Predictive value of different thresholds of morning cortisol in diagnosing adrenal insufficiency

Asma Abu Ghasham , Suhaib Radi , Amal Aljawi , Suaad Bougis , Ghaday Alansari , Nooran Felemban , Wafa Saber , Aseel Attar , Mohamed Eldigire Ahmed , Majed Almaghrabi
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Abstract

Objective

Adrenal insufficiency (AI) is diagnosed with morning cortisol but ACTH stimulation test is usually needed to confirm the diagnosis. In this study we investigated different morning cortisol thresholds that can safely rule out AI without requiring a confirmatory ACTH stimulation test.

Design

Retrospective cohort study.

Methods

We included patients aged 18 and above who underwent the 250 mcg ACTH stimulation test from June 2018 to June 2022. Basal and post-ACTH serum cortisol values at 30 and 60 min were documented. Sensitivity, specificity and logistic regression analysis were employed to assess morning cortisol level's ability to predict AI as confirmed by ACTH stimulation test.

Results

237 patients were included, 66 diagnosed with AI and 171 had normal ACTH results. Hypertension and type 2 Diabetes correlated with lower AI incidence. Median morning cortisol was 138.0 nmol/L for AI group and 286.0 nmol/L for non-AI patients. A morning cortisol of 285 nmol/L had 90.6 % sensitivity, 50.3 % specificity, and a negative predictive value of 93.3 % for ruling out AI. A threshold of 306 nmol/L increased sensitivity to 95.3 % with 40 % specificity.

Conclusion

Morning cortisol is an effective diagnostic tool for ruling out AI. Using multiple thresholds based on clinical suspicion and the integration of predictive pre-test probability can reduce the need for excessive ACTH stimulation tests. This study contributes to the growing evidence of utilizing morning serum cortisol in the diagnosis of adrenal insufficiency.

Clinical relevance statement

Diagnosing Adrenal Insufficiency (AI) can be challenging due to debate regarding the cortisol cut-off value that can exclude AI without additional tests. The confirmatory short synacthen test has certain limitations including financial implications and time restrictions. We investigated the performance of various morning cortisol levels that can diagnose AI without additional testing.

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早晨皮质醇不同阈值对诊断肾上腺功能不全的预测价值
目的肾上腺功能不全(AI)可通过晨间皮质醇诊断,但通常需要进行促肾上腺皮质激素(ACTH)刺激试验来确诊。在这项研究中,我们调查了不同的晨间皮质醇阈值,这些阈值可以安全地排除 AI,而无需进行确诊性 ACTH 刺激试验。方法我们纳入了 2018 年 6 月至 2022 年 6 月期间接受 250 微克 ACTH 刺激试验的 18 岁及以上患者。记录30分钟和60分钟的基础和ACTH后血清皮质醇值。采用敏感性、特异性和逻辑回归分析来评估早晨皮质醇水平预测经ACTH刺激试验证实的AI的能力。结果237名患者被纳入,66名被诊断为AI,171名ACTH结果正常。高血压和 2 型糖尿病与较低的 AI 发病率相关。人工流产组患者的晨间皮质醇中位数为 138.0 nmol/L,非人工流产组患者的晨间皮质醇中位数为 286.0 nmol/L。清晨皮质醇为 285 nmol/L 对排除人工流产的敏感性为 90.6%,特异性为 50.3%,阴性预测值为 93.3%。结论:早晨皮质醇是排除人工流产的有效诊断工具。根据临床怀疑使用多个阈值,并结合预测性检测前概率,可减少对过量促肾上腺皮质激素刺激试验的需求。这项研究为越来越多的证据表明利用晨间血清皮质醇诊断肾上腺功能不全做出了贡献。临床意义声明:由于对无需额外检查即可排除肾上腺功能不全的皮质醇临界值存在争议,因此诊断肾上腺功能不全(AI)具有挑战性。确诊性短程皮质醇试验具有一定的局限性,包括经济影响和时间限制。我们研究了各种早晨皮质醇水平的性能,这些水平无需额外检查即可诊断出 AI。
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来源期刊
Endocrine and Metabolic Science
Endocrine and Metabolic Science Medicine-Endocrinology, Diabetes and Metabolism
CiteScore
2.80
自引率
0.00%
发文量
4
审稿时长
84 days
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