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cosyntropin (ACTH, Cortrosyn) stimulation test (delta cortisol test)

Indications: - test of choice for diagnosis of adrenal insufficiency in most settings - most useful when AM serum cortisole is 4-12 ug/dL Contraindications: - unnecessary when when AM serum cortisole is < 3 ug/dL Procedure: 1) A baseline cortisol level is drawn 2) 250 ug of ACTH (cosyntropin or Cortrosyn) is injected IV or IM 3) plasma cortisol is measured 30 & 60 min later 4) aldosterone response to ACTH stimulation may also be measured in connection with serum ACTH to distinguish primary from secondary adrenal insufficiency 5) serum aldosterone is measured from the samples collected at baseline, 30 & 60 minutes for cortisol determination (see above) 6) 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] a) ruled in - baseline serum cortisol < 10 ug/dL - increase of < 9 ug/dL after adrenal stimulation b) ruled out - stimulated cortisol to > 44 ug/dL - increase of serum cortisol > 17 ug/dL after stimulation c) other values indeterminant 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

Related

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)

General

provocative clinical test special chemistry test

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995,l pg 474
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 654
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 17. American College of Physicians, Philadelphia 1998, 2015
  4. 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: 16645969
  5. Annane D et al, Diagnosis of adrenal insufficiency in severe sepsis and septic shock. Am J Respir Crit Care Med 2006, 174:1319 PMID: 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: 17158285