Abstract
An ACTH stimulation test is the standard diagnostic test for adrenal insufficiency (AI). We aimed to investigate the diagnostic performance between serum morning (0800 h) cortisol and serum basal (0900-1300 h) cortisol levels and determine the proper cut-off point to facilitate AI diagnosis to reduce the number of tests. A six-year retrospective study was performed in a tertiary care medical center. We identified 416 patients who had undergone either low (LDT) or high dose (HDT) ACTH stimulation outpatient tests. AI was defined as a peak serum cortisol level of <500 nmol/L at 30 or 60 minutes after LDT or HDT. The associations between AI and serum basal and morning cortisol levels were demonstrated by logistic regression model. Diagnostic performance was evaluated by ROC analysis. Of the 416 patients, 93 (22.4%) were categorized as having AI. The adjusted area under the curve (AUC) for the basal cortisol level for the diagnosis of AI was significantly higher than that for the morning cortisol (0.82 vs 0.69, p <0.001) level. The proposed cut-off values for the basal cortisol were <85 nmol/L (specificity 99.7%) and >350 nmol/L(sensitivity 98.9%). By using these proposed cut-off points, approximately 30% of the ACTH stimulation tests could be eliminated. The serum basal cortisol level with the proposed cut-off points were considered as an alternative option for diagnosis of AI. Utilizing the serum basal cortisol level can facilitate AI diagnosis as it is convenient, is not a time-specific test and has a high diagnostic performance.
Highlights
Adrenal insufficiency (AI) is a lethal disease if left undiagnosed
The serum basal cortisol level with the proposed cut-off points were considered as an alternative option for diagnosis of AI
Basal cortisol in adrenal insufficiency diagnosis had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript
Summary
Adrenal insufficiency (AI) is a lethal disease if left undiagnosed. A variety of tests have been proposed to identify inadequate levels of glucocorticoid production [1]. The dynamic tests that have been reported to properly assess AI were high-dose (HDT) and low-dose ACTH stimulation tests (LDT) [2,3,4,5] To perform these tests, serum cortisol is drawn at 0 minutes (basal cortisol), and either the standard 250 μg [3] or 1–5 μg [6, 7] of ACTH is administered before 30- and 60-minute serum cortisol levels are drawn. Using ACTH stimulation as a reference standard for AI, some studies have proposed lower and upper cut-off values for serum morning cortisol levels of 375–500 nmol/L (13.6–18.0 μg/dL), respectively [8, 9]. One study showed evidence supporting the use of basal cortisol levels to predict AI They proposed that if the basal cortisol was >450 nmol/L (16.3 μg/dL), AI could be ruled out, with a negative predictive value of 98.7%.
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