Secondary adrenal insufficiency laboratory findings: Difference between revisions

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__NOTOC__
__NOTOC__
{{Adrenal insufficiency}}
{{Secondary adrenal insufficiency}}
{{CMG}}
{{CMG}} {{AE}} {{IQ}}
 


==Overview==
==Overview==
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
Laboratory findings consistent with the diagnosis of [[adrenal insufficiency]] may include [[eosinophilia]],[[lymphocytosis]],normocytic [[anemia]],[[hyponatremia]] , mild [[hypercalcemia]], and [[azotemia]]. Secondary [[adrenal insufficiency]] may be confirmed by dynamic tests such as [[insulin]] tolerance test and [[corticotropin]] stimulation test (standard and low dose). [[Adrenal]] function can be assessed by measuring basal [[ACTH]] secretion and [[ACTH]] reserve (via [[Metyrapone]] stimulation test).
 
OR
 
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
 
OR
 
[Test] is usually normal among patients with [disease name].
 
OR
 
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
 
OR
 
There are no diagnostic laboratory findings associated with [disease name].


==Laboratory Findings==
==Laboratory Findings==


*There are no diagnostic laboratory findings associated with [disease name].
OR
*An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
*[Test] is usually normal among patients with [disease name].
*Laboratory findings consistent with the diagnosis of [disease name] include
**[Abnormal test 1]
**[Abnormal test 2]
**[Abnormal test 3]
*Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
===Laboratory Findings===
====ACTH Stimulation Test====
If the person is in [[adrenal crisis]], the [[ACTH stimulation test]]<ref>{{cite journal|pmid=21656493 | doi=10.1024/0040-5930/a000174 | volume=68 | issue=6 | title=[Adrenal insufficiency--diagnosis and treatment in clinical practice] | year=2011 | month=June | author=Henzen C | journal=Ther Umsch | pages=337–43}}</ref>  may be given. If not in crisis, cortisol, ACTH, aldosterone, [[renin]], potassium and sodium are tested from a blood sample before the decision is made if the ACTH stimulation test needs to be performed. X-rays or CT of the adrenals may also be done. The best test for adrenal insufficiency of autoimmune origin, representing more than ninety percent of all cases in a Western population, is measurement of 21-hydroxylase autoantibodies.
{| border="4" cellspacing="1" cellpadding="4" style="text-align:center; margin:10px;"
{| border="4" cellspacing="1" cellpadding="4" style="text-align:center; margin:10px;"
|-
|-
| style="background:#ddcef2" | '''Source of pathology|| style="background:#cef2e0" |'''CRH|| style="background:#cef2e0" |'''ACTH|| style="background:#cef2e0" |'''DHEA|| style="background:#cef2e0" |'''DHEA-S|| style="background:#cef2e0" |'''cortisol||style="background:#cef2e0;" |'''aldosterone|| style="background:#cef2e0" |'''renin|| style="background:#cef2e0" |'''Na|| style="background:#cef2e0" |'''K|| style="background:#f2e0ce" |'''Causes'''<sup>5</sup>
| style="background:#ddcef2" | '''Source of pathology'''|| style="background:#cef2e0" |'''CRH'''|| style="background:#cef2e0" |'''ACTH'''|| style="background:#cef2e0" |'''DHEA'''|| style="background:#cef2e0" |'''DHEA-S'''|| style="background:#cef2e0" |'''cortisol'''|| style="background:#cef2e0;" |'''aldosterone'''|| style="background:#cef2e0" |'''renin'''|| style="background:#cef2e0" |'''Na'''|| style="background:#cef2e0" |'''K'''|| style="background:#f2e0ce" |'''Causes'''<sup>5</sup>
|-
|-
| style="background:#cedff2" | '''hypothalamus'''<br>(tertiary)<sup>1</sup>|| style="background:#F8F8F8" |low|| style="background:#F8F8F8"|low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low<sup>3</sup>||style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low||style="background:#F8F8F8" |tumor of the hypothalamus ([[adenoma]]), [[antibodies]], [[environment (biophysical)|environment]] (i.e. toxins), [[head injury]]
| style="background:#cedff2" | '''hypothalamus'''<br>(tertiary)<sup>1</sup>|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low<sup>3</sup>|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |tumor of the hypothalamus ([[adenoma]]), [[antibodies]], [[environment (biophysical)|environment]] (i.e. toxins), [[head injury]]
|-
|-
| style="background:#cedff2" | '''pituitary'''<br>(secondary)|| style="background:#F8F8F8" |high<sup>2</sup>|| style="background:#F8F8F8"|low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low<sup>3</sup>||style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low||style="background:#F8F8F8" |tumor of the pituitary ([[adenoma]]), antibodies, environment, head injury,<br>'''surgical removal'''<sup>6</sup>, [[Sheehan's syndrome]]
| style="background:#cedff2" | '''pituitary'''<br>(secondary)|| style="background:#F8F8F8" |high<sup>2</sup>|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low<sup>3</sup>|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |tumor of the pituitary ([[adenoma]]), antibodies, environment, head injury,<br>'''surgical removal'''<sup>6</sup>, [[Sheehan's syndrome]]
|-
|-
| style="background:#cedff2" | '''adrenal glands'''<br>(primary)<sup>7</sup>|| style="background:#F8F8F8" |high|| style="background:#F8F8F8"|high|| style="background:#F8F8F8" |high|| style="background:#F8F8F8" |high|| style="background:#F8F8F8" |low<sup>4</sup>||style="background:#F8F8F8" |low|| style="background:#F8F8F8" |high|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |high||style="background:#F8F8F8" |tumor of the adrenal (adenoma), [[Stress (biology)|stress]], antibodies, environment, [[Addison's Disease]], [[Physical trauma|trauma]], surgical removal ([[Segmental resection|resection]]), [[wikt:miliary|miliary]] [[tuberculosis]] of the adrenal
| style="background:#cedff2" | '''adrenal glands'''<br>(primary)<sup>7</sup>|| style="background:#F8F8F8" |high|| style="background:#F8F8F8" |high|| style="background:#F8F8F8" |high|| style="background:#F8F8F8" |high|| style="background:#F8F8F8" |low<sup>4</sup>|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |high|| style="background:#F8F8F8" |low|| style="background:#F8F8F8" |high|| style="background:#F8F8F8" |tumor of the adrenal (adenoma), [[Stress (biology)|stress]], antibodies, environment, [[Addison's Disease]], [[Physical trauma|trauma]], surgical removal ([[Segmental resection|resection]]), [[wikt:miliary|miliary]] [[tuberculosis]] of the adrenal
|}
|}


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====Routine Investigations====
====Routine Investigations====
* [[Complete blood count]] and differential count - [[Eosinophilia]] and [[lymphocytosis]] (increased number of [[eosinophil]]s or [[lymphocyte]]s, two types of [[white blood cell]]s).  [[Normocytic anemia]] may be present.
* [[Complete blood count]] and differential count:
**[[Eosinophilia]]
**[[Lymphocytosis]]
**[[Normocytic anemia]] may be present.
* Serum [[ACTH]] levels - elevated in primary adrenal insufficiency and decreased in secondary form.
* Serum [[ACTH]] levels - elevated in primary adrenal insufficiency and decreased in secondary form.
* [[Hypoglycemia]] - low blood sugar (worse in children)
* [[Hypoglycemia]]<ref name="pmid3002680">{{cite journal |vauthors=Burke CW |title=Adrenocortical insufficiency |journal=Clin Endocrinol Metab |volume=14 |issue=4 |pages=947–76 |year=1985 |pmid=3002680 |doi= |url=}}</ref><ref name="pmid12456538">{{cite journal |vauthors=Todd GR, Acerini CL, Ross-Russell R, Zahra S, Warner JT, McCance D |title=Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom |journal=Arch. Dis. Child. |volume=87 |issue=6 |pages=457–61 |year=2002 |pmid=12456538 |pmc=1755820 |doi= |url=}}</ref><ref name="pmid6276646">{{cite journal |vauthors=Stacpoole PW, Interlandi JW, Nicholson WE, Rabin D |title=Isolated ACTH deficiency: a heterogeneous disorder. Critical review and report of four new cases |journal=Medicine (Baltimore) |volume=61 |issue=1 |pages=13–24 |year=1982 |pmid=6276646 |doi= |url=}}</ref>
* [[Serum electrolytes]]:
* [[Serum electrolytes]]:
** [[Hyponatraemia]] - (low blood sodium levels)
** [[Hyponatraemia]] - (low blood sodium levels)<ref name="pmid27271953">{{cite journal |vauthors=Cuesta M, Garrahy A, Slattery D, Gupta S, Hannon AM, Forde H, McGurren K, Sherlock M, Tormey W, Thompson CJ |title=The contribution of undiagnosed adrenal insufficiency to euvolaemic hyponatraemia: results of a large prospective single-centre study |journal=Clin. Endocrinol. (Oxf) |volume=85 |issue=6 |pages=836–844 |year=2016 |pmid=27271953 |doi=10.1111/cen.13128 |url=}}</ref>
** [[Hyperkalemia]] - (raised blood [[potassium]] levels), due to loss of production of the hormone [[aldosterone]]
** [[Hyperkalemia]]- not present
** Mild [[hypercalcemia]] - in 20% patients
** Mild [[hypercalcemia]] - in 20% patients
** Mild non–anion-gap [[metabolic acidosis]]
** Mild non–anion-gap [[metabolic acidosis]]
* Serum [[cortisol]] - decreased (<25mcg/dL)
* Serum [[cortisol]] - decreased (<25mcg/dL)
* Urine and sweat [[sodium]] - elevated
* Urine and sweat [[sodium]] - elevated
* Elevated [[BUN]] and [[creatinine]] - when [[hypovolemia]] is the cause.
* Azotemia- Elevated [[BUN]] and [[creatinine]] - when [[hypovolemia]] is the cause.
* [[Prolactin]] - mild elevation may be present.
* [[Prolactin]] - mild elevation may be present.
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Hormone
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Test
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Procedure
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Normal response
|-
| rowspan="3" |'''ACTH'''
|'''[[Insulin]] tolerance'''
|
* Administer [[insulin]], 0.05–0.15 U/kg [[Intravenous|IV]]
* Sample [[blood]] at −30, 0, 30, 60, and 120 min for [[cortisol]] and [[glucose]]
|
* [[Glucose]] should drop <40 mg/dL (2.2 mmol/L)
* Peak [[cortisol]] should be >500–550 nmol/L (>18.1–20 μg/dL) depending on [[assay]]
|-
|'''[[Corticotropin]] standard dose (250 μg)'''
|
* Administer [[Adrenocorticotropic hormone|ACTH]] 1–24 ([[cosyntropin]]), 250 μg [[Intramuscular|IM]] or [[Intravenous|IV]]
* Sample blood at 0, 30, and 60 min for [[cortisol]]
|
* [[Cortisol]] should be at 30 or 60 min >500–550 nmol/L (>18.1–20 μg/dL) depending on [[assay]]
|-
|'''[[Corticotropin]] low dose (1 μg)'''
|
* Administer [[Adrenocorticotropic hormone|ACTH]] 1–24 ([[cosyntropin]]), 1 μg [[Intravenous|IV]]
* Sample [[blood]] at 0 and 30 min for [[cortisol]]
|
* [[Cortisol]] should be at 30 min >500 nmol/L (18.1 μg/dL) depending on [[assay]]
|-
|'''[[Antidiuretic hormone|ADH]]'''
|'''Water deprivation test''' 
|
* Initiate [[fluid]] deprivation for 8h (starting from 8 AM)
* Weigh patient at beginning of testing, then measure weight and [[urine]] volume hourly during the test
* Measure [[plasma]] and urine [[osmolality]] every 2–3 hours
* At 4 PM administer [[Desmopressin (patient information)|DDAVP]] 2 μg im and allow patient to drink freely
|[[Diabetes insipidus|'''Diabetes insipidus (DI)''']]: [[Plasma]] [[osmolality]] >295 mOsm/L with inappropriately [[hypotonic]] [[urine]] ([[urine]] [[osmolality]]/[[plasma]] [[osmolality]] ratio <2) during the [[fluid]] deprivation confirms [[Diabetes insipidus|DI]] (test is discontinued)
* '''[[Central DI]]:''' After administering [[Desmopressin (patient information)|DDAVP]], [[urine]] [[osmolality]] >800 mOsm/kg with [[central DI]]
* '''[[Nephrogenic DI]]:''' After administering [[DDAVP]], [[urine]] [[osmolality]] <300 mOsm/kg with [[nephrogenic DI]]
'''[[Polydipsia|Partial/primary polydipsia]]:''' With partial [[Diabetes insipidus|DI]] or primary [[polydipsia]], [[urine]] concentrates partially during the water deprivation test (300–800 mOsm/kg), and further investigation is required including a prolonged water deprivation test or [[DDAVP]] therapeutic trial
|}
===1.[[Corticotropin]]:===
==== (a) Basal [[Adrenocorticotropic hormone|ACTH]] secretion: ====
The normal range of [[serum]] [[cortisol]] is 5 to 25 mcg/dL (138 to 690 nmol/L). [[Serum]] [[cortisol]] levels are measured at 8 to 9 am and results are interpreted as follows:
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Serum cortisol
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Basal adrenocorticotrophic hormone (ACTH)
|-
|'''Low''': ≤3 mcg/dL (83 nmol/L)
|[[Cortisol]] deficiency
|-
|'''High''': ≥18 mcg/dL (497 nmol/L)
|No [[cortisol]] deficiency even in times of stress
|-
|'''Intermediate''': >3 mcg/dL (83 nmol/L) 
but
<18 mcg/dL (497 nmol/L)
|Needs evaluation for [[Adrenocorticotropic hormone|ACTH]] reserve
|}
==== (b) [[Adrenocorticotropic hormone|ACTH]] reserve: ====
*Patients with intermediate [[cortisol]] levels need to be tested for [[Adrenocorticotropic hormone|ACTH]] reserve. There are several tests to check the [[Adrenocorticotropic hormone|ACTH]] reserve. [[Metyrapone]] test is preferred over others as it is applicable to all adults with no age restriction and has good correlation with [[stress]] related [[cortisol]] response. The major disadvantage of the test is that it needs [[inpatient]] observation for [[blood pressure]] and [[Pulse|pulse monitoring]] to prevent [[postural hypotension]].
*[[Insulin]]-induced [[hypoglycemia]] test is not preferred as it needs continuous monitoring for [[hypoglycemic]] [[symptoms]] during the first hour of [[insulin]] administration in patients who are elderly and have [[cardiovascular]] or [[Cerebrovascular disease|cerebrovascular]] issues or a [[seizure disorder]]. [[Hypoglycemia]] is treated with [[intravenous]] [[glucose]]. The standard or low dose [[ACTH stimulation test|cosynotropin stimulation test]] is not recommended as it can give falsely normal results.<ref name="pmid4330677">{{cite journal |vauthors=Spark RF |title=Simplified assessment of pituitary-adrenal reserve. Measurement of serum 11-deoxycortisol and cortisol after metyrapone |journal=Ann. Intern. Med. |volume=75 |issue=5 |pages=717–23 |year=1971 |pmid=4330677 |doi= |url=}}</ref><ref name="pmid4313728">{{cite journal |vauthors=Jubiz W, Meikle AW, West CD, Tyler FH |title=Single-dose metyrapone test |journal=Arch. Intern. Med. |volume=125 |issue=3 |pages=472–4 |year=1970 |pmid=4313728 |doi= |url=}}</ref><ref name="pmid5949228">{{cite journal |vauthors=Landon J, Greenwood FC, Stamp TC, Wynn V |title=The plasma sugar, free fatty acid, cortisol, and growth hormone response to insulin, and the comparison of this procedure with other tests of pituitary and adrenal function. II. In patients with hypothalamic or pituitary dysfunction or anorexia nervosa |journal=J. Clin. Invest. |volume=45 |issue=4 |pages=437–49 |year=1966 |pmid=5949228 |pmc=292718 |doi=10.1172/JCI105358 |url=}}</ref><ref name="pmid8550765">{{cite journal |vauthors=Streeten DH, Anderson GH, Bonaventura MM |title=The potential for serious consequences from misinterpreting normal responses to the rapid adrenocorticotropin test |journal=J. Clin. Endocrinol. Metab. |volume=81 |issue=1 |pages=285–90 |year=1996 |pmid=8550765 |doi=10.1210/jcem.81.1.8550765 |url=}}</ref><ref name="pmid8849565">{{cite journal |vauthors=Soule SG, Fahie-Wilson M, Tomlinson S |title=Failure of the short ACTH test to unequivocally diagnose long-standing symptomatic secondary hypoadrenalism |journal=Clin. Endocrinol. (Oxf) |volume=44 |issue=2 |pages=137–40 |year=1996 |pmid=8849565 |doi= |url=}}</ref><ref name="pmid2005201">{{cite journal |vauthors=Dickstein G, Shechner C, Nicholson WE, Rosner I, Shen-Orr Z, Adawi F, Lahav M |title=Adrenocorticotropin stimulation test: effects of basal cortisol level, time of day, and suggested new sensitive low dose test |journal=J. Clin. Endocrinol. Metab. |volume=72 |issue=4 |pages=773–8 |year=1991 |pmid=2005201 |doi=10.1210/jcem-72-4-773 |url=}}</ref><ref name="pmid9589655">{{cite journal |vauthors=Mayenknecht J, Diederich S, Bähr V, Plöckinger U, Oelkers W |title=Comparison of low and high dose corticotropin stimulation tests in patients with pituitary disease |journal=J. Clin. Endocrinol. Metab. |volume=83 |issue=5 |pages=1558–62 |year=1998 |pmid=9589655 |doi=10.1210/jcem.83.5.4831 |url=}}</ref><ref name="pmid10931104">{{cite journal |vauthors=Soule S, Van Zyl Smit C, Parolis G, Attenborough S, Peter D, Kinvig S, Kinvig T, Coetzer E |title=The low dose ACTH stimulation test is less sensitive than the overnight metyrapone test for the diagnosis of secondary hypoadrenalism |journal=Clin. Endocrinol. (Oxf) |volume=53 |issue=2 |pages=221–7 |year=2000 |pmid=10931104 |doi= |url=}}</ref><ref name="pmid11894974">{{cite journal |vauthors=Nye EJ, Grice JE, Hockings GI, Strakosch CR, Crosbie GV, Walters MM, Torpy DJ, Jackson RV |title=Adrenocorticotropin stimulation tests in patients with hypothalamic-pituitary disease: low dose, standard high dose and 8-h infusion tests |journal=Clin. Endocrinol. (Oxf) |volume=55 |issue=5 |pages=625–33 |year=2001 |pmid=11894974 |doi= |url=}}</ref><ref name="pmid11966747">{{cite journal |vauthors=Suliman AM, Smith TP, Labib M, Fiad TM, McKenna TJ |title=The low-dose ACTH test does not provide a useful assessment of the hypothalamic-pituitary-adrenal axis in secondary adrenal insufficiency |journal=Clin. Endocrinol. (Oxf) |volume=56 |issue=4 |pages=533–9 |year=2002 |pmid=11966747 |doi= |url=}}</ref><ref name="pmid26649617">{{cite journal |vauthors=Ospina NS, Al Nofal A, Bancos I, Javed A, Benkhadra K, Kapoor E, Lteif AN, Natt N, Murad MH |title=ACTH Stimulation Tests for the Diagnosis of Adrenal Insufficiency: Systematic Review and Meta-Analysis |journal=J. Clin. Endocrinol. Metab. |volume=101 |issue=2 |pages=427–34 |year=2016 |pmid=26649617 |doi=10.1210/jc.2015-1700 |url=}}</ref>
*The [[corticotropin-releasing hormone]] test indicates [[Pituitary gland|pituitary]]-[[Adrenal gland|adrenal]] function and is as reliable as [[insulin]]-induced [[hypoglycemia]] test but has a limitation that only a small number of patients can be evaluated and may cause transient [[nausea]].
==== Metyrapone test: ====
[[Metyrapone]] blocks [[11-b-hydroxylase deficiency|11-beta-hydroxylase]] (CYP11B1), an [[enzyme]] that [[catalyzes]] the last step in [[cortisol]] production resulting in decreased [[cortisol]] and increased [[11-Deoxycortisol|11-deoxycortisol]] concentration. In this test 750 mg of [[Metyrapone]] is administered [[Oral|orally]] every 4 hours for 24 hours. Serum [[cortisol]] and [[11-Deoxycortisol|11-deoxycortisol]] concentration are checked at 8 am after 24 hours and the results are interpreted as follows:
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Subject
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Cortisol level
! align="center" style="background:#4479BA; color: #FFFFFF;" + |11-deoxycortisol level
|-
|Normal subjects
|< 7 mcg/dL (172 nmol/L)
|≥10 mcg/dL (289 nmol/L)
|-
|Patients with decreased [[Adrenocorticotropic hormone|ACTH]] reserve
|<7 mcg/dL (172 nmol/L)
|<10 mcg/dL (289 nmol/L)
|}


==References==
==References==
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[[Category:Needs content]]
[[Category:Needs content]]
[[Category:Endocrinology]]
[[Category:Needs overview]]


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Latest revision as of 13:39, 16 November 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Overview

Laboratory findings consistent with the diagnosis of adrenal insufficiency may include eosinophilia,lymphocytosis,normocytic anemia,hyponatremia , mild hypercalcemia, and azotemia. Secondary adrenal insufficiency may be confirmed by dynamic tests such as insulin tolerance test and corticotropin stimulation test (standard and low dose). Adrenal function can be assessed by measuring basal ACTH secretion and ACTH reserve (via Metyrapone stimulation test).

Laboratory Findings

Source of pathology CRH ACTH DHEA DHEA-S cortisol aldosterone renin Na K Causes5
hypothalamus
(tertiary)1		 low low low low low3 low low low low tumor of the hypothalamus (adenoma), antibodies, environment (i.e. toxins), head injury
pituitary
(secondary)		 high2 low low low low3 low low low low tumor of the pituitary (adenoma), antibodies, environment, head injury,
surgical removal6, Sheehan's syndrome
adrenal glands
(primary)7		 high high high high low4 low high low high tumor of the adrenal (adenoma), stress, antibodies, environment, Addison's Disease, trauma, surgical removal (resection), miliary tuberculosis of the adrenal
1 Automatically includes diagnosis of secondary (hypopituitarism)
2 Only if CRH production in the hypothalamus is intact
3 Value doubles or more in stimulation
4 Value less than doubles in stimulation
5 Most common, does not include all possible causes
6 Usually because of very large tumor (macroadenoma)
7 Includes Addison's disease

Routine Investigations

Hormone Test Procedure Normal response
ACTH Insulin tolerance
  • Glucose should drop <40 mg/dL (2.2 mmol/L)
  • Peak cortisol should be >500–550 nmol/L (>18.1–20 μg/dL) depending on assay
Corticotropin standard dose (250 μg)
  • Sample blood at 0, 30, and 60 min for cortisol
  • Cortisol should be at 30 or 60 min >500–550 nmol/L (>18.1–20 μg/dL) depending on assay
Corticotropin low dose (1 μg)
  • Cortisol should be at 30 min >500 nmol/L (18.1 μg/dL) depending on assay
ADH Water deprivation test 
  • Initiate fluid deprivation for 8h (starting from 8 AM)
  • Weigh patient at beginning of testing, then measure weight and urine volume hourly during the test
  • At 4 PM administer DDAVP 2 μg im and allow patient to drink freely
 Diabetes insipidus (DI): Plasma osmolality >295 mOsm/L with inappropriately hypotonic urine (urine osmolality/plasma osmolality ratio <2) during the fluid deprivation confirms DI (test is discontinued)

Partial/primary polydipsia: With partial DI or primary polydipsia, urine concentrates partially during the water deprivation test (300–800 mOsm/kg), and further investigation is required including a prolonged water deprivation test or DDAVP therapeutic trial

1.Corticotropin:

(a) Basal ACTH secretion:

The normal range of serum cortisol is 5 to 25 mcg/dL (138 to 690 nmol/L). Serum cortisol levels are measured at 8 to 9 am and results are interpreted as follows:

Serum cortisol Basal adrenocorticotrophic hormone (ACTH)
Low: ≤3 mcg/dL (83 nmol/L) Cortisol deficiency
High: ≥18 mcg/dL (497 nmol/L) No cortisol deficiency even in times of stress
Intermediate: >3 mcg/dL (83 nmol/L) 

but

<18 mcg/dL (497 nmol/L)

Needs evaluation for ACTH reserve

(b) ACTH reserve:

Metyrapone test:

Metyrapone blocks 11-beta-hydroxylase (CYP11B1), an enzyme that catalyzes the last step in cortisol production resulting in decreased cortisol and increased 11-deoxycortisol concentration. In this test 750 mg of Metyrapone is administered orally every 4 hours for 24 hours. Serum cortisol and 11-deoxycortisol concentration are checked at 8 am after 24 hours and the results are interpreted as follows:

Subject Cortisol level 11-deoxycortisol level
Normal subjects < 7 mcg/dL (172 nmol/L) ≥10 mcg/dL (289 nmol/L)
Patients with decreased ACTH reserve <7 mcg/dL (172 nmol/L) <10 mcg/dL (289 nmol/L)

References

  1. ↑ Burke CW (1985). "Adrenocortical insufficiency". Clin Endocrinol Metab. 14 (4): 947–76. PMID 3002680.
  2. ↑ Todd GR, Acerini CL, Ross-Russell R, Zahra S, Warner JT, McCance D (2002). "Survey of adrenal crisis associated with inhaled corticosteroids in the United Kingdom". Arch. Dis. Child. 87 (6): 457–61. PMC 1755820. PMID 12456538.
  3. ↑ Stacpoole PW, Interlandi JW, Nicholson WE, Rabin D (1982). "Isolated ACTH deficiency: a heterogeneous disorder. Critical review and report of four new cases". Medicine (Baltimore). 61 (1): 13–24. PMID 6276646.
  4. ↑ Cuesta M, Garrahy A, Slattery D, Gupta S, Hannon AM, Forde H, McGurren K, Sherlock M, Tormey W, Thompson CJ (2016). "The contribution of undiagnosed adrenal insufficiency to euvolaemic hyponatraemia: results of a large prospective single-centre study". Clin. Endocrinol. (Oxf). 85 (6): 836–844. doi:10.1111/cen.13128. PMID 27271953.
  5. ↑ Spark RF (1971). "Simplified assessment of pituitary-adrenal reserve. Measurement of serum 11-deoxycortisol and cortisol after metyrapone". Ann. Intern. Med. 75 (5): 717–23. PMID 4330677.
  6. ↑ Jubiz W, Meikle AW, West CD, Tyler FH (1970). "Single-dose metyrapone test". Arch. Intern. Med. 125 (3): 472–4. PMID 4313728.
  7. ↑ Landon J, Greenwood FC, Stamp TC, Wynn V (1966). "The plasma sugar, free fatty acid, cortisol, and growth hormone response to insulin, and the comparison of this procedure with other tests of pituitary and adrenal function. II. In patients with hypothalamic or pituitary dysfunction or anorexia nervosa". J. Clin. Invest. 45 (4): 437–49. doi:10.1172/JCI105358. PMC 292718. PMID 5949228.
  8. ↑ Streeten DH, Anderson GH, Bonaventura MM (1996). "The potential for serious consequences from misinterpreting normal responses to the rapid adrenocorticotropin test". J. Clin. Endocrinol. Metab. 81 (1): 285–90. doi:10.1210/jcem.81.1.8550765. PMID 8550765.
  9. ↑ Soule SG, Fahie-Wilson M, Tomlinson S (1996). "Failure of the short ACTH test to unequivocally diagnose long-standing symptomatic secondary hypoadrenalism". Clin. Endocrinol. (Oxf). 44 (2): 137–40. PMID 8849565.
  10. ↑ Dickstein G, Shechner C, Nicholson WE, Rosner I, Shen-Orr Z, Adawi F, Lahav M (1991). "Adrenocorticotropin stimulation test: effects of basal cortisol level, time of day, and suggested new sensitive low dose test". J. Clin. Endocrinol. Metab. 72 (4): 773–8. doi:10.1210/jcem-72-4-773. PMID 2005201.
  11. ↑ Mayenknecht J, Diederich S, Bähr V, Plöckinger U, Oelkers W (1998). "Comparison of low and high dose corticotropin stimulation tests in patients with pituitary disease". J. Clin. Endocrinol. Metab. 83 (5): 1558–62. doi:10.1210/jcem.83.5.4831. PMID 9589655.
  12. ↑ Soule S, Van Zyl Smit C, Parolis G, Attenborough S, Peter D, Kinvig S, Kinvig T, Coetzer E (2000). "The low dose ACTH stimulation test is less sensitive than the overnight metyrapone test for the diagnosis of secondary hypoadrenalism". Clin. Endocrinol. (Oxf). 53 (2): 221–7. PMID 10931104.
  13. ↑ Nye EJ, Grice JE, Hockings GI, Strakosch CR, Crosbie GV, Walters MM, Torpy DJ, Jackson RV (2001). "Adrenocorticotropin stimulation tests in patients with hypothalamic-pituitary disease: low dose, standard high dose and 8-h infusion tests". Clin. Endocrinol. (Oxf). 55 (5): 625–33. PMID 11894974.
  14. ↑ Suliman AM, Smith TP, Labib M, Fiad TM, McKenna TJ (2002). "The low-dose ACTH test does not provide a useful assessment of the hypothalamic-pituitary-adrenal axis in secondary adrenal insufficiency". Clin. Endocrinol. (Oxf). 56 (4): 533–9. PMID 11966747.
  15. ↑ Ospina NS, Al Nofal A, Bancos I, Javed A, Benkhadra K, Kapoor E, Lteif AN, Natt N, Murad MH (2016). "ACTH Stimulation Tests for the Diagnosis of Adrenal Insufficiency: Systematic Review and Meta-Analysis". J. Clin. Endocrinol. Metab. 101 (2): 427–34. doi:10.1210/jc.2015-1700. PMID 26649617.

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