diagnostic Tool ◽  
Salivary Cortisol ◽  
Roc Analysis ◽  
Area Under The Curve ◽  
Serum Cortisol ◽  
Serum Cortisol Level ◽  
Specific Reference ◽  
Reference Ranges ◽  
Secondary Adrenal Insufficiency

BackgroundSalivary cortisol is increasingly used to assess patients with suspected hypo- and hypercortisolism. This study established disease-specific reference ranges for an automated electrochemiluminescence immunoassay (ECLIA).MethodsUnstimulated saliva from 62 patients with hypothalamic–pituitary disease was collected at 0800 h. A peak serum cortisol level below 500 nmol/l during the insulin tolerance test (ITT) was used to identify hypocortisolism. Receiver-operating characteristic (ROC) analysis allowed establishment of lower and upper cutoffs with at least 95% specificity for adrenal insufficiency and adrenal sufficiency. Saliva from 40 patients with confirmed hypercortisolism, 45 patients with various adrenal masses, and 115 healthy subjects was sampled at 2300 h and after low-dose dexamethasone suppression at 0800 h. ROC analysis was used to calculate thresholds with at least 95% sensitivity for hypercortisolism. Salivary cortisol was measured with an automated ECLIA.ResultsWhen screening for secondary adrenal insufficiency, a lower cutoff of 3.2 nmol/l and an upper cutoff of 13.2 nmol/l for unstimulated salivary cortisol allowed a highly specific diagnosis (i.e. similar to the ITT result) in 26% of patients. For identification of hypercortisolism, cutoffs of 6.1 nmol/l (sensitivity 95%, specificity 91%, area under the curve (AUC) 0.97) and 2.0 nmol/l (sensitivity 97%, specificity 86%, AUC 0.97) were established for salivary cortisol at 2300 h and for dexamethasone-suppressed salivary cortisol at 0800 h.ConclusionsThe newly established thresholds facilitated initial screening for secondary adrenal insufficiency and allowed excellent identification of hypercortisolism. Measurement by an automated immunoassay will allow broader use of salivary cortisol as a diagnostic tool.

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