Morning salivary cortisol versus short Synacthen test as a test of adrenal suppression

Glucocorticoid Withdrawal-An Overview on When and How to Diagnose Adrenal Insufficiency in Clinical Practice

Glucocorticoids (GCs) are widely used due to their anti-inflammatory and immunosuppressive effects. As many as 1-3% of the population are currently on GC treatment. Prolonged therapy with GCs is associated with an increased risk of GC-induced adrenal insufficiency (AI). AI is a rare and often underdiagnosed clinical condition characterized by deficient GC production by the adrenal cortex. AI can be life-threatening; therefore, it is essential to know how to diagnose and treat this disorder. Not only oral but also inhalation, topical, nasal, intra-articular and intravenous administration of GCs may lead to adrenal suppression. Moreover, recent studies have proven that short-term (<4 weeks), as well as low-dose (<5 mg prednisone equivalent per day) GC treatment can also suppress the hypothalamic-pituitary-adrenal axis. Chronic therapy with GCs is the most common cause of AI. GC-induced AI remains challenging for clinicians in everyday patient care. Properly conducted GC withdrawal is crucial in preventing GC-induced AI; however, adrenal suppression may occur despite following recommended GC tapering regimens. A suspicion of GC-induced AI requires careful diagnostic workup and prompt introduction of a GC replacement treatment. The present review provides a summary of current knowledge on the management of GC-induced AI, including diagnostic methods, treatment schedules, and GC withdrawal regimens in adults.

Treatment with Intravenous Methylprednisolone in Patients with Graves' Orbitopathy Significantly Affects Adrenal Function: Assessment of Serum, Salivary Cortisol and Serum Dehydroepiandrosterone Sulfate

Treatment of active, moderate-to-severe Graves’ orbitopathy (GO) is the administration of intravenous methylprednisolone (IVMP). IVMP may be followed by additional therapy with oral prednisone. The aim of this study was to analyze the impact of IVMP on adrenal function by evaluation of serum, salivary cortisol and serum dehydroepiandrosterone sulfate (DHEA-S). Fourteen patients received IVMP treatment (cumulative dose of 4.5 g in 12 weekly infusions) followed by oral prednisone (for three months). All patients showed normal adrenal function before the 12th IVMP pulse and one patient was diagnosed with secondary adrenal insufficiency (AI) after prednisone treatment. DHEA-S was significantly lower before the 12th IVMP pulse and after oral prednisone (p = 0.015 and p = 0.00002, respectively) in comparison to evaluation before therapy. DHEA-S levels were below the reference range in one and three patients before the 12th IVMP pulse and after prednisone therapy, respectively. We observed decreased serum (p = 0.05) and salivary (p = 0.011) cortisol levels after oral prednisone therapy in comparison to evaluation before therapy. Treatment with IVMP in a cumulative dose of 4.5 g affects adrenal function, causing more severe impairment of DHEA-S secretion than that of cortisol but does not cause secondary AI. Additional therapy with oral glucocorticoids after IVMP can cause secondary AI.

Low salivary cortisol levels in patients with rheumatoid arthritis exposed to oral glucocorticoids: a cross-sectional study set within UK electronic health records

BACKGROUND

Glucocorticoids (GCs) suppress endogenous cortisol levels which can lead to adrenal insufficiency (AI). The frequency of GC-induced AI remains unclear. In this cross-sectional study, low morning salivary cortisol (MSC) levels were used as a measure of adrenal function. The study aim was to investigate the prevalence of low MSC in patients with rheumatoid arthritis (RA) currently and formerly exposed to oral GCs, and the association with potential risk factors.

METHODS

Sample collection was nested within UK primary care electronic health records (from the Clinical Practice Research Datalink). Participants were patients with RA with at least one prescription for oral GCs in the past 2 years. Self-reported oral GC use was used to define current use and current dose; prescription data were used to define exposure duration. MSC was determined from saliva samples; 5 nmol/L was the cut-off for low MSC. The prevalence of low MSC was estimated, and logistic regression was used to assess the association with potential risk factors.

RESULTS

66% of 38 current and 11 % of 38 former GC users had low MSC. Among former users with low MSC, the longest time since GC withdrawal was 6 months. Current GC dose, age and RA duration were significantly associated with increased risk of low MSC.

CONCLUSION

The prevalence of low MSC among current GC users is high, and MSC levels may remain suppressed for several months after GC withdrawal. Clinicians should therefore consider the risk of suppressed cortisol and remain vigilant for symptoms of AI following GC withdrawal.

Salivary cortisol and cortisone in the clinical setting

PURPOSE OF REVIEW

A resurgence of interest in salivary biomarkers has generated evidence for their value in assessing adrenal function. The advantages of salivary measurements include only free hormone is detected, samples can be collected during normal daily routines and stress-induced cortisol release is less likely to occur than during venepuncture. We review the use of salivary biomarkers to diagnose and monitor patients for conditions of cortisol excess and deficiency and discuss the value of measuring salivary cortisone versus salivary cortisol.

RECENT FINDINGS

Developments in laboratory techniques have enabled the measurement of salivary hormones with a high level of sensitivity and specificity. In states of altered cortisol binding, salivary biomarkers are more accurate measures of adrenal reserve than serum cortisol. Salivary cortisone is a superior marker of serum cortisol compared with salivary cortisol, specifically when serum cortisol is low and during hydrocortisone therapy when contamination of saliva may result in misleading salivary cortisol concentrations.

SUMMARY

Salivary cortisol and cortisone can be used to assess cortisol excess, deficiency and hydrocortisone replacement, with salivary cortisone having the advantage of detection when serum cortisol levels are low and there is no interference from oral hydrocortisone.

Cortisol secretion in children with symptoms of reactive attachment disorder

Maltreated children with reactive attachment disorder (RAD) have severe problems with social relationships and affect regulation. An association between early maltreatment and changes in the daily rhythm of cortisol secretion has already been reported for maltreated toddlers. We sought to find out whether such changes were apparent in school-age children with symptoms of RAD, who had experienced early maltreatment but were currently adopted in well-functioning families. We recruited 66 children: 34 adopted children, aged 5-12 years, with an early history of maltreatment and with social difficulties such as indiscriminate friendliness; and 32 age- and sex-matched comparison children with no history of maltreatment or social difficulties. Daily rhythms of cortisol production were determined from saliva samples collected over 2 days. The adopted group had significantly lower absolute levels of cortisol compared to the control group, but a typical profile of cortisol secretion. There was no association between cortisol secretion and symptom scores for psychopathology.

Inadequacies of glucocorticoid replacement and improvements by physiological circadian therapy

Patients with adrenal insufficiency need lifelong glucocorticoid replacement, but many suffer from poor quality of life, and overall there is increased mortality. Moreover, it appears that use of glucocorticoids at the higher end of the replacement dose range is associated with increased risk for cardiovascular and metabolic bone disease. These data highlight some of the inadequacies of current regimes. The cortisol production rate is estimated to be equivalent to 5.7-7.4 mg/m(2) per day, and a major difficulty for replacement regimes is the inability to match the distinct circadian rhythm of circulating cortisol levels, which are low at the time of sleep onset, rise between 0200 and 0400 h, peaking just after waking and then fall during the day. Another issue is that current dose equivalents of glucocorticoids used for replacement are based on anti-inflammatory potency, and few data exist as to doses needed for equivalent cardiovascular and bone effects. Weight-adjusted, thrice-daily dosing using hydrocortisone (HC) reduces glucocorticoid overexposure and represents the most refined regime for current oral therapy, but does not replicate the normal cortisol rhythm. Recently, proof-of-concept studies have shown that more physiological circadian glucocorticoid therapy using HC infusions and newly developed oral formulations of HC have the potential for better biochemical control in patients with adrenal insufficiency. Whether such physiological replacement will have an impact on the complications seen in patients with adrenal insufficiency will need to be analysed in future clinical trials.

Salivary steroid assays – research or routine?

Salivary concentrations of unconjugated steroids reflect those for free steroids in serum although concentrations may differ because of salivary gland metabolism. Samples for salivary steroid analysis are stable for up to 7 days at room temperature, one month or more at 4°C and three months or more at −20°C. When assessed against strict criteria, the evidence shows that salivary cortisol in evening samples or following dexamethasone suppression provides a reliable and effective screen for Cushing's syndrome. Sequential salivary cortisol measurements are also extremely helpful for the investigation of suspected cyclical Cushing's syndrome. There is potential for the identification of adrenal insufficiency when used with Synacthen stimulation. Salivary 17-hydroxyprogesterone and androstenedione assays are valued as non-invasive tests for the home-monitoring of hydrocortisone replacement therapy in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. The diagnostic value of salivary oestradiol, progesterone, testosterone, dehydroepiandrosterone and aldosterone testing is compromised by rapid fluctuations in salivary concentrations of these steroids. Multiple samples are required to obtain reliable information, and at present the introduction of these assays into routine laboratory testing is not justified.

Exacerbation of hepatitis C induced subclinical hypoadrenalism by Interferon-alpha2beta: A case report

Adrenal disease is an uncommon manifestation of hepatitis C infection and its related treatment regimen. This is a case of subclinical hypoadrenalism, probably induced by hepatitis C infection and further exacerbated by interferon-α2β and Ribavirin therapy. The adrenal deterioration during the treatment course was observed closely with 24-hour salivary profiles and 250 μg adrenocorticotropin stimulation tests using parallel serum and salivary cortisol concentrations. A number of possible pathogenic mechanisms are discussed, and the controversy over its management is emphasized.

Variability in hydrocortisone plasma and saliva pharmacokinetics following intravenous and oral administration to patients with adrenal insufficiency

OBJECTIVE

The best method for determining hydrocortisone replacement therapy is not well defined. This study aimed to assess interindividual variability in cortisol pharmacokinetics and to investigate whether measurement of salivary cortisol provides a useful alternative to plasma concentration measurements.

DESIGN

Intravenous (IV) and oral crossover.

PATIENTS

Twenty-seven patients with primary or secondary adrenal insufficiency who had been on stable replacement therapy for at least 3 months.

MEASUREMENTS

Plasma and salivary concentrations of cortisol were measured up to 8 h following administration of hydrocortisone.

RESULTS

After IV administration, Cmax ranged from 715 to 8313 nmol/l, area under the curve (AUC) from 1112 to 12 177 nmol h/l and cortisol clearance had a median (range) of 0.267 (0.076-0.540) l/h/kg. After oral administration, Cmax ranged from 422 to 1554 nmol/l, AUC 1081-5471 nmol h/l and oral clearance had a median (range) of 0.267 (0.081-0.363) l/h/kg. There was no clear relationship between paired saliva and plasma cortisol concentrations after IV or oral dosing. Plasma and salivary AUC(2-8 h) after IV administration were highly correlated (r2 = 0.77) but differences between predicted and measured plasma AUCs ranged from 3% to 90%. There was a poor correlation between plasma and saliva AUC(2-6 h) after oral administration (r2 = 0.16).

CONCLUSIONS

The wide interindividual variability in plasma and salivary profiles of cortisol following the administration of IV and oral hydrocortisone to patients with adrenal insufficiency and the poor correlation between salivary and plasma measurements suggest that salivary cortisol measurements cannot be used for individual hydrocortisone dosage adjustment.

Adrenal suppression and osteoporosis after treatment of nasal polyposis

CONCLUSION

Patients with severe nasal polyposis (NP) and a high steroid consumption have a high prevalence of glucocorticoid-induced osteoporosis and secondary adrenal insufficiency.

OBJECTIVES

To evaluate the risk of complications of the medical treatment in patients presenting with the diagnosis of NP.

PATIENTS AND METHODS

This was a prospective study. A total of 46 consecutive patients with NP were included when the oral steroid consumption during the past year was greater than three short courses of systemic steroid treatment (i.e. more than 21 days per year of treatment, prednisolone 1 mg/kg body weight per day, for 6-10 days). The nasal function was checked on the basis of five criteria: nasal obstruction, anterior rhinorrhea, posterior rhinorrhea, facial pain, and loss of sense of smell. Two tests were carried out for each patient: (i) a bone mineral density evaluation by dual energy X-ray absorptiometry (DXA) at three different sites in the lumbar spine and femur, and (ii) an evaluation of the hypothalamic-pituitary-adrenal (HPA) axis by the synacthen test.

RESULTS

Most of the patients had a severe NP associated with asthma (78.3% of the population), and aspirin idiosyncrasy (28.3%). In all, 10.9% and 43.5% of patients had osteoporosis and osteopenia at the lumbar spine site. Twenty patients (48.8% of the tested patients) had an asymptomatic adrenal insufficiency.