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

2013 ◽  
Vol 169 (2) ◽  
pp. 139-145 ◽  
Author(s):  
Michael J O'Grady ◽  
Conor Hensey ◽  
Miriam Fallon ◽  
Hilary Hoey ◽  
Nuala Murphy ◽  
...  
Keyword(s):  
Paediatric Population ◽  
Tolerance Test ◽  
Specific Reference ◽  
Cortisol Response ◽  
Reference Ranges ◽  
Factors Affecting ◽  
Insulin Tolerance ◽  
Morning Cortisol ◽  
Systemic Glucocorticoids ◽  
Cortisol Responses

ObjectiveBased on adult data, a peak cortisol response ≥500 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.DesignThe present study was a retrospective cohort study.MethodsRetrospective 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.ResultsTwo hundred and twenty-three tests were analysed. Peak cortisol responses ≥500 nmol/l occurred in 183 (82%) tests. Age was negatively associated with peak cortisol responses (r=−0.15, P=0.03). A peak cortisol response <500 nmol/l was significantly less common in patients aged <12 years (9/97 (9%) vs 31/126 (25%); P=0.004). 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 ≥12 years (P<0.004). Similarly, median cortisol increment was significantly higher in younger patients (301 nmol/l compared with 226 nmol/l (P=0.0004)).ConclusionsUse of a single peak cortisol threshold in children of all ages is not appropriate and will result in overdiagnosis of adrenal insufficiency in adolescents.

scholarly journals Evaluation of pituitary function in the fatigued patient: a review of 59 cases

2006 ◽  
Vol 154 (1) ◽  
pp. 147-157 ◽  
Author(s):  
Jerry R Greenfield ◽  
Katherine Samaras
Keyword(s):  
Autoimmune Disease ◽  
Gastrointestinal Haemorrhage ◽  
Early Morning ◽  
Tolerance Test ◽  
Secondary Adrenal Insufficiency ◽  
Presenting Symptoms ◽  
Insulin Tolerance ◽  
Morning Cortisol ◽  
History Of ◽  
Cortisol Responses

Objective: The aim of this study was to review the results of dynamic pituitary testing in patients presenting with fatigue. Methods: We reviewed clinical histories and insulin tolerance test (ITT) results of 59 patients who presented with fatigue and other symptoms of glucocorticoid insufficiency over a 4-year period. All patients referred for ITT had an early-morning cortisol level of <400 nM and a low or normal ACTH level. Results: Peak cortisol and GH responses following insulin-induced hypoglycaemia were normal in only seven patients (12%). Median age of the remaining 52 patients was 47 years (range, 17–67 years); all but five were female. Common presenting symptoms were neuroglycopaenia (n = 47), depression (n = 37), arthralgia and myalgia (n = 28), weight gain (n = 25), weight loss (n = 9), postural dizziness (n = 15) and headaches (n = 13). Other medical history included autoimmune disease (n = 20; particularly Hashimoto’s thyroiditis, Graves’ disease and coeliac disease), postpartum (n = 8) and gastrointestinal (n = 2) haemorrhage and hyperprolactinaemia (n = 13). 31 subjects had peak cortisol levels of <500 nM (suggestive of ACTH deficiency; 18 of whom had levels < 400 nM) and a further six had indeterminate results (500–550 nM). The remaining 15 subjects had normal cortisol responses (median 654 nM; range, 553–1062 nM) but had low GH levels following hypoglycaemic stimulation (5.9 mU/l; 3–11.6 mU/l). Conclusion: Our results suggest that patients presenting with fatigue and symptoms suggestive of hypocortisolism should be considered for screening for secondary adrenal insufficiency, particularly in the presence of autoimmune disease or a history of postpartum or gastrointestinal haemorrhage. Whether physiological glucocorticoid replacement improves symptoms in this patient group is yet to be established.

The Use of the Short Tetracosactrin Test for the Investigation of Suspected Pituitary Hypofunction

1996 ◽  
Vol 33 (2) ◽  
pp. 112-118 ◽  
Author(s):  
T W M Wang ◽  
M S Wong ◽  
J Falconer Smith ◽  
T A Howlett
Keyword(s):  
Hpa Axis ◽  
Tolerance Test ◽  
Insulin Tolerance Test ◽  
Cortisol Response ◽  
Established Method ◽  
Time Points ◽  
Routes Of Administration ◽  
Insulin Tolerance ◽  
Significant Difference ◽  
Cortisol Responses

The short Synacthen (tetracosactrin) test (SST) is an established method of assessing adrenocortical reserve, and is increasingly replacing the insulin tolerance test (ITT) for the assessment of the hypothalamic-pituitary-adrenal (HPA) axis. However, there is no consensus on how the test is performed, and various time points and routes of administration are used. The present study was done, first, to determine whether there was any difference in cortisol responses when Synacthen was administered intramuscularly compared with intravenously and, secondly, to compare cortisol responses at 30 and 60 min. We found no significant difference between the two routes of administration. However, cortisol responses at 60 min were significantly higher than at 30 min ( P < 0·05). Previous validations for the use of the SST in place of the ITT have used cortisol responses 30 min after Synacthen. We conclude that where the SST is used to assess the HPA axis, cortisol response at 30 min after intravenous Synacthen should be used.

Intravenous insulin tolerance test: criteria for evaluation of the growth hormone and cortisol response

1984 ◽  
Vol 104 (4_Supplc) ◽  
pp. S31-S33
Author(s):  
M. C. Alevizaki - Harhalaki ◽  
C. C. Alevizaki ◽  
H. D. Demertzi ◽  
D. G. Ikkos ◽  
A. Papas
Keyword(s):  
Growth Hormone ◽  
Tolerance Test ◽  
Insulin Tolerance Test ◽  
Cortisol Response ◽  
Intravenous Insulin ◽  
Insulin Tolerance ◽  
Test Criteria ◽  
Criteria For Evaluation

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 SUN-307 Partial Secondary Adrenal Insufficiency and Growth Hormone Deficiency in Fibromyalgia

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Lucinda Gruber ◽  
Sanjeev Nanda ◽  
Todd B Nippoldt ◽  
Alice Y Chang ◽  
Irina Bancos
Keyword(s):  
Adrenal Insufficiency ◽  
Gh Deficiency ◽  
Tolerance Test ◽  
Insulin Tolerance Test ◽  
Cortisol Concentration ◽  
Stimulation Test ◽  
Gh Replacement ◽  
Insulin Tolerance ◽  
Morning Cortisol ◽  
Cosyntropin Stimulation Test

Abstract Introduction: Low or borderline cortisol concentrations and impaired response to dynamic testing have been reported in patients with fibromyalgia, potentially related to hypothalamus-pituitary dysfunction.1,2 Superimposed adrenal insufficiency (AI) may contribute to some fibromyalgia symptoms or delay improvement in patients enrolled in fibromyalgia treatment programs. We hypothesized that a subset of patients with fibromyalgia have: 1) partial secondary AI and concomitant growth hormone (GH) deficiency 2) a discordance in Cosyntropin stimulation test and 3) improvement in fibromyalgia symptoms with initiation of glucocorticoid and/or GH replacement. Design: This was a retrospective study of patients with fibromyalgia diagnosed with partial secondary AI based on abnormal insulin tolerance test (peak cortisol &lt; 18 mcg/dL) at our institution from June 2002 to August 2019. Patients were excluded if they had other reasons for adrenal insufficiency, including steroid exposure and opioid use. Results: We identified 22 patients (18 women, 82%) diagnosed with partial AI at a median age of 38 years (range 19-65). The fibromyalgia symptoms included fatigue (n=22, 100%), pain (n=22, 100%), sleep disturbance (n=15, 68%), and bowel changes (n=13, 59%). The median morning cortisol concentration was 8.6 mcg/dL (range 1.1-11); 9 patients (41%) had a morning cortisol concentration below the normal range (7 mcg/dL). The median ACTH level was 15.5 pg/mL (range 7.7-54). Nineteen patients had baseline IGF1 levels, with a median z-score of -0.94 (range -1.96 to 1.70). MRI pituitary imaging was performed in 20 patients and showed no significant pituitary pathology. All patients achieved hypoglycemia &lt;=40 mg/dL during the insulin tolerance test. Peak median cortisol level was 11 mcg/dL (range 5.4-17). Nineteen patients (86%) also had partial GH deficiency (defined as a peak GH &lt; 4 ng/mL) with a median GH level of 0.36 ng/mL (range 0.03-3.83). Cosyntropin stimulation test was performed in 13 patients (59%) with a 1 mcg dose in 2 patients and 250 mcg dose in 11 patients. The peak cortisol was &gt;=18 mcg/dL in 10 (77%) patients. All patients were started on physiologic glucocorticoid replacement, and 12 patients were started on GH replacement. Endocrinology follow-up information was available for 13 patients, and 8 (62%) reported symptom improvement after starting treatment. Conclusions: Patients with fibromyalgia can have co-existing partial secondary AI and GH deficiency as defined by insulin-induced hypoglycemia. Cosyntropin stimulation test can be used in patients with fibromyalgia, but a normal test does not rule out partial secondary AI. Replacing the underlying deficiency improved symptoms in some patients demonstrating certain fibromyalgia symptoms may overlap with AI and GH deficiency. 1Gur et al. Ann Rheum Dis. 2004. 63(11):1504-1506. 2Kirnap et al. Clin Endocrinol (Oxf). 2001. 55(4):455-459.

scholarly journals 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?

2010 ◽  
Vol 163 (3) ◽  
pp. 377-382 ◽  
Author(s):  
Z Karaca ◽  
F Tanriverdi ◽  
H Atmaca ◽  
C Gokce ◽  
G Elbuken ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Pituitary Surgery ◽  
Serum Cortisol ◽  
Tolerance Test ◽  
Cortisol Response ◽  
Basal Serum ◽  
Insulin Tolerance ◽  
Basal Cortisol ◽  
Cortisol Levels ◽  
Pituitary Adrenal Axis

BackgroundThe 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.MethodsThe 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.ResultsPatients with a preoperative basal cortisol level of <165 nmol/l (6 μg/dl) showed insufficient cortisol response and those with levels higher than 500 nmol/l (18 μg/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 μg/dl) or 220 nmol/l (8 μg/dl) or 193 nmol/l (7 μg/dl) or 165 nmol/l (6 μg/dl) or 83 nmol/l (3 μg/dl) on the 2nd–6th postoperative days respectively.ConclusionSerum 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.

Sign in / Sign up

Export Citation Format

Share Document