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Aim:Although the peak cortisol response in the low-dose test does not reach the generally accepted value of 18 μg/dL, there are many patients whose adrenal insufficiency diagnosis was ruled out by getting an adequate response with the standard-dose test. Thus, the standard-dose adrenocorticotropic hormone (ACTH) stimulation test is unnecessarily applied to many patients. This study aims to compare low- and standard-dose ACTH stimulation tests in diagnosing adrenal insufficiency and to determine a new optimal threshold level for low-dose ACTH stimulation tests to avoid unnecessary standard-dose ACTH tests.Methods:In this single-center cross-sectional study, patients with suspected adrenal insufficiency who underwent low-dose (1 mcg) and standard-dose (250 mcg) ACTH stimulation tests were evaluated. Cases were separated into two groups: (I) inadequate cortisol response (

The ACTH (adrenocorticotropic hormone) stimulation test is the gold standard for the diagnosis of adrenal insufficiency (AI), performed with ACTH high dose (HDT) or low dose (LDT). As salivary cortisol has been proposed as an alternative to serum cortisol, our aim was to evaluate the reliability of salivary cortisol compared to serum cortisol for diagnosing AI in children. Data were collected retrospectively. Salivary and serum cortisol values derived by 80 ACTH stimulation tests were obtained (39 F, 36 M; median age 11.5 years, IQR 6.9). Sampling was performed at baseline and after 30 and 60 min from ACTH administration during the HDT, and at baseline and 10, 20, 30, 40 and 60 min after the stimulation for the LDT. A serum cortisol level > 420 nmol/L ruled out AI. The correlation coefficients between serum and salivary cortisol for the HDT (n = 24) were 0.80 at t0, 0.48 at t30 and 0.75 at t60. All patients were adrenal sufficient. In 41% of the LDT, peak serum cortisol indicated insufficient adrenal function. The correlation coefficients between serum and salivary cortisol were 0.59 at t0 and 0.33 at the peak. For a cut-off of salivary cortisol < 15 nmol/L, sensitivity was 73.9% and specificity 69.6%. Our data do not support salivary cortisol as a valid alternative to serum cortisol during LDT. Regarding the HDT, results are more encouraging, however, further studies are needed. [ABSTRACT FROM AUTHOR]

Aim: Although the peak cortisol response in the low-dose test does not reach the generally accepted value of 18 µg/dL, there are many patients whose adrenal insufficiency diagnosis was ruled out by getting an adequate response with the standard-dose test. Thus, the standard-dose adrenocorticotropic hormone (ACTH) stimulation test is unnecessarily applied to many patients. This study aims to compare low- and standard-dose ACTH stimulation tests in diagnosing adrenal insufficiency and to determine a new optimal threshold level for low-dose ACTH stimulation tests to avoid unnecessary standard-dose ACTH tests. Methods: In this single-center cross-sectional study, patients with suspected adrenal insufficiency who underwent low-dose (1 mcg) and standard-dose (250 mcg) ACTH stimulation tests were evaluated. Cases were separated into two groups: (I) inadequate cortisol response (<18 mcg/dL) to low-dose test and adequate response (≥18 mcg/dL) to the standard dose, (II) adrenal insufficiency by inadequate responses to both tests. In addition, the cortisol responses to the stimulation tests of the group not diagnosed with adrenal insufficiency and those diagnosed with adrenal insufficiency were compared. Results: Comparing 115 cases' peak cortisol levels, we found that the values of standard-dose tests were statistically significantly higher than those of low-dose tests (p<0.001). According to the receiver operating characteristic analysis we performed to determine a new cut-off level to eliminate adrenal insufficiency in the low-dose test, when the cut-off value was set as 16 µg/dL; 100% sensitivity, 35.64% specificities, 17.72% positive predictive value, and 100% negative predictive value were obtained. It has been shown that this new cut-off value would eliminate the diagnosis of adrenal insufficiency without performing the standard dose test in 36 cases. Conclusion: The need for standard-dose testing can be reduced by lowering the cut-off point of the low-dose test from the accepted adequate cortisol level of 18 mcg/dL to 16 mcg/dL. [ABSTRACT FROM AUTHOR]

The ACTH (adrenocorticotropic hormone) stimulation test is the gold standard for the diagnosis of adrenal insufficiency (AI), performed with ACTH high dose (HDT) or low dose (LDT). As salivary cortisol has been proposed as an alternative to serum cortisol, our aim was to evaluate the reliability of salivary cortisol compared to serum cortisol for diagnosing AI in children. Data were collected retrospectively. Salivary and serum cortisol values derived by 80 ACTH stimulation tests were obtained (39 F, 36 M; median age 11.5 years, IQR 6.9). Sampling was performed at baseline and after 30 and 60 min from ACTH administration during the HDT, and at baseline and 10, 20, 30, 40 and 60 min after the stimulation for the LDT. A serum cortisol level > 420 nmol/L ruled out AI. The correlation coefficients between serum and salivary cortisol for the HDT (n = 24) were 0.80 at t0, 0.48 at t30 and 0.75 at t60. All patients were adrenal sufficient. In 41% of the LDT, peak serum cortisol indicated insufficient adrenal function. The correlation coefficients between serum and salivary cortisol were 0.59 at t0 and 0.33 at the peak. For a cut-off of salivary cortisol < 15 nmol/L, sensitivity was 73.9% and specificity 69.6%. Our data do not support salivary cortisol as a valid alternative to serum cortisol during LDT. Regarding the HDT, results are more encouraging, however, further studies are needed.

Purpose: Beta-thalassemia major is a severe, congenital hematological disorder and, if untreated, leads to early mortality. Progress in therapeutical strategies improved clinical outcomes and life expectancy; however, increased survival led to the development of new disorders, including endocrinopathies. Little is known on the possible impairment of adrenocortical function, a potentially life-threatening condition, in long-term thalassaemic survivors. We therefore decided to assess adrenal reserve and the value of salivary cortisol during ACTH stimulation in the diagnosis of adrenocortical insufficiency in adult patients with β-thalassemia major.Methods: Cross-sectional study including 72 adults with β-thalassemia major. Patients were tested with 1 µg ACTH for serum and salivary cortisol.Results: Subnormal serum cortisol responses to ACTH stimulation (i.e., <500 nmol/l) were registered in 15 out of 72 patients. Salivary cortisol increased in parallel with serum cortisol and a clear-cut positive correlation was detected at each timepoint. Moreover, peak salivary cortisol values after ACTH stimulation were significantly lower in patients with impaired adrenal reserve (513.6 ± 52.33 vs. 914.1 ± 44.04 nmol/l p < 0.0001).Conclusions: Our results attest to the need for testing for adrenal insufficiency among adult thalassaemic patients, as up to 20% presented impaired adrenal reserve. Salivary and serum cortisol levels during stimulation with ACTH were closely correlated and the use of salivary cortisol sampling during ACTH testing may represent a surrogate to serum cortisol in these patients. [ABSTRACT FROM AUTHOR]

The possible risk of adverse effects due to regular use of inhaled corticosteroids (ICS) is a real concern. Our aim was to describe the factors that have an impact on hypothalamic-pituitary-adrenal axis suppression (HPA-AS) in children and adolescents taking ICS regularly. The HPA axis status of patients who were on moderate-to-high-dose ICS [>176 and >264 μg/day fluticasone propionate-hydrofluoroalkane (FP-HFA) for patients 0-11 and ≥12 years, respectively] was investigated. Various types of ICS were converted to FP-HFA equivalent according to National Asthma Education and Prevention Program (NAEPP) guidelines. Participants with a baseline (8 a.m.) serum cortisol <15 μg/dL underwent a low-dose ACTH stimulation test (LDAT) to diagnose HPA-AS. Among 91 patients, 60 (75.9 %) participants underwent LDAT, and seven (7.7, 95 % CI 3.5-15.3 %) were diagnosed with HPA-AS. Ciclesonide was more frequently used by the participants with HPA-AS compared to patients with a normal HPA axis (42.9 vs. 4.8 %, p = 0.009). Use of ICS at moderate-to-high doses for at least 7 months distinguished participants with HPA-AS from those with a normal HPA axis. Among the duration, type, and dose of ICS, solely the use of ICS with a body mass index (BMI)-adjusted daily dose of ≥22 μg FP was found to increase the risk for HPA-AS (odds ratio (OR) 7.22, 95 % confidence interval (CI) 1.23-42.26, p = 0.028). The receiver operating characteristics (ROC) curve analysis revealed a cutoff value of 291 μg/day FP (area under the curve (AUC) = 0.840, p = 0.003) for predicting HPA-AS Conclusion: The prevalence of HPA-AS was found to be 7.7 % in children taking not only high-dose ICS but also moderate-dose ICS. Dose alone was found to be an actual risk factor for HPA-AS. [ABSTRACT FROM AUTHOR]