scholarly journals MON-136 Reducing Unnecessary Inpatient Adrenocorticotropin Stimulation Tests

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Ridha Ali ◽  
Heather Anne Lochnan ◽  
Julie Shaw ◽  
Christopher S Tran
Keyword(s):  
Dynamic Testing ◽  
Serum Cortisol ◽  
Stimulation Test ◽  
Inpatient Service ◽  
Acth Stimulation Test ◽  
Acth Stimulation ◽  
Basal Cortisol ◽  
Stimulation Tests ◽  
One Year ◽  
The One

Abstract Background: Outpatient adrenocorticotropin (ACTH) stimulation tests can be challenging to interpret due to heterogeneously reported cut-offs. Inpatient stimulation tests present additional challenges due to the presence of acute illness and unreliable coordination of dynamic function testing on a busy inpatient service. This study aims to characterize the use of ACTH stimulation tests in hospitalized patients to determine necessity of testing. Methods: We conducted an inpatient audit of ACTH simulation tests done to rule out adrenal insufficiency between April 2018 to March 2019 at our institution. Normal post-ACTH response was defined as peak cortisol ≥500 nmol/L. Testing was considered inappropriate in patients with normal post-ACTH response who had a serum cortisol ≥250 nmol/L drawn during the same admission prior to stimulation testing. Cut-offs were based on previous analysis of 195 outpatient stimulation tests. Results: During the one-year study period there were 40 inpatients who had an ACTH stimulation test. Nineteen (48%) were considered unnecessary because patients either had a pre-ACTH serum cortisol ≥250 nmol/L and/or a 0-minute cortisol value just prior to the ACTH stimulation test ≥250 nmol/L. Except for a single instance where the patient was inappropriately on prednisone when basal cortisol was tested, all patients with any pre-ACTH cortisol ≥250 nmol/L had a normal post-ACTH response Conclusion: Institutions may avoid unnecessary inpatient ACTH stimulation tests by implementing protocols which ensure that basal cortisol levels are drawn and below locally determined cut-offs before proceeding to dynamic testing. To characterize further, a three-year analysis of inpatient ACTH stimulation tests is underway.

scholarly journals Salivary Cortisol Determination in ACTH Stimulation Test to Diagnose Adrenal Insufficiency in Patients with Liver Cirrhosis

2019 ◽  
Vol 2019 ◽  
pp. 1-8
Author(s):  
Lara Albert ◽  
Joaquím Profitós ◽  
Jordi Sánchez-Delgado ◽  
Ismael Capel ◽  
José Miguel González-Clemente ◽  
...  
Keyword(s):  
Liver Cirrhosis ◽  
Adrenal Insufficiency ◽  
Salivary Cortisol ◽  
Serum Cortisol ◽  
Stimulation Test ◽  
Decompensated Cirrhosis ◽  
Acth Test ◽  
Acth Stimulation Test ◽  
Acth Stimulation ◽  
Cirrhotic Patients

Purpose. The prevalence of adrenal insufficiency (AI) in patients with decompensated liver cirrhosis is unknown. Because these patients have lower levels of cortisol-binding carrier proteins, their total serum cortisol (TSC) correlates poorly with free serum cortisol (FC). Salivary cortisol (SaC) correlates better with FC. We aimed to establish SaC thresholds for AI for the 250 μg intravenous ACTH test and to estimate the prevalence of AI in noncritically ill cirrhotic patients. Methods. We included 39 patients with decompensated cirrhosis, 39 patients with known AI, and 45 healthy volunteers. After subjects fasted ≥8 hours, serum and saliva samples were collected for determinations of TSC and SaC at baseline 0’(T0) and at 30-minute intervals after intravenous administration of 250 μg ACTH [30’(T30), 60’(T60), and 90’(T90)]. Results. Based on the findings in healthy subjects and patients with known AI, we defined AI in cirrhotic patients as SaC-T0< 0.08 μg/dL (2.2 nmol/L), SaC-T60 < 1.43 μg/dl (39.5 nmol/L), or ΔSaC<1 μg/dl (27.6 nmol/L). We compared AI determination in cirrhotic patients with the ACTH test using these SaC thresholds versus established TSC thresholds (TSC-T0< 9 μg/dl [248 nmol/L], TSC-T60 < 18 μg/dl [497 nmol/L], or ΔTSC<9 μg/dl [248 nmol/L]). SaC correlated well with TSC. The prevalence of AI in cirrhotic patients was higher when determined by TSC (48.7%) than by SaC (30.8%); however, this difference did not reach statistical significance. AI was associated with sex, cirrhosis etiology, and Child-Pugh classification. Conclusions. Measuring SaC was more accurate than TSC in the ACTH stimulation test. Measuring TSC overestimated the prevalence of AI in noncritically ill cirrhotic patients.

scholarly journals ACTH stimulation test (250 μg): is salivary cortisol an alternative to serum cortisol?

2016 ◽  
Author(s):  
Lara Albert ◽  
Olga Gimenez-Palop ◽  
Ismael Capel ◽  
Gonzalez-Clemente Jose Miguel ◽  
David Subias ◽  
...  
Keyword(s):  
Salivary Cortisol ◽  
Serum Cortisol ◽  
Stimulation Test ◽  
Acth Stimulation Test ◽  
Acth Stimulation

scholarly journals Technical details influence the diagnostic accuracy of the 1 μg ACTH stimulation test

2010 ◽  
Vol 162 (1) ◽  
pp. 109-113 ◽  
Author(s):  
Matthew Wade ◽  
Smita Baid ◽  
Karim Calis ◽  
Hershel Raff ◽  
Ninet Sinaii ◽  
...  
Keyword(s):  
Age Groups ◽  
Stimulation Test ◽  
High Rate ◽  
Acth Stimulation Test ◽  
Acth Stimulation ◽  
Clinical Research Center ◽  
Stimulation Tests ◽  
Acth Concentration ◽  
Cortisol Responses ◽  
And Gender

ObjectiveTo examine the factors causing inadequate cortisol responses to the 1 μg ACTH stimulation test.DesignRandom test assignment (by age and gender) at 0800 or 1600 h.MethodsWe recruited 20 healthy adults to each of the three age groups (<40 years, 40–55 years, and >55 years; half females in each group). ACTH stimulation tests were performed in an outpatient clinic at the NIH Clinical Research Center. Plasma cortisol was measured just before, and 30 and 60 min after the administration of 1 μg ACTH (1–24). The ACTH concentration in diluted and administered solutions was measured.ResultsTwenty-five volunteers (19 at 1600 h) had a subnormal cortisol response (peak cortisol 10.4–17.5 μg/dl), using a criterion <18 μg/dl (497 nmol/l), for a specificity of 58% (confidence interval (CI) 45–71%). Afternoon testing had a significant impact on failure rates (odds ratio 6.98, CI 2.17–22.43), while gender and age did not. The stock solution contained 1 μg ACTH, but after administration through tubing it contained only 0.5–0.8 μg.ConclusionsThe high rate of abnormal results, especially in the afternoon, and loss of ACTH through tubing suggest that morning testing and minimal tubing should be adopted to avoid an inappropriate diagnosis of adrenal insufficiency. Earlier time points and standardized protocols would facilitate comparison of studies.

The Incidence of Adrenal Insufficiency in Myeloma Patients Receiving Pulse-Dose Dexamethasone

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 5640-5640
Author(s):  
Aimaz Afrough ◽  
Amy Sidorski ◽  
Roberto Salvatori ◽  
Ivan Borrello
Keyword(s):  
Adrenal Insufficiency ◽  
Cortisol Level ◽  
Research Funding ◽  
Serum Cortisol ◽  
Stimulation Test ◽  
Serum Cortisol Level ◽  
Acth Stimulation Test ◽  
Acth Stimulation ◽  
Pulse Dose ◽  
Significant Difference

Abstract Introduction: Glucocorticoids (GC's) are major drugs in the treatment of multiple myeloma (MM). Chronic administration of supra-physiological doses of GC's suppresses the hypothalamus-pituitary-adrenal (HPA) axis and is associated with secondary adrenal insufficiency (AI). In MM, GC's are usually administered in weekly high dose pulses. Due to long GC-free periods in such therapy, GC-induced AI is not usually considered to be a consequence of GC therapy in MM (Krasner, AS. JAMA, 1999. 282(7): p. 671-6). Here we report on the incidence of AI in MM patients treated at our center with pulse-dose GC. Methods: This is a retrospective cross-sectional study of patients with MM treated with GC-based regimens. Patients were required to have at least a random serum cortisol or a standard 250 mcg ACTH stimulation test result available in their medical record during dexamethasone-based chemotherapy. Patients were excluded if they were on dexamethasone more than 1 day a week, were lost to follow-up, had prior use of synthetic progestational agents such as megestrol or had been on oral glucocorticoids for any other medical indication. Diagnosis of AI was established by a frankly low AM serum cortisol level (<3 ug/dL) or an inadequate cortisol response to ACTH stimulation test (Salvatori, R. JAMA, 2005. 294(19): p. 2481-8). Results: A total of 45 patients were included in this study with median age of 62 (range, 49-89). Fifteen (33.3%) of patients were diagnosed with AI. The median random cortisol level in AI group was 2.3 ug/dL (range, 0.3-7.4 ug/dL) compared to 9.9 ug/dL (range, 1.0-21.2 ug/dL) in the non-AI group. The median time between the last dexamethasone dose and the serum cortisol assay was 5 days (range, 1-21). The median number of GC-based chemotherapy cycles taken before diagnosis of AI was 15 (range, 2-60). The median cumulative dexamethasone consumption was 1280 mg (range, 180-5220 mg). There was no correlation between developing AI and dose or duration of dexamethasone treatment. We observed clinical trend between cumulative doses of ≥1500 mg (P= 0.055) or use of clarithromycin (P=0.079) and developing AI, without reaching a statistically significant difference. Conclusion: The rate of AI was 33% among patients with MM on weekly pulse-dose dexamethasone. As such, patients should be periodically evaluated for this to enable early detection and proper management. Disclosures Borrello: BMS: Honoraria, Research Funding; WindMIL Therapeutics: Equity Ownership, Patents & Royalties, Research Funding; Celgene: Honoraria, Research Funding, Speakers Bureau.

scholarly journals Long acting porcine sequence ACTH in the diagnosis of adrenal insufficiency

2019 ◽  
Vol 181 (6) ◽  
pp. 639-645 ◽  
Author(s):  
Abilash Nair ◽  
Chellamma Jayakumari ◽  
Geena Susan George ◽  
Puthiyaveettil Khadar Jabbar ◽  
Darvin V Das ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Area Under The Curve ◽  
Serum Cortisol ◽  
High Accuracy ◽  
Stimulation Test ◽  
Acth Stimulation Test ◽  
Acth Stimulation ◽  
Synacthen Test ◽  
Long Acting ◽  
Short Synacthen Test

Objectives Injectable tetracosactide hexa-acetate, ACTH 1-24 (Synacthen), is not marketed in many countries including India, whereas Injectable long acting porcine sequence, ACTH 1-39 (Acton Prolongatum®) is easily available and much cheaper. This study aimed to find the diagnostic accuracy of ACTH stimulation test using i.m. Acton Prolongatum® (acton prolongatum stimulation test, APST) in comparison with Synacthen (short synacthen test, SST) for the diagnosis of glucocorticoid insufficiency. Methods Subjects with a suspicion of adrenal insufficiency based on clinical features underwent a SST with 250 µg Synacthen followed by APST using 30 units of Acton Prolongatum®. Serum cortisol levels were measured at 60 and 120 min following injection of Acton Prolongatum®. Stimulated peak cortisol of less than 18 µg/dL on SST was considered as adrenal insufficiency. Results Forty seven patients with mean age of 36.7 ± 14.4 years were enrolled for the study. Based on SST, twenty (n = 20) persons were classified as having adrenal insufficiency, whereas twenty-seven (n = 27) were found to be normal. Area under the curve of APST (at 120 min) was 0.986 when compared to SST, thus proving its high accuracy. A serum cortisol cut off value of 19.5 µg/dL at 120-min following stimulation with Acton Prolongatum® showed a sensitivity of 100% and specificity of 88%. Conclusion ACTH stimulation test using Acton Prolongatum® is an economical and accurate alternative to the short Synacthen test.

scholarly journals THE ICET-A SURVEY ON CURRENT CRITERIA USED BY CLINICIANS FOR THE ASSESSMENT OF CENTRAL ADRENAL INSUFFICIENCY IN THALASSEMIA: ANALYSIS OF RESULTS AND RECOMMENDATIONS

2016 ◽  
Vol 8 ◽  
pp. 2016034
Author(s):  
Vincenzo De Sanctis
Keyword(s):  
Adrenal Insufficiency ◽  
Predictive Value ◽  
Serum Cortisol ◽  
Stimulation Test ◽  
Serum Cortisol Level ◽  
Second Step ◽  
Acth Stimulation Test ◽  
Acth Stimulation ◽  
Basal Serum ◽  
Central Adrenal Insufficiency

Introduction: In March 2015, the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescent Medicine (ICET-A) implemented a two-step survey on central adrenal insufficiency (CAI) assessment in TM patients and after analysis of the collected data,  recommendations for the assessment of hypothalamic-pituitary- adrenal (HPA) axis in clinical practice were defined.Methods: To ascertain the current practice for assessment of CAI in thalassemia, the Coordinator of ICET-A sent two questionnaires by email: i) The first to evaluate the current interpretation of basal serum cortisol level (first step) and ii) The second to evaluate the current usage of ACTH test and the variability in practice" (second step). Based on the surveys the core ICET-A group prepared the recommendations for the assessment of suspected CAI in thalassemia (third step).Results: A total of 19 thalassemologists/endocrinologists have participated in the first survey and 35 specialists participated in the second step questionnaire. The survey demonstrated a considerable variability in almost all aspects of relevant current criteria used for the diagnosis of CAI.  A ROC analysis using peak value > 20 μg/dl (> 550 nmol/L), after ACTH stimulation test, was performed with the aim of identifying the optimal basal serum cortisol cut-off. The optimal threshold that maximizes sensitivity plus specificity for morning basal cortisol against peak post-ACTH value >20 μg/dl (>550 nmol/L) was 10 μg/dl (275 nmol/L).,Furthermore, the values associated with highest negative predictive value (NPV) and highest, positive predictive value (PPV) were 4.20 (115 nmol/L) and 18.45 μg/dl (510 nmol/L), respectively.Surprisingly, 20 specialists in thalassemia working in blood bank, thalassemia centres (day hospital), internal medicine, hematology and onco-hematology had poor knowledge and experience in testing for CAI and stopped filling the questionnaire after the second question. In contrast, 9 endocrinologists (8 pediatricians) and 6 hematologists working in collaboration with endocrinologists completed the questionnaire.Conclusions: While waiting more extensive adequately powered and targeted studies, physicians should adopt an acceptable policy for accurate assessment of HPA in TM patients. Regular surveillance, early diagnosis, treatment and follow-up in a multi-disciplinary specialized setting are also recommended. The ICET-A recommendations are reported in order to facilitate for interested physicians the approach to successful assessment of adrenal function in thalassemia. Key words: Thalassemia, adrenal insufficiency, pitfall in the diagnosis, ACTH stimulation test, guidelines.

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

Sign in / Sign up

Export Citation Format

Share Document