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Sbardella E, Isidori AM, Woods CP, Argese N, Tomlinson JW, Shine B, Jafar-Mohammadi B, Grossman AB. Baseline morning cortisol level as a predictor of pituitary-adrenal reserve: a comparison across three assays. Clin Endocrinol (Oxf) 2017; 86:177-184. [PMID: 27616279 DOI: 10.1111/cen.13232] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/16/2016] [Accepted: 09/07/2016] [Indexed: 12/18/2022]
Abstract
CONTEXT The short ACTH stimulation test (250 μg) is the dynamic test most frequently used to assess adrenal function. It is possible that a single basal cortisol could be used to predict the dynamic response, but research has been hampered by the use of different assays and thresholds. OBJECTIVE To propose a morning baseline cortisol criterion of three of the most commonly used modern cortisol immunoassays - Advia Centaur (Siemens), Architect (Abbott) and the Roche Modular System (Roche) - that could predict adrenal sufficiency. DESIGN Observational, retrospective cross-sectional study at two centres. PATIENTS AND MEASUREMENTS Retrospective analysis of the results of 1019 Short Synacthen tests (SSTs) with the Advia Centaur, 449 SSTs with the Architect and 2050 SSTs with the Roche Modular System assay. Serum cortisol levels were measured prior to injection of 250 μg Synacthen and after 30 min. Overall, we were able to collate data from a total of 3518 SSTs in 3571 patients. RESULTS Using receiver-operator curve analysis, baseline cortisol levels for predicting passing the SST with 100% specificity were 358 nmol/l for Siemens, 336 nmol/l for Abbott and 506 nmol/l for Roche. Utilizing these criteria, 589, 158 and 578 SSTs, respectively, for Siemens, Abbott and Roche immunoassays could have been avoided. CONCLUSIONS We have defined assay-specific morning cortisol levels that are able to predict the integrity of the hypothalamo-pituitary-adrenal axis. We propose that this represents a valid tool for the initial assessment of adrenal function and has the potential to obviate the need for dynamic testing in a significant number of patients.
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Affiliation(s)
- Emilia Sbardella
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Conor P Woods
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
| | - Nicola Argese
- Department of Endocrinology, S.S. Annunziata Hospital, Taranto, Italy
| | - Jeremy W Tomlinson
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
| | - Brian Shine
- Department of Clinical Biochemistry, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Bahram Jafar-Mohammadi
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
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Woods CP, Argese N, Chapman M, Boot C, Webster R, Dabhi V, Grossman AB, Toogood AA, Arlt W, Stewart PM, Crowley RK, Tomlinson JW. Adrenal suppression in patients taking inhaled glucocorticoids is highly prevalent and management can be guided by morning cortisol. Eur J Endocrinol 2015; 173:633-42. [PMID: 26294794 PMCID: PMC4588051 DOI: 10.1530/eje-15-0608] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 08/20/2015] [Indexed: 02/06/2023]
Abstract
CONTEXT Up to 3% of US and UK populations are prescribed glucocorticoids (GC). Suppression of the hypothalamo-pituitary-adrenal axis with the potential risk of adrenal crisis is a recognized complication of therapy. The 250 μg short Synacthen stimulation test (SST) is the most commonly used dynamic assessment to diagnose adrenal insufficiency. There are challenges to the use of the SST in routine clinical practice, including both the staff and time constraints and a significant recent increase in Synacthen cost. METHODS We performed a retrospective analysis to determine the prevalence of adrenal suppression due to prescribed GCs and the utility of a morning serum cortisol for rapid assessment of adrenal reserve in the routine clinical setting. RESULTS In total, 2773 patients underwent 3603 SSTs in a large secondary/tertiary centre between 2008 and 2013 and 17.9% (n=496) failed the SST. Of 404 patients taking oral, topical, intranasal or inhaled GC therapy for non-endocrine conditions, 33.2% (n=134) had a subnormal SST response. In patients taking inhaled GCs without additional GC therapy, 20.5% (34/166) failed an SST and suppression of adrenal function increased in a dose-dependent fashion. Using receiver operating characteristic curve analysis in patients currently taking inhaled GCs, a basal cortisol ≥348 nmol/l provided 100% specificity for passing the SST; a cortisol value <34 nmol/l had 100% sensitivity for SST failure. Using these cut-offs, 50% (n=83) of SSTs performed on patients prescribed inhaled GCs were unnecessary. CONCLUSION Adrenal suppression due to GC treatment, particularly inhaled GCs, is common. A basal serum cortisol concentration has utility in helping determine which patients should undergo dynamic assessment of adrenal function.
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Affiliation(s)
- Conor P Woods
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Nicola Argese
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Matthew Chapman
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Christopher Boot
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Rachel Webster
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Vijay Dabhi
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Ashley B Grossman
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Andrew A Toogood
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Wiebke Arlt
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Paul M Stewart
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Rachel K Crowley
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
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