Cargando…

Careful Evaluation of Cosyntropin Dose in the Diagnosis of Adrenal Insufficiency

Introduction: The use of the 250μg cosyntropin dose or otherwise called high-dose ACTH test is the gold standard test for diagnosis of primary adrenal insufficiency. The 1μg dose test or the low-dose test is mostly reserved for diagnosis of secondary adrenal insufficiency. Careful consideration of t...

Descripción completa

Detalles Bibliográficos
Autores principales: Musurakis, Clio, Chitrakar, Solab, Sharag, Randa Eldin, Shrestha, Ekta, Pethe, Gauri, Qureshi, Faisal
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Oxford University Press 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8090221/
http://dx.doi.org/10.1210/jendso/bvab048.246
_version_ 1783687229793632256
author Musurakis, Clio
Chitrakar, Solab
Sharag, Randa Eldin
Shrestha, Ekta
Pethe, Gauri
Qureshi, Faisal
author_facet Musurakis, Clio
Chitrakar, Solab
Sharag, Randa Eldin
Shrestha, Ekta
Pethe, Gauri
Qureshi, Faisal
author_sort Musurakis, Clio
collection PubMed
description Introduction: The use of the 250μg cosyntropin dose or otherwise called high-dose ACTH test is the gold standard test for diagnosis of primary adrenal insufficiency. The 1μg dose test or the low-dose test is mostly reserved for diagnosis of secondary adrenal insufficiency. Careful consideration of the results produced during the diagnostic process is imperative to avoid mislabeling of patients with a disease that requires lifelong treatment. Case Report: This is the case of a 45-year-old female with a history of asthma and psoriasis who presented with emesis. Home medications included monthly TNF-alpha inhibitor injections for psoriasis, triamcinolone acetonide topical spray and budesonide-formoterol inhaler. On admission, she also had nausea, chills and diaphoresis, as well as palpitations, lightheadedness, and shortness of breath. When she arrived at the ER, vitals were remarkable for low blood pressure. Labs were unremarkable except for CMP concerning for anion gap metabolic acidosis, hyponatremia, and hypokalemia. A random serum cortisol was 6.4 mcg/dL, which was relatively low. ACTH was within normal range. Due to concern for adrenal insufficiency, a 1μg cosyntropin test was performed which showed a peak cortisol concentration of less than 18 mcg/dL. As the response was assessed as suboptimal, endocrinology was consulted to offer a treatment plan for steroids. However, the test was repeated using the gold standard 250μg cosyntropin dose and the patient then showed an adequate response and she was not started on steroids. Conclusions: This is a case that demonstrates how the 250 μg ACTH or high-dose stimulation test should be used for diagnosis of primary adrenal insufficiency (AI), as it is the gold standard. The 1 μg ACTH or low-dose stimulation test can be used for diagnosis of primary AI but only when the high dose test is not available. On the other hand, the 1 μg ACTH stimulation test has been shown to be more sensitive than the 250 μg test in diagnosing secondary adrenal insufficiency. When using the most appropriate test correctly, the clinician can only then offer the patient the best treatment strategies. Our patient did not require chronic replacement therapy. The steroids in this case could have harmed the patient as chronic administration could cause adrenal gland suppression.
format Online
Article
Text
id pubmed-8090221
institution National Center for Biotechnology Information
language English
publishDate 2021
publisher Oxford University Press
record_format MEDLINE/PubMed
spelling pubmed-80902212021-05-06 Careful Evaluation of Cosyntropin Dose in the Diagnosis of Adrenal Insufficiency Musurakis, Clio Chitrakar, Solab Sharag, Randa Eldin Shrestha, Ekta Pethe, Gauri Qureshi, Faisal J Endocr Soc Adrenal Introduction: The use of the 250μg cosyntropin dose or otherwise called high-dose ACTH test is the gold standard test for diagnosis of primary adrenal insufficiency. The 1μg dose test or the low-dose test is mostly reserved for diagnosis of secondary adrenal insufficiency. Careful consideration of the results produced during the diagnostic process is imperative to avoid mislabeling of patients with a disease that requires lifelong treatment. Case Report: This is the case of a 45-year-old female with a history of asthma and psoriasis who presented with emesis. Home medications included monthly TNF-alpha inhibitor injections for psoriasis, triamcinolone acetonide topical spray and budesonide-formoterol inhaler. On admission, she also had nausea, chills and diaphoresis, as well as palpitations, lightheadedness, and shortness of breath. When she arrived at the ER, vitals were remarkable for low blood pressure. Labs were unremarkable except for CMP concerning for anion gap metabolic acidosis, hyponatremia, and hypokalemia. A random serum cortisol was 6.4 mcg/dL, which was relatively low. ACTH was within normal range. Due to concern for adrenal insufficiency, a 1μg cosyntropin test was performed which showed a peak cortisol concentration of less than 18 mcg/dL. As the response was assessed as suboptimal, endocrinology was consulted to offer a treatment plan for steroids. However, the test was repeated using the gold standard 250μg cosyntropin dose and the patient then showed an adequate response and she was not started on steroids. Conclusions: This is a case that demonstrates how the 250 μg ACTH or high-dose stimulation test should be used for diagnosis of primary adrenal insufficiency (AI), as it is the gold standard. The 1 μg ACTH or low-dose stimulation test can be used for diagnosis of primary AI but only when the high dose test is not available. On the other hand, the 1 μg ACTH stimulation test has been shown to be more sensitive than the 250 μg test in diagnosing secondary adrenal insufficiency. When using the most appropriate test correctly, the clinician can only then offer the patient the best treatment strategies. Our patient did not require chronic replacement therapy. The steroids in this case could have harmed the patient as chronic administration could cause adrenal gland suppression. Oxford University Press 2021-05-03 /pmc/articles/PMC8090221/ http://dx.doi.org/10.1210/jendso/bvab048.246 Text en © The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society. https://creativecommons.org/licenses/by-nc-nd/4.0/This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/by-nc-nd/4.0/ (https://creativecommons.org/licenses/by-nc-nd/4.0/) ), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
spellingShingle Adrenal
Musurakis, Clio
Chitrakar, Solab
Sharag, Randa Eldin
Shrestha, Ekta
Pethe, Gauri
Qureshi, Faisal
Careful Evaluation of Cosyntropin Dose in the Diagnosis of Adrenal Insufficiency
title Careful Evaluation of Cosyntropin Dose in the Diagnosis of Adrenal Insufficiency
title_full Careful Evaluation of Cosyntropin Dose in the Diagnosis of Adrenal Insufficiency
title_fullStr Careful Evaluation of Cosyntropin Dose in the Diagnosis of Adrenal Insufficiency
title_full_unstemmed Careful Evaluation of Cosyntropin Dose in the Diagnosis of Adrenal Insufficiency
title_short Careful Evaluation of Cosyntropin Dose in the Diagnosis of Adrenal Insufficiency
title_sort careful evaluation of cosyntropin dose in the diagnosis of adrenal insufficiency
topic Adrenal
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8090221/
http://dx.doi.org/10.1210/jendso/bvab048.246
work_keys_str_mv AT musurakisclio carefulevaluationofcosyntropindoseinthediagnosisofadrenalinsufficiency
AT chitrakarsolab carefulevaluationofcosyntropindoseinthediagnosisofadrenalinsufficiency
AT sharagrandaeldin carefulevaluationofcosyntropindoseinthediagnosisofadrenalinsufficiency
AT shresthaekta carefulevaluationofcosyntropindoseinthediagnosisofadrenalinsufficiency
AT pethegauri carefulevaluationofcosyntropindoseinthediagnosisofadrenalinsufficiency
AT qureshifaisal carefulevaluationofcosyntropindoseinthediagnosisofadrenalinsufficiency