SERUM MORNING CORTISOL AS A SCREENING TEST FOR ADRENAL INSUFFICIENCY

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

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Long acting porcine sequence ACTH in the diagnosis of adrenal insufficiency

Acta Endocrinologica ◽

10.1530/eje-19-0558 ◽

2019 ◽

Vol 181 (6) ◽

pp. 639-645 ◽

Cited By ~ 1

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.

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New Cutoffs for the Biochemical Diagnosis of Adrenal Insufficiency after ACTH Stimulation using Specific Cortisol Assays

Journal of the Endocrine Society ◽

10.1210/jendso/bvab022 ◽

2021 ◽

Vol 5 (4) ◽

Author(s):

Bradley R Javorsky ◽

Hershel Raff ◽

Ty B Carroll ◽

Alicia Algeciras-Schimnich ◽

Ravinder Jit Singh ◽

...

Keyword(s):

Adrenal Insufficiency ◽

Adrenocorticotropic Hormone ◽

Serum Cortisol ◽

Serum Samples ◽

Acth Stimulation ◽

Normal Response ◽

Baseline Cortisol ◽

Biochemical Diagnosis ◽

Antibody Assays ◽

Stimulation Tests

Abstract Context The normal cortisol response 30 or 60 minutes after cosyntropin (ACTH[1–24]) is considered to be ≥18 μg/dL (500 nmol/L). This threshold is based on older serum cortisol assays. Specific monoclonal antibody immunoassays or LC-MS/MS may have lower thresholds for a normal response. Objective To calculate serum cortisol cutoff values for adrenocorticotropic hormone (ACTH) stimulation testing with newer specific cortisol assays. Methods Retrospective analysis of ACTH stimulation tests performed in ambulatory and hospitalized patients suspected of adrenal insufficiency (AI). Serum samples were assayed for cortisol in parallel using Elecsys I and Elecsys II immunoassays, and when volume was available, by Access immunoassay and LC-MS/MS. Results A total of 110 patients were evaluated. Using 18 μg/dL as the cortisol cutoff after ACTH stimulation, 14.5%, 29%, 22.4%, and 32% of patients had a biochemical diagnosis of AI using the Elecsys I, Elecsys II, Access, and LC-MS/MS assays, respectively. Deming regressions of serum cortisol were used to calculate new cortisol cutoffs based on the Elecsys I cutoff of 18 μg/dL. For 30-minute values, new cutoffs were 14.6 μg/dL for Elecsys II, 14.8 μg/dL for Access, and 14.5 μg/dL for LC-MS/MS. Baseline cortisol <2 μg/dL was predictive of subnormal stimulated cortisol values. Conclusion To reduce false positive ACTH stimulation testing, we recommend a new serum cortisol cutoff of 14 to 15 μg/dL depending on the assay used (instead of the historical value of 18 μg/dL with older polyclonal antibody assays). Clinicians should be aware of the new cutoffs for the assays available to them when evaluating patients for AI.

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

International Journal of Endocrinology ◽

10.1155/2019/7251010 ◽

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.

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

Endocrines ◽

10.3390/endocrines1020012 ◽

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.

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

Neuroendocrinology ◽

10.1159/000514216 ◽

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.

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THE FREQUENCY OF ADRENAL INSUFFICIENCY IN ADOLESCENTS AND YOUNG ADULTS WITH THALASSEMIA MAJOR VERSUS THALASSEMIA INTERMEDIA IN IRAN

Mediterranean Journal of Hematology and Infectious Diseases ◽

10.4084/mjhid.2015.005 ◽

2014 ◽

Vol 7 ◽

pp. e2015005 ◽

Cited By ~ 4

Author(s):

Sara Matin ◽

Masoud Ghanei Jahromi ◽

Zohreh Karemizadeh ◽

Sezaneh Haghpanah ◽

Vincenzo De Sanctis ◽

...

Keyword(s):

Adrenal Insufficiency ◽

Standard Dose ◽

Serum Cortisol ◽

Thalassemia Major ◽

Cross Sectional Study ◽

Cortisol Response ◽

Acth Stimulation ◽

Cross Sectional ◽

Basal Cortisol ◽

The Mean

Background: Endocrine dysfunction is not uncommon complication in patients with transfusion dependent thalassemia and is thought to occur as a consequence of excessive iron overload. The main objective of this study is to determine the frequency of adrenal insufficiency in patients with thalassemia major and thalassemia intermediate. Methods: This cross-sectional study was done at the Shiraz University of Medical Sciences, Shiraz, Southern Iran, in 2013. One hundred and ninety patients were divided into two groups; thalassemia major(TM) and thalassemia intermediate (TI) groups. We measured 8 AM serum cortisol, ACTH and ferritin concentrations in all patients. Results: The mean age of the TM and TI group were 22.5±5.7 and 23.8±6 years, respectively. 90 patients (47.4%) were splenectomized, 34 (36.2%) with TM and 56 (58.2%) with TI (p : 0.001). The mean serum ferritin levels were 3056.5±2306 and 666.2±616.5 in TM and TI respectively (p: 0.001). Three patients with TM (1.6%) had low basal cortisol and ACTH levels. However their cortisol response to ACTH stimulation was normal. Conclusions: Low basal concentrations of cortisol and ACTH occurred in 1.6% of our adolescents young adult patients with TM suggesting a central defect of cortisol secretion at the basal state. However, cortisol response to standard – dose ACTH was normal in all patients with TM and TI.

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

Blood ◽

10.1182/blood.v128.22.5640.5640 ◽

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.

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Long-acting intramuscular ACTH stimulation test for the diagnosis of secondary adrenal insufficiency in children

Journal of Pediatric Endocrinology and Metabolism ◽

10.1515/jpem-2018-0330 ◽

2019 ◽

Vol 32 (1) ◽

pp. 57-63 ◽

Cited By ~ 1

Author(s):

Rajni Sharma ◽

Shamnad Madathil ◽

Vivek Maheshwari ◽

Kakali Roy ◽

Brijesh Kumar ◽

...

Keyword(s):

Adrenal Insufficiency ◽

Serum Cortisol ◽

Diagnostic Value ◽

Tolerance Test ◽

Hormone Deficiency ◽

Cortisol Response ◽

Acth Test ◽

Acth Stimulation ◽

Long Acting ◽

Short Synacthen Test

Abstract Background The diagnosis of adrenal insufficiency (AI) is based on the basal and stimulated levels of serum cortisol in response to the short Synacthen test (SST). In patients with secondary AI (SAI) due to hypothalamic-pituitary-adrenal (HPA) axis defects, the SST has been validated against the insulin tolerance test (ITT), which is the gold standard. However, injection Synacthen is not easily available in some countries, and endocrinologists often use Acton-Prolongatum (intramuscular [IM] long-acting adrenocorticotropic hormone [ACTH]) in place of Synacthen. There are no studies validating the use of IM-ACTH in children with suspected AI. We evaluated the diagnostic value of the IM-ACTH test against the ITT for the diagnosis of SAI in children. Methods All children with suspected growth hormone deficiency (GHD) undergoing a routine ITT were evaluated using the IM-ACTH test within 1 week. Results Forty-eight patients (36 boys/12 girls, age range: 5–14 years) were evaluated using both the ITT and the IM-ACTH test. Twenty-eight patients had a normal cortisol response (≥18 μg/dL, 500 nmol/L) in the ITT and 20 had low values. In patients with a normal cortisol response on the ITT, the peak value obtained after the IM-ACTH test was higher than that on the ITT (28.7 μg/dL [± 8.8] vs. 23.8 μg/dL [± 4.54], respectively; p=0.0012). Compared to the ITT, the sensitivity and specificity of the IM-ACTH test for the diagnosis of SAI at cortisol cut-offs <18 μg/dL (500 nmol/L) and <22 μg/dL (600 nmol/L) were 57.1% and 92.8%, and 100% and 73.5%, respectively. Conclusions A peak cortisol value <18 μg/dL on the IM-ACTH test is highly suggestive of SAI, whereas a value >22 μg/dL rules out SAI.

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Predictive Factors of Adrenal Insufficiency in Outpatients with Indeterminate Serum Cortisol Levels: A Retrospective Study

Medicina ◽

10.3390/medicina56010023 ◽

2020 ◽

Vol 56 (1) ◽

pp. 23

Author(s):

Worapaka Manosroi ◽

Mattabhorn Phimphilai ◽

Jiraporn Khorana ◽

Pichitchai Atthakomol ◽

Tanyong Pipanmekaporn

Keyword(s):

Retrospective Study ◽

Adrenal Insufficiency ◽

Predictive Factors ◽

Tertiary Care ◽

Serum Cortisol ◽

Serum Cortisol Level ◽

Dynamic Tests ◽

Acth Stimulation ◽

Tertiary Care Medical Center ◽

Stimulation Tests

Background and Objectives: To diagnose adrenal insufficiency (AI), adrenocorticotropic hormone (ACTH) stimulation tests may need to be performed, but those tests may not be available in some institutions. In addition, they may not be necessary for some patients. The objective of this study was to identify clinical and biochemical factors that could facilitate AI diagnosis in outpatient departments and decrease the number of unnecessary dynamic tests. Materials and Methods: This seven-year retrospective study was performed in a tertiary care medical center. A total of 517 patients who had undergone ACTH stimulation tests in the outpatient department were identified. AI was described as a peak serum cortisol level of <18 µg/dL at 30 or 60 min after stimulation. The associations between clinical factors, biochemical factors, and AI were analyzed using the Poisson regression model and reported by the risk ratio (RR). Results: AI was identified in 128 patients (24.7%). Significant predictive factors for the diagnosis of AI were chronic kidney disease (RR = 2.52, p < 0.001), Cushingoid appearance (RR = 3.44, p < 0.001), nausea and/or vomiting (RR = 1.84, p = 0.003), fatigue (RR = 1.23, p < 0.001), serum basal cortisol <9 µg/dL (RR = 3.36, p < 0.001), serum cholesterol <150 mg/dL (RR = 1.26, p < 0.001), and serum sodium <135 mEq/L (RR = 1.09, p = 0.001). The predictive ability of the model was 83% based on the area under the curve. Conclusion: The easy-to-obtain clinical and biochemical factors identified may facilitate AI diagnosis and help identify patients with suspected AI. Using these factors in clinical practice may also reduce the number of nonessential dynamic tests for AI.

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MON-136 Reducing Unnecessary Inpatient Adrenocorticotropin Stimulation Tests

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.1372 ◽

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.

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