cosyntropin (ACTH, Cortrosyn) stimulation test (delta cortisol test)
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Indications
- test of choice for diagnosis of adrenal insufficiency in most settings
- most useful when AM serum cortisole is 4-12 ug/dL
Contraindications
Procedure
- A baseline cortisol level is drawn
- 250 ug of ACTH (cosyntropin or Cortrosyn) is injected IV or IM
- plasma cortisol is measured 30 & 60 min later
- aldosterone response to ACTH stimulation may also be measured in connection with serum ACTH to distinguish primary from secondary adrenal insufficiency
- serum aldosterone is measured from the samples collected at baseline, 30 & 60 minutes for cortisol determination (see above)
- serum 17-hydroxyprogesteone &/or serum 17-hydroxypregnenolone may also be measured
Interpretation
- a normal response is a stimulated cortisol of > 18-20 ug/dL
- this test detects both primary & secondary adrenal failure except within a few weeks of onset of pituitary dysfunction
- in an ICU setting, diagnosis of adrenal insufficiency[5]
- ruled in
- baseline serum cortisol < 10 ug/dL
- increase of < 9 ug/dL after adrenal stimulation
- ruled out
- stimulated cortisol to > 44 ug/dL
- increase of serum cortisol > 17 ug/dL after stimulation
- other values indeterminant
- ruled in
| Chronic low-dose steroids suppressive response to some degree | ||
|---|---|---|
| agent | baseline cortisol | cortisol 60 min post ACTH |
| placebo | 12.6 ug/dL | 28.6 ug/dL |
| budesonide 3 mg QD | 12.4 ug/dL | 23.4 ug/dL |
| budesonide 9 mg QD | 10.4 ug/dL | 19.8 ug/dL |
| prednisolone 7.5 mg QD | 9.1 ug//dL | 18.5 ug/dL |
- peak serum aldosterone levels < 4 ng/mL suggest primary adrenal insufficiency
Management
- in the case of suspected acute adrenal insufficiency (Addisonian crisis), therapy must not be delayed
- if dexamethasone is used in the initial therapy, the cosyntropin stimulation test can still be performed because dexamethasone does not interfere with cortisol measurements
More general terms
Additional terms
- Addison's disease (primary adrenal failure)
- adrenocorticotropic hormone; corticotropin; adrenocorticotropin (ACTH)
- aldosterone (Electrocortin, Aldocortin)
- cortisol; hydrocortisone (Cortef, Solu-Cortef, Alphaderm, Cetacort, Cortenema, Nutracort)
- cosyntropin (Cortrosyn)
- secondary adrenal insufficiency (SAI)
References
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995,l pg 474
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 654
- ↑ Medical Knowledge Self Assessment Program (MKSAP) 11, 17. American College of Physicians, Philadelphia 1998, 2015
- ↑ Kirwan JR et al, The effect of therapeutic glucocorticoids on the adrenal response in a randomized controlled trial in patients with rheumatoid arthritis. Arthritis Rheum 2006; 54:1415 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16645969
- ↑ 5.0 5.1 Annane D et al, Diagnosis of adrenal insufficiency in severe sepsis and septic shock. Am J Respir Crit Care Med 2006, 174:1319 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16973979
Meyer NJ and Hall JB Relative adrenal insufficiency in the ICU: Can we at least make the diagnosis? Am J Respir Crit Care Med 2006, 174:1282 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17158285