Is Low Dose Synacthen Test Reliable in Detecting Adrenal Insufficiency in Cirrhosis

Abstract

Background and Aim: To detect adrenal insufficiency in cirrhosis using low dose (1 μg) synacthen test and to compare it with, S. cortisol and salivary cortisol. Background adrenal insufficiency is very common in CLD. Even in stable CLD patients various studies showed prevalence of cirrhosis varying from 20 to 70%. Free cortisol is the most reliable method used for estimation of adrenal insufficiency. But it is expensive and time consuming. Salivary cortisol in various studies correlated well with free cortisol. Serum total cortisol may not be a reliable in detecting adrenal insufficiency. Low dose (1 μg) synacthen test may be reliable and cost effective method in detecting adrenal insufficiency. Methods: Prospective observational study. 31 stable CLD patients admitted in medical gastro trivandrum were taken and S. total cortisol, salivary cortisol at 8 am was sent. Low dose (1 μg) synacthen was administered i.v. to the patients at 8 am and S. total cortisol at 8.30 am was also measured. Similar tests were also done for 15 acute viral hepatitis patients. Those with basal S. cortisol <4 μg/dl, post-synacthen <18 μg/dl were considered to have adrenal insufficiency. Results: Prevalence of adrenal insufficiency in stable CLD using low dose synacthen was 40%. Prevalence of adrenal insufficiency in stable CLD using salivary cortisol is 44%. Prevalence of adrenal insufficiency in stable CLD using total was S. cortisol 12% which rose to 60% when higher cut off 10 μg/dl was used. Similarly prevalence of adrenal insufficiency in a/c viral hepatitis was 6%, 25% and 33% using S. cortisol, low dose synacthen test and salivary cortisol. The prevalence of adrenal insufficiency was more in those with alcohol as etiology of cirrhosis, MELD > 16 and Child C cirrhosis. Conclusion: Low dose synacthen test is a reliable test to detect adrenal insufficiency in cirrhosis. Prevalence of adrenal insufficiency in cirrhosis was 44%. Total serum cortisol at lower cutoff has high false negativity and higher cutoff has high false positivity. Low dose synacthen was found to have equally efficient compared to salivary cortisol in detecting AI in cirrhosis and is very cost effective. The authors have none to declare.