Dynamic testing of cortisol in consecutive patients with suspected adrenal disorders: a comparison of Elecsys Cortisol II and LC-MS/MS

IntroductionShort Synacthen Test (SST), a standard diagnostic test to confirm Adrenal insufficiency (AI), involves substantial expenses.ObjectivesThis study aimed to assess the predictive value of baseline Cortisol levels for SST outcomes and establish baseline cut-off levels for confirming AI to minimize the necessity of SST.MethodsAll SST data from 2019 to 2024 at National Hospital Kandy, Sri Lanka, were obtained retrospectively. A peak Cortisol ≥500nmol/L at 30 or 60-min post-SST was considered as a normal adrenal reserve, whereas failure indicated AI. Pearson's correlation and Logistic Regression analysis assessed baseline and post-SST Cortisol at 30 and 60-min. A 2 × 2 table assesses test agreement. Receiver operating characteristic (ROC) curve analysis evaluated the SST outcomes at 30 and 60-min separately assessing sensitivity, specificity, and area under the curve (AUC).ResultsA total of 307 patients were enrolled, and 63.19% exhibited a failed SST response. Baseline Cortisol positively correlated with post-SST Cortisol at 30-min (r = 0.74, P < .05) and 60-min (r = 0.68, P < .05) with a good AUC for both 30 min (AUC = 0.855) and 60 min (AUC = 0.829). Baseline Cortisol demonstrated the higher odds ratio per unit (OR = 1.015 per nmol/L), indicating greater sensitivity to small changes. ROC curves were utilized to derive cut-offs for baseline Cortisol levels predicting SST outcomes. At 30-min, baseline Cortisol <135nmol/L suggests AI (100% sensitivity, 44% specificity), and >381.5nmol/L indicates normal adrenal reserve (100% specificity, 21.8% sensitivity). Similarly at 60-min, baseline Cortisol <75.3nmol/L suggests AI (100% sensitivity, 19.7% specificity), and >357nmol/L indicates normal adrenal reserve (100% specificity, 16.8% sensitivity).ConclusionsApplying these cut-offs could avoid 41.69% (30 min) or 19% (60 min) of total SSTs, excluding AI and normal adrenal reserve. 30-min SST Cortisol correlates more strongly with baseline Cortisol, showing a higher r-value, higher OR and AUC. Hence, 30-min provides better cut-offs with higher sensitivity and specificity minimizing need for SST. Patients with baseline Cortisol between 135 and 381nmol/L can undergo SST with only a 30-min Cortisol measurement.

Background Short ACTH stimulation (Synacthen) tests are performed to investigate for adrenal insufficiency. Previous work suggests that morning cortisol concentrations can be used to rule in or out adrenal insufficiency to avoid performance of a Synacthen test. This study aimed to determine the optimal cortisol concentration for rule-in or rule-out adrenal insufficiency based on 30-minute cortisol (COR30) for adequate response using the assay-specific cut-off from The Endocrine Society of Australia/The Australasian Association for Clinical Biochemistry and Laboratory Medicine/The Royal College of Pathologists of Australasia (ESA/AACB/RCPA) Harmonization of Endocrine Dynamic Testing - Adult (HEDTA), in an Asian population. Methods Synacthen tests performed at our institution from 2012-2024, with a baseline cortisol between 6 and 10 am (COR0(6-10)), were extracted from the laboratory database. Plasma cortisol concentrations were measured by Beckman Coulter DxI 800. Synacthen tests were classified as adequate or inadequate based on the Beckman Coulter specific HEDTA cut-off for COR30 of 420 nmol/L. Performance characteristics (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under receiver operator characteristic (AUROC) curve) of COR0(6-10) concentrations to predict adequate or inadequate response were calculated using Microsoft Excel. Results 4609 Synacthen tests were included, 77% of which had adequate Synacthen response. COR0(6-10) &amp;gt;300 nmol/L could exclude inadequate COR30 response with sensitivity 95%, specificity 48%, PPV 35%, NPV 97%; and COR0(6-10) &amp;gt;364 nmol/L had sensitivity 99%, specificity 29%, PPV 29%, NPV 99%. COR0(6-10) &amp;lt;155 nmol/L could rule-in inadequate COR30 response with sensitivity 53%, specificity 95%, PPV 76%, NPV 87%; and COR0(6-10) &amp;lt;97 nmol/L had sensitivity 35%, specificity 99%, PPV 91%, NPV 84%. AUROC of COR0(6-10) for adequate COR30 response was 0.86. If patients with COR0(6-10) &amp;lt;97 nmol/L and &amp;gt;300 nmol/L did not proceed to Synacthen testing, up to 46% of tests could be avoided, while keeping misclassification under 5%. Conclusions Morning cortisol cut-offs were determined for rule-in and rule-out of adrenal insufficiency in an Asian population. Patients with morning cortisol &amp;gt;300 nmol/L or &amp;lt;97 nmol/L may be able to avoid Synacthen testing unless there is a strong suspicion of clinical discordance. Such a testing strategy could significantly decrease the number of Synacthen tests while keeping misclassification to a minimum.

In adrenal incidentaloma (AI) patients, beside the cortisol secretion, a different 11β-hydroxysteroid dehydrogenase type 2 (HSD11B2) activity, measurable by 24-h urinary cortisol/cortisone ratio (R-UFF/UFE) (the higher R-UFF/UFE the lower HSD11B2 activity), could influence the occurrence of the subclinical hypercortisolism (SH)-related complications (hypertension, type 2 diabetes, obesity). We evaluated whether in AI patients, UFF levels are associated to UFE levels, and the HSD11B2 activity to the complications presence. In 156 AI patients (93F, age 65.2±9.5years), the following were measured: serum cortisol after 1mg-dexamethasone test (1mg-DST), ACTH, UFF, UFE levels, and R-UFF/UFE (by liquid chromatography-tandem mass spectrometry), the latter was also evaluated in 63 matched-controls. We diagnosed SH (n=22) in the presence of ≥2 among ACTH <2.2pmol/L, increased UFF levels, and 1mg-DST >83nmol/L. Patients showed higher UFF levels and R-UFF/UFE than controls (75.9±43.1 vs 54.4±22.9nmol/24h and 0.26±0.12 vs 0.20±0.07, p<0.005, respectively) but comparable UFE levels (291±91.1 vs 268±61.5, p=0.069). The R-UFF/UFE was higher in patients with high (h-UFF, n=28, 0.41±0.20) than in those with normal (n-UFF, 0.22±0.10, p<0.005) UFF levels and in patients with SH than in those without SH (0.30±0.12 vs 0.25±0.12, p=0.04). UFF levels were associated with R-UFF/UFE (r=0.849, p<0.001) in n-UFF, but not in h-UFF patients. Among h-UFF patients, the complications prevalence was not associated with R-UFF/UFE values. In AI patients, the UFF increase is not associated with a UFE increase. The HSD11B2 activity is inversely associated with UFF levels in n-UFF patients but not in h-UFF patients, and it is not associated with the SH complications.

There is no consensus on the biochemical diagnostic criteria for subclinical hypercortisolism (SH). Using parameters related to the hypothalamic-pituitary-adrenal axis, we aimed to develop a diagnostic model of SH for predicting postsurgical hypocortisolism and metabolic complications. Prospective and cross-sectional, observational, multicentre study in Korea. After exclusion of overt Cushing's syndrome, adrenal incidentaloma (AI) patients who underwent unilateral adrenalectomy (n = 99) and AI patients (n = 843) were included. Primary outcome was defined as the presence of postsurgical hypocortisolism; secondary outcome was the presence of ≥4 complications (components of the metabolic syndrome and low bone mass). Postsurgical hypocortisolism was determined on the fifth postsurgery day using the ACTH stimulation test. Thirty-three of the 99 patients developed postsurgical hypocortisolism. Analysis of the presurgery overnight 1-mg dexamethasone suppression test (1-mg DST) showed that all patients with cortisol levels of >138 nmol/l experienced postsurgical hypocortisolism, whereas those with levels of ≤61 nmol/l did not. The models of (i) 1-mg DST >138 nmol/l or (ii) >61 nmol/l with the presence of one among low levels of ACTH and dehydroepiandrosterone-sulphate had the highest accuracy (89·9%, P < 0·001) and odds ratio [OR 111·62, 95% confidence interval (CI) 21·98-566·74, P < 0·001] for predicting postsurgical hypocortisolism. Finally, patients with the same criteria in the 843 AI patients showed the highest risk for having ≥4 complications (OR 3·51, 95% CI 1·84-6·69, P < 0·001), regardless of gender, age, body mass index and bilaterality. Our proposed model is able to accurately predict subtle cortisol excess and its chronic manifestations in AI patients.

To evaluate if the parameters of hypothalamic-pituitary-adrenal (HPA) axis activity could predict the occurrence and duration of post-surgical hypocortisolism (PSH) in patients with Cushing's syndrome (CS) and with adrenal incidentaloma (AI). We studied 80 patients (54 females, age 53.3±11years), who underwent adrenalectomy for CS (17 patients) or for AI (53 patients). Before surgery, we measured adrenocorticotroph hormone (ACTH), urinary free cortisol (UFC) and serum cortisol after 1mg dexamethasone suppression test (1mg-DST) levels. After surgery, all patients were given a steroid replacement therapy, and PSH was searched after 2months by a low-dose (1µg, iv) corticotropin stimulation test, that was repeated every 6months in PSH patients for at least 4years. The PSH occurred in 82.4 and 46% of CS and AI patients, respectively. In the whole sample and in AI patients separately considered, the PSH was independently predicted by the preoperative cortisol levels after 1mg-DST, however, with a low (<70%) accuracy. In AI patients the PSH occurrence was not ruled out even by the cortisol levels after 1mg-DST lower than 1.8μg/dL (50nmol/L). In the 50% of CS patients and in 31% of AI patients the PSH lasted more than 18months and in 35.7% of CS patients it persisted for more than 36months. In AI patients, the PSH duration was not predictable by any parameter. However, a PSH duration of at least 12months was significantly predicted before adrenalectomy (sensitivity 91.7%, specificity 41.2%, positive predictive value 52.4%, negative predictive value 87.5%, p=0.05) by the presence of at least 2 out of low ACTH levels, increased UFC levels and cortisol levels after 1mg-DST≥3.0µg/dL (83nmol/L). The PSH occurrence and its duration are hardly predictable before surgery. All patients undergoing unilateral adrenalectomy should receive a steroid substitutive therapy.

Background and Objectives: Adrenal insufficiency (AI) is an endocrine disorder characterized by inadequate cortisol production, leading to non-specific symptoms that delay diagnosis. The Low Dose Synacthen Test (LDST) is commonly used to evaluate adrenal function, but traditional cortisol cut-offs may not accurately reflect adrenal function in all patients. This study aims to identify baseline cortisol cut-offs to accurately rule in and out AI, reassess the value of cortisol increment during LDST, and evaluate the accuracy of 30 and 60 min cortisol measurements in diagnosing AI. Materials and Methods: We conducted a cross-sectional analysis of patients who underwent LDST at Farhat Hached University Hospital. Diagnostic accuracy of baseline cortisol levels and cortisol increment was assessed using ROC curve analysis to determine optimal cut-offs for predicting LDST outcomes. Results: Among 163 patients (mean age 42.9 years, 63% female), baseline cortisol ≤ 5.35 μg/dL had 100% specificity but 41.5% sensitivity for LDST failure. Conversely, baseline cortisol ≥ 12.4 μg/dL had 100% sensitivity with 45.9% specificity. Single measurements at 30 and 60 min correctly classified 92.64% and 93.87% of cases, respectively. ROC analysis of 30 and 60 min cortisol increments showed high diagnostic accuracy (AUC 0.923 and 0.914, respectively). The optimal cortisol increment cut-off was 6.35 μg/dL for ruling in AI (99% specificity). Conclusions: We propose a novel AI diagnostic algorithm based on a single 30 min cortisol measurement, complemented by revised baseline cortisol cut-offs and cortisol increment as additional criteria. This approach may enhance diagnostic accuracy and minimize unnecessary testing, warranting further clinical validation.

Short Synacthen test (SST) involves measuring the baseline, 30-, and 60-minute serum cortisol levels, after injecting 250 μg of synthetic adrenocorticotropic hormone or Synacthen (ACTH). This study aimed to review the current clinical practice of performing SST to establish a standardized test protocol and to additionally test the hypothesis regarding performing the 60-minute cortisol test alone and the dependence of overall SST result on baseline cortisol level.Patients >14 years who underwent SST from January 2010 to December 2017 were included. Pearson's chi-square cross-tabulation was used to identify individuals with inconsistent 30- and 60-minute serum cortisol test results. Logistic regression analysis was performed to predict normal responses based on the baseline cortisol value.Of the 965 patients identified from pharmacy, medical, and laboratory records, 849 were included. Mean baseline, 30-, and 60-minute cortisol levels after ACTH injection were 394 ± 286.58, 722 ± 327.11, and 827 ± 369.30 nmol/L, respectively. Overall, 715 (84%) and 134 (16%) patients had normal and abnormal responses, respectively. Primary and secondary adrenal insufficiency was diagnosed in 10% and 35%, respectively, while ACTH levels were not measured in 55% of the patients. Overall, 9.49% (n = 72) of the patients had a suboptimal response at 30 minutes, but reached the threshold value of 550 nmol/L at 60 minutes. This particular subgroup's mean change (240 nmol/L) in cortisol level from baseline to 30-minute was higher than that observed in patients with abnormal response at both time-points (mean change, 152 nmol/L). No patient with 30-minute optimal responses had 60-minute suboptimal responses. The baseline serum cortisol threshold of ≥226 nmol/L had 80% sensitivity, 71% specificity, and 93% positive predictive value for detecting a normal SST (P-value < .0001).Relying on a 60-minute cortisol level can identify all normal and abnormal responses, while relying on 30-minute cortisol level alone may produce false-positives. Additionally, a baseline cortisol level of ≥226 nmol/L is a reliable threshold for determining adequate adrenal function, particularly with a low pretest hypoadrenalism probability.

BackgroundLong-term glucocorticoid (GC) therapy is commonly used to treat rheumatological conditions. This may result in tertiary adrenal insufficiency, as a result of suppression of the HPA axis, when GC doses are weaned/withdrawn. There is little published data about tertiary adrenal insufficiency in this group. This study aims to further evaluate prevalence, characteristics and recovery of adrenal insufficiency in these patients at a large UK teaching hospital.MethodsWe retrospectively identified patients seen in outpatient clinics between January 2014 and September 2019 who had received tapering doses of long-term GC to treat their underlying condition (largely patients with polymyalgia rheumatica, giant cell arteritis or other vasculitis) and had either had a 9am cortisol or short synacthen test (SST). Data were collected using a standardised proforma.ResultsThere was a total of 238 patients, median age of 71 years with a female preponderance (75%). Mean duration of glucocorticoid use was 63.3 months. Mean peak dose of glucocorticoid was 29.2mg.142 patients had 9am cortisol as the first line test to assess adrenal function. 65% of these were considered sub-optimal based on local protocol (cortisol <350nmol/L). 38% of these patients went on to have SST, of which 56% continued to show evidence of sub-optimal cortisol production. All patients where baseline 9am cortisol was <100nmol/L failed to reach stimulated cortisol of >500nmol/L on SST, whereas 31% failed SST if 9am cortisol was 250-350 nmol/L.In total 138 SSTs were performed of which 51% (n=70) were abnormal (cortisol <500nmol/L post synacthen). When baseline cortisol was <100nmol/L on SST, all patients had a suboptimal peak response. However, where baseline cortisol on SST was >350 nmol/L only 3% had a sub-optimal peak cortisol.32 of these patients with an abnormal baseline SST went on to have a repeat SST within 2 years. 50% (n=16) continued to be suboptimal. Of the 32 patients, 38% (n=12) were switched to hydrocortisone with 33% showing complete adrenal recovery, average time to recovery of 25 months. 62% (n=20) patients did not switch, with 60% demonstrating recovery within the same time period (p=0.05). Mean ACTH levels in patients who had sub-optimal SST were 23.1 ng/L (n=19). ACTH levels were not different between those who recovered and those who did not (p=0.23).ConclusionOur study suggests that tertiary adrenal insufficiency is highly prevalent in this cohort of patients with rheumatological conditions requiring long-term glucocorticoid therapy. A 9am cortisol threshold of greater than 350nmol/L excludes most patients with adrenal insufficiency. These data also suggest no significant difference in adrenal recovery if switched to hydrocortisone versus continuing on prednisolone. ACTH levels were not fully suppressed in patients with adrenal insufficiency and did not predict recovery.

Obstetrical & Gynecological Survey: March 2003 - Volume 58 - Issue 3 - p 180-181 doi: 10.1097/01.OGX.0000055758.75837.AE

Patients with rheumatic diseases are often treated with prolonged, high-dose systemic glucocorticoids which can cause hypothalamic-pituitary-adrenal (HPA) axis suppression and development of tertiary adrenal insufficiency. Adrenal insufficiency carries the risk of serious, potentially life-threatening adrenal crisis. Our study evaluated the prevalence, characteristics and recovery of patients with underlying rheumatology conditions who had received prolonged glucocorticoid treatment. Retrospective, cross-sectional study. We evaluated 238 patients seen in outpatient rheumatology clinic, managed in accordance with current nationally and internationally accepted clinical guidelines. Data collected included patient demographics, historical steroid data, 09.00h cortisol/short synacthen test (SST) results and follow-up data on those with repeat assessments. Overall, 65% of our cohort had a 09.00h cortisol <350nmol/L. On SST, 43% of patients demonstrated evidence of possible tertiary adrenal insufficiency. Prednisolone equivalent dose at time of SST was significantly higher in the group who failed SST vs. those who passed; mean of 5.57mg vs. 3.59mg (p=.005). 09.00h cortisol result correlated with 30-min cortisol on SST (R2 =.20, p=.002). 0-min cortisol on SST correlated more strongly with 30-min cortisol than 09.00h cortisol (R2 =.59, p-value<.001). Patients with 0-min cortisol >350nmol/L, all passed their SST. Patients who remained on prednisolone were more likely to recover (71%) vs. those switched to hydrocortisone (27%), P=.02. Peak steroid dose was predictive of recovery; significantly lower in those who recovered (mean of 22.3mg vs. 33.8mg, P=.03). Steroid duration was not found to be a predictor of recovery [recovery (64.2months) vs. non-recovery (55.6months), P=.58]. There was no correlation found to outcome on SST with age, sex, peak steroid dose, steroid duration, underlying rheumatological condition, additional exogenous steroid use or serum sodium. Forty three percent of our patients demonstrated sub-optimal adrenal function on SST. Steroid dose at the time of SST was the only significant predictive risk factor for tertiary adrenal insufficiency. 09.00h cortisol demonstrated good correlation with outcome on SST and could represent a valid screening test to reduce need for SST if 09.00h >350nmol/L. Further prospective data are required to further characterize risk factors, predictive features of recovery and establish optimal management strategy of steroids (prednisolone vs hydrocortisone) to encourage adrenal recovery.

BACKGROUND: Remission of Cushing’s syndrome (CS) is generally defined as morning serum cortisol values <5mcg/dL (<138 nmol/L) or Urine Free Cortisol <10-20ug/dL (< 28 – 56 nmol/d) after tumor resection, which reflects suppression of the hypothalamic-pituitary-adrenal (HPA) axis by sustained hypercortisolism. Endocrine Society guidelines recommend glucocorticoid replacement until the HPA axis is normal as assessed by a morning (AM) or post-ACTH stimulation test cortisol level of approximately 18 ug/dL (500 nmol/L) or greater (1). Patients with subnormal cortisol levels remain on glucocorticoid until retested in 3-6 months. The goal of this study was to determine whether a baseline cortisol value predicts a normal response to the ACTH stimulation test.Methods: We reviewed 235 ACTH stimulation (stim) tests conducted on 76 patients with secondary adrenal insufficiency following remission of CS. Patients had resection of a single adrenal gland (n=7), pituitary adenoma [with (n=3) or without (n = 47) subsequent radiation], 70% of pituitary tissue (n=5), or ACTH secreting intrathoracic tumor (n=13). One had an ectopic ACTH secreting tumor in spontaneous remission (n=1). ACTH stim tests were conducted between 0800h and 0900h, 24 hours after the last dose of glucocorticoid, using 250 mcg of cosyntropin intravenously. Cortisol levels were measured just before administration of cosyntropin, and 30 and 60 minutes afterwards. Patients were considered to have passed the test if baseline or peak cortisol values reached > 18mcg/dL. Baseline cortisol values were compared to the ‘pass’ rate.Results: Baseline F values (ug/dL) and passing rates (# pass/total) were:<4: 1/91;4-4.9: 2/27;5-5.9: 8/31;6-6.9: 2/21;7-7.9: 7/25;8-8.9: 4/12;9-9.9: 8/12;>10 - < 15: 6/1115 – 19.5: 5/5Thus, Am cortisol values >9 ug/dl were significantly more likely to predict a normal response to ACTH stim than lower values (p<0.0001). ACTH values (n=184) did not predict peak F levels. However, no patient with ACTH value <5 pg/ml passed the test; all had peak F values of 0-10.5.Conclusion: Baseline cortisol can be a guide as to whether the more costly stimulation test is needed. In the small cohort with baseline 0800h – 0900h cortisol >15 ug/dL, all passed the test, suggesting that it is not needed in such patients. We recommend use of an ACTH stimulation test to assess recovery of the HPA axis when a morning cortisol reaches 9 mcg/dL, with an expected pass rate of about 66%.Reference: 1. Nieman LK, Biller BM, Findling JW, Murad MH, Newell-Price J, Savage MO et al. Treatment of Cushing’s Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 100:2807, 2015.

Subclinical Cushing syndrome is a condition of mild autonomous cortisol excess (MACE) that lacks typical features of Cushing syndrome but is associated with many complications. It represents a common hormonal dysfunction among patients with adrenal incidentaloma (AI), defined as unexpected masses or lesions found in the adrenal glands during radiological examinations of the chest or abdomen unrelated to adrenal gland assessment. The study evaluated the accuracy of dehydroepiandrosterone sulfate (DHEA-S) and dehydroepiandrosterone sulfate ratio (calculated by dividing the DHEA-S value by the age and sex-adjusted normal range of DHEA-S) in detecting MACE in AI patients. A cross-sectional study was conducted from April 2021 to July 2022 at the Faiha Specialized Diabetes, Endocrine, and Metabolism Centre (FDEMC) in Basrah, southern Iraq, involving 38 AI patients. Comprehensive laboratory and radiological evaluations were performed, including tests for adrenocorticotropic hormone (ACTH), renin, aldosterone, aldosterone/renin ratio (ARR), metanephrine, normetanephrine, cortisol, DHEA-S, and the 1-mg overnight dexamethasone suppression test (1-mg ONDST). Among the AI patients, 14% had MACE. Both DHEA-S ≤75 µg/dL and a DHEA-S ratio ≤1.7 exhibited a sensitivity of 80% each, with specificities of 73.3% and 76.6%, respectively, in diagnosing MACE in individuals aged ≤65 years. The negative predictive values were 95.7% and 95.8%, respectively. Low DHEA-S and DHEA-S ratio had high sensitivity and specificity in predicting MACE among AI patients aged ≤65 years, with strong negative predictive value.

American Association Of Clinical Endocrinologists And American Association Of Endocrine Surgeons Medical Guidelines For The Management Of Adrenal Incidentalomas

Subclinical Cushing's syndrome (SCS) is a condition of slight but chronic cortisol excess in patients with adrenal incidentaloma (AI) without typical signs and symptoms of Cushing's syndrome. Adiponectin has potent roles in modulating energy balance and metabolic homeostasis and acts in opposition to glucocorticoids. This study aimed to evaluate adiponectin level in SCS and nonfunctional AI (NAI) patients and its relation with metabolic parameters. Patients with AI (n = 40) and metabolically healthy controls (n = 30) were included. In AI patients and controls, detailed medical history assessment, physical examinations, anthropometric measurements, and laboratory measurements were performed. Age, body mass index, waist circumference, and lipid profiles were significantly higher and waist-to-hip ratio and adiponectin level were significantly lower in the AI patients than in the controls. The midnight cortisol and urinary free cortisol levels were significantly higher in the SCS patients (n = 8) than in the NAI patients (n = 32). Adiponectin level of the SCS group was significantly lower than those of the NAI and control groups. The sensitivity and specificity for an adiponectin level of ≤13.00 ng/mL in predicting the presence of SCS were 87.5% and 77.4%, respectively. In conclusion, adiponectin is valuable in predicting the presence of SCS in AI patients.

ObjectiveThe short synacthen test (SST) is widely used across the UK to assess adrenal reserve but there remains no consensus on the timing of cortisol sampling to help diagnose adrenal...